Peter Matthiessen

Defunctioning Stoma Reduces Symptomatic Anastomotic Leakage After Low Anterior Resection of the Rectum for Cancer: A Randomized Multicenter Trial

Objective:The aim of this randomized multicenter trial was to assess the rate of symptomatic anastomotic leakage in patients operated on with low anterior resection for rectal cancer and who were intraoperatively randomized to a defunctioning stoma or not. Summary Background Data:The introduction of total mesorectal excision surgery as the surgical technique of choice for carcinoma in the lower and mid rectum has led to decreased local recurrence and improved oncological results. Despite these advances, perioperative morbidity remains a major issue, and the most feared complication is symptomatic anastomotic leakage. The role of the defunctioning stoma in regard to anastomotic leakage is controversial and has not been assessed in any randomized trial of sufficient size. Methods:From December 1999 to June 2005, a total of 234 patients were randomized to a defunctioning loop stoma or no loop stoma. Loop ileostomy or loop transverse colostomy was at the choice of the surgeon. Inclusion criteria for randomization were expected survival >6 months, informed consent, anastomosis ≤7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events. Results:The overall rate of symptomatic leakage was 19.2% (45 of 234). Patients randomized to a defunctioning stoma (n = 116) had leakage in 10.3% (12 of 116) and those without stoma (n = 118) in 28.0% (33 of 118) (odds ratio = 3.4; 95% confidence interval, 1.6–6.9; P < 0.001). The need for urgent abdominal reoperation was 8.6% (10 of 116) in those randomized to stoma and 25.4% (30 of 118) in those without (P < 0.001). After a follow-up of median 42 months (range, 6–72 months), 13.8% (16 of 116) of the initially defunctioned patients still had a stoma of any kind, compared with 16.9% (20 of 118) those not defunctioned (not significant). The 30-day mortality after anterior resection was 0.4% (1 of 234) and after elective reversal a defunctioning stoma 0.9% (1 of 111). Median age was 68 years (range, 32–86 years), 45.3% (106 of 234) were females, 79.1% (185 of 234) had preoperative radiotherapy, the level of anastomosis was median 5 cm, and intraoperative blood loss 550 mL, without differences between the groups. Conclusion:Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.

Risk factors for anastomotic leakage after anterior resection of the rectum.

Objective  Surgical technique and peri‐operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re‐operations in relation to anastomotic leakage.

What Is the Risk for a Permanent Stoma After Low Anterior Resection of the Rectum for Cancer? A Six-Year Follow-Up of a Multicenter Trial

PURPOSE: The aim of this study was to assess the risk for permanent stoma after low anterior resection of the rectum for cancer. METHODS: In a nationwide multicenter trial 234 patients undergoing low anterior resection of the rectum were randomly assigned to a group with defunctioning stomas (n = 116) or a group with no defunctioning stomas (n = 118). The median age was 68 years, 45% of the patients were women, 79% had preoperative radiotherapy, and 4% had International Union Against Cancer cancer stage IV. The patients were analyzed with regard to the presence of a permanent stoma, the type of stoma, the time point at which the stoma was constructed or considered as permanent, and the reasons for obtaining a permanent stoma. Median follow-up was 72 months (42-108). One patient with a defunctioning stoma who died within 30 days after the rectal resection was excluded from the analysis. RESULTS: During the study period 19% (45/233) of the patients obtained a permanent stoma: 25 received an end sigmoid stoma and 20 received a loop ileostomy. The end sigmoid stomas were constructed at a median of 22 months (1-71) after the low anterior resection of the rectum, and the loop ileostomies were considered as permanent at a median of 12.5 months (1-47) after the initial rectal resection. The reasons for loop ileostomy were metastatic disease (n = 6), unsatisfactory anorectal function (n = 6), deteriorated general medical condition (n = 3), new noncolorectal cancer (n = 2), patient refusal of further surgery (n = 2), and chronic constipation (n = 1). Reasons for end sigmoid stoma were unsatisfactory anorectal function (n = 22) and urgent surgery owing to anastomotic leakage (n = 3). The risk for permanent stomas in patients with symptomatic anastomotic leakage was 56% (25/45) compared with 11% (20/188) in those without symptomatic anastomotic leakage (P < .001). CONCLUSION: One patient of 5 ended up with a permanent stoma after low anterior resection of the rectum for cancer, and half of the patients with a permanent stoma had previous symptomatic anastomotic leakage.

Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA.

Objective: To evaluate short-term outcomes of a new treatment for perforated diverticulitis with purulent peritonitis in a randomized controlled trial. Background: Perforated diverticulitis with purulent peritonitis (Hinchey III) has traditionally been treated with surgery including colon resection and stoma (Hartmann procedure) with considerable postoperative morbidity and mortality. Laparoscopic lavage has been suggested as a less invasive surgical treatment. Methods: Laparoscopic lavage was compared with colon resection and stoma in a randomized controlled multicenter trial, DILALA (ISRCTN82208287). Initial diagnostic laparoscopy showing Hinchey III was followed by randomization. Clinical data was collected up to 12 weeks postoperatively. Results: Eighty-three patients were randomized, out of whom 39 patients in laparoscopic lavage and 36 patients in the Hartmann procedure groups were available for analysis. Morbidity and mortality after laparoscopic lavage did not differ when compared with the Hartmann procedure. Laparoscopic lavage resulted in shorter operating time, shorter time in the recovery unit, and shorter hospital stay. Conclusions: In this trial, laparoscopic lavage as treatment for patients with perforated diverticulitis Hinchey III was feasible and safe in the short-term.

Increase of serum C-reactive protein is an early indicator of subsequent symptomatic anastomotic leakage after anterior resection.

Objective  This prospective study investigated the factors which might indicate anastomotic leakage after low anterior resection.

Safety of the temporary loop ileostomy

Objective To evaluate the complications of the temporary loop ileostomy.

Is Early Detection of Anastomotic Leakage Possible by Intraperitoneal Microdialysis and Intraperitoneal Cytokines After Anterior Resection of the Rectum for Cancer

PurposeThis prospective study assessed methods of detecting intraperitoneal ischemia and inflammatory response in patients with and without postoperative complications after anterior resection of the rectum.MethodsIn 23 patients operated on with anterior resection of the rectum for rectal carcinoma, intraperitoneal lactate, pyruvate, and glucose levels were monitored postoperatively for six days by using microdialysis with catheters applied in two locations: intraperitoneally near the anastomosis, and in the central abdominal cavity. A reference catheter was placed subcutaneously in the pectoral region. Cytokines, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-a, were measured in intraperitoneal fluid by means of a pelvic drain for two postoperative days.ResultsThe intraperitoneal lactate/pyruvate ratio near the anastomosis was higher on postoperative Day 5 (P--.029) and Day 6 (P--.009) in patients with clinical anastomotic leakage (n--) compared with patients without leakage (n--6). The intraperitoneal levels of IL-6 (P--.002; P--.012, respectively) and IL-10 (P--.002; P--.041, respectively) were higher on postoperative Days 1 and 2 in the leakage group, and TNF-a was higher in the leakage group on Day 1 (P--.011). In-hospital clinical anastomotic leakage was diagnosed on median Day 6, and leakage after hospital discharge on median Day 20.ConclusionsThe intraperitoneal lactate/pyruvate ratio and cytokines, IL-6, IL-10, and TNF-α, were increased in patients who developed symptomatic anastomotic leakage before clinical symptoms were evident.

Population-based study of risk factors for postoperative death after anterior resection of the rectum†

The aim of this population‐based study was to analyse risk factors for death within 30 days after anterior resection of the rectum.

High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage

It is controversial whether division of the inferior mesenteric artery close to the aorta influences the risk of anastomotic leakage, especially in the elderly and unfit. This population‐based study was carried out to evaluate the independent association between a high arterial ligation and anastomotic leakage in anterior resection for rectal cancer.

Anastomotic-vaginal fistula (AVF) after anterior resection of the rectum for cancer--occurrence and risk factors.

Objective  The aim of the study was to assess recto‐vaginal fistula (RVF) after anterior resection of the rectum for cancer with regard to occurrence and risk factors.