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Der Chirurg

, Volume 81, Issue 11, pp 968–973 | Cite as

Stoma bei tiefer anteriorer Resektion: Kontra

  • M.S. Kasparek
  • K.-W. JauchEmail author
Leitthema

Zusammenfassung

Zum Schutz vor der gefürchteten Komplikation einer Anastomoseninsuffizienz ist die Anlage eines protektiven Stomas im Rahmen der tiefen Rektumresektion heute weitgehend Standard. Dies ist vor allem bei Patienten mit anerkannten Risikofaktoren für eine Anastomoseninsuffizienz, wie männliches Geschlecht, tiefe Anastomose, präoperative Radio-Chemo-Therapie, intraoperative Komplikationen, Steroideinnahme etc., aus Gründen der Patientensicherheit unumstritten. Trotzdem halten wir es für diskussionswürdig, bei Patienten ohne diese Risikofaktoren auf ein protektives Stoma im Rahmen der tiefen Rektumresektion zu verzichten. Hierdurch können den Patienten potenzielle Komplikationen der Stomaanlage und der Stomarückverlagerung und die damit verbundene, erneute Hospitalisation erspart werden. Bei zuverlässiger Patientenselektion, zu der es leider noch keine ausreichende Evidenz gibt, könnte so der Verzicht auf ein Stoma im Rahmen der tiefen Rektumresektion die Patientenzufriedenheit erhöhen und die Behandlungs- und sekundären Kosten senken, ohne die Patientensicherheit zu gefährden. Solange diese Evidenz nicht erarbeitet wurde, stellt das Risiko einer Anastomoseninsuffizienz bei Verzicht auf die Stomaanlage allerdings eine medikolegal kritische Situation dar, die dieses Vorgehen nur nach umfassender Risikoaufklärung und bei dringlichem Wunsch des Patienten rechtfertigt.

Schlüsselwörter

Rektumresektion Anastomose Protektives Stoma Mortalität Komplikation 

Stoma creation during low anterior resection: the cons

Abstract

Creation of a protective stoma is nowadays considered the standard of care in patients undergoing low rectal resection to protect these patients from the potentially hazardous consequences of an anastomotic leak. This appears reasonable in patients with acknowledged risk factors such as male gender, low anastomosis, preoperative radiochemotherapy, intraoperative complications, or steroid treatment to ensure patients’ safety. However, from our view, it is debatable, if patients without these risk factors can undergo low rectal resection without a stoma. This approach can prevent patients form potential risks of stoma creation as well as closure and the associated readmission to the hospital. Based on reliable patient selection, avoiding a protective stoma during low rectal resection can increase patients’ satisfaction and decrease primary and secondary medical costs. However, this approach is hampered by the lack of evidence for patient selection, leading to legal concerns that justify this approach only in highly motivated patients after detailed counseling of the individual patient.

Keywords

Rectal resection Anastomosis Protective stomata Mortality Complication 

Notes

Interessenskonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Der Autor har Referentenhonorare der Fa. B. Braun erhalten.

Literatur

  1. 1.
    Alves A, Panis Y, Lelong B et al (2008) Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy. Br J Surg 95:693–698CrossRefPubMedGoogle Scholar
  2. 2.
    Bakx R, Busch OR, Bemelman WA et al (2004) Morbidity of temporary loop ileostomies. Dig Surg 21:277–281CrossRefPubMedGoogle Scholar
  3. 3.
    Bakx R, Busch OR, Van Geldere D et al (2003) Feasibility of early closure of loop ileostomies: a pilot study. Dis Colon Rectum 46:1680–1684CrossRefPubMedGoogle Scholar
  4. 4.
    Bernell O, Lapidus A, Hellers G (2000) Risk factors for surgery and postoperative recurrence in Crohn’s disease. Ann Surg 231:38–45CrossRefPubMedGoogle Scholar
  5. 5.
    Bloemen JG, Visschers RG, Truin W et al (2009) Long-term quality of life in patients with rectal cancer: association with severe postoperative complications and presence of a stoma. Dis Colon Rectum 52:1251–1258PubMedGoogle Scholar
  6. 6.
    Cartmell MT, Jones OM, Moran BJ et al (2008) A defunctioning stoma significantly prolongs the length of stay in laparoscopic colorectal resection. Surg Endosc 22:2643–2647CrossRefPubMedGoogle Scholar
  7. 7.
    Chand M, Nash GF, Talbot RW (2008) Timely closure of loop ileostomy following anterior resection for rectal cancer. Eur J Cancer Care 17:611–615Google Scholar
  8. 8.
    Chude GG, Rayate NV, Patris V et al (2008) Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology 55:1562–1567PubMedGoogle Scholar
  9. 9.
    Stumpf M, Junge K, Wendlandt M et al (2009) Risk factors for anastomotic leakage after colorectal surgery. Zentralbl Chir 134:242–248CrossRefPubMedGoogle Scholar
  10. 10.
    Duchesne JC, Wang YZ, Weintraub Sl et al (2002) Stoma complications: a multivariate analysis. Am Surg 68:961–966PubMedGoogle Scholar
  11. 11.
    Enker WE, Merchant N, Cohen AM et al (1999) Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 230:544–552CrossRefPubMedGoogle Scholar
  12. 12.
    Fielding LP, Stewart-Brown S, Hittinger R et al (1984) Covering stoma for elective anterior resection of the rectum: an outmoded operation? Am J Surg 147:524–530CrossRefPubMedGoogle Scholar
  13. 13.
    Giannakopoulos GF, Veenhof AA, Van Der Peet Dl et al (2009) Morbidity and complications of protective loop ileostomy. Colorectal Dis 11:609–612CrossRefPubMedGoogle Scholar
  14. 14.
    Gooszen AW, Geelkerken RH, Hermans J et al (2000) Quality of life with a temporary stoma: ileostomy vs colostomy. Dis Colon Rectum 43:650–655CrossRefPubMedGoogle Scholar
  15. 15.
    Graffner H, Fredlund P, Olsson SA et al (1983) Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument. A randomized study. Dis Colon Rectum 26:87–90CrossRefPubMedGoogle Scholar
  16. 16.
    Hallbook O, Matthiessen P, Leinskold T et al (2002) Safety of the temporary loop ileostomy. Colorectal Dis 4:361–364CrossRefPubMedGoogle Scholar
  17. 17.
    Huh JW, Kim HR, Kim YJ (2010) Anastomotic leakage after laparoscopic resection of rectal cancer: the impact of fibrin glue. Am J Surg 199:435–441CrossRefPubMedGoogle Scholar
  18. 18.
    Huser N, Michalski CW, Erkan M et al (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248:52–60CrossRefPubMedGoogle Scholar
  19. 19.
    Kald A, Juul KN, Hjortsvang H et al (2008) Quality of life is impaired in patients with peristomal bulging of a sigmoid colostomy. Scand J Gastroenterol 43:627–633CrossRefPubMedGoogle Scholar
  20. 20.
    Koperna T (2003) Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer: a call for benchmarking. Arch Surg 138:1334–1339CrossRefPubMedGoogle Scholar
  21. 21.
    Maggiori L, Bretagnol F, Lefevre JH et al (2010) Conservative Management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer. Colorectal Dis (Epub ahead of print)Google Scholar
  22. 22.
    Matthiessen P, Hallbook O, Andersson M et al (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469CrossRefPubMedGoogle Scholar
  23. 23.
    Matthiessen P, Hallbook O, Rutegard J et al (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214CrossRefPubMedGoogle Scholar
  24. 24.
    Merad F, Hay JM, Fingerhut A et al (1998) Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research. Ann Surg 227:179–186CrossRefPubMedGoogle Scholar
  25. 25.
    Montedori A, Cirocchi R, Farinella E et al (2010) Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev 5:CD006878PubMedGoogle Scholar
  26. 26.
    Nugent KP, Daniels P, Stewart B et al (1999) Quality of life in stoma patients. Dis Colon Rectum 42:1569–1574CrossRefPubMedGoogle Scholar
  27. 27.
    Pakkastie TE, Ovaska JT, Pekkala ES et al (1997) A randomised study of colostomies in low colorectal anastomoses. Eur J Surg Oncol 163:929–933Google Scholar
  28. 28.
    Paun BC, Cassie S, Maclean AR et al (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818CrossRefPubMedGoogle Scholar
  29. 29.
    Peng J, Lu J, Xu Y et al (2010) Standardized pelvic drainage of anastomotic leaks following anterior resection without diversional stomas. Am J Surg 199(6):753–758CrossRefPubMedGoogle Scholar
  30. 30.
    Phang PT, Hain JM, Perez-Ramirez JJ et al (1999) Techniques and complications of ileostomy takedown. Am J Surg 177:463–466CrossRefPubMedGoogle Scholar
  31. 31.
    Pimentel JM, Duarte A, Patricio J (2003) The role of a protecting stoma in low anterior resection with TME and colonic J-pouch for rectal cancer; results of a prospective randomized trial. Colorectal Dis 5(2):83CrossRefGoogle Scholar
  32. 32.
    Siassi M, Hohenberger W, Losel F et al (2008) Quality of life and patient’s expectations after closure of a temporary stoma. Int J Colorectal Dis 23:1207–1212CrossRefPubMedGoogle Scholar
  33. 33.
    Siassi M, Weiss M, Hohenberger W et al (2009) Personality rather than clinical variables determines quality of life after major colorectal surgery. Dis Colon Rectum 52:662–668PubMedGoogle Scholar
  34. 34.
    Suding P, Jensen E, Abramson MA et al (2008) Definitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg 143:907–911CrossRefPubMedGoogle Scholar
  35. 35.
    Tan WS, Tang CL, Shi L et al (2009) Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 96:462–472CrossRefPubMedGoogle Scholar
  36. 36.
    Tsikitis VL, Larson DW, Poola VP et al (2009) Postoperative morbidity with diversion after low anterior resection in the era of neoadjuvant therapy: a single institution experience. J Am Coll Surg 209:114–118CrossRefPubMedGoogle Scholar
  37. 37.
    Tsunoda A, Tsunoda Y, Narita K et al (2008) Quality of life after low anterior resection and temporary loop ileostomy. Dis Colon Rectum 51:218–222CrossRefPubMedGoogle Scholar
  38. 38.
    Ulrich AB, Seiler C, Rahbari N et al (2009) Diverting stoma after low anterior resection: more arguments in favor. Dis Colon Rectum 52:412–418PubMedGoogle Scholar
  39. 39.
    Weidenhagen R, Gruetzner KU, Wiecken T et al (2008) Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg Endosc 22:1818–1825CrossRefPubMedGoogle Scholar
  40. 40.
    Yau T, Watkins D, Cunningham D et al (2009) Longitudinal assessment of quality of life in rectal cancer patients with or without stomas following primary resection. Dis Colon Rectum 52:669–677PubMedGoogle Scholar
  41. 41.
    Hornung HM, Jauch KW, Strauss T, Swoboda W (2010) Economic consequences of complications in abdominal and thoracic surgery in the german DRG payment system. Zentralbl Chir 135:143–148CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Klinikum der Universität MünchenMünchenDeutschland

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