Advertisement

Surgical Endoscopy

, Volume 34, Issue 2, pp 839–846 | Cite as

Who needs diverting ileostomy following laparoscopic low anterior resection in rectal cancer patients? Analysis of 417 patients in a single institute

  • Hiroki Shimizu
  • Shigeki YamaguchiEmail author
  • Toshimasa Ishii
  • Hiroka Kondo
  • Kiyoka Hara
  • Kenichi Takemoto
  • Shintaro Ishikawa
  • Takuhisa Okada
  • Asami Suzuki
  • Isamu Koyama
Article

Abstract

Background

Anastomotic leakage (AL) is one of the most serious complications after low anterior resection (LAR) for rectal cancer, and the significance of diverting stoma to prevent AL is still controversial. The aim of this study is to clarify the potential benefits and safety of diverting ileostomy (DI) following laparoscopic LAR in rectal cancer patients.

Methods

This was a retrospective cohort study of 417 rectal cancer patients who underwent laparoscopic LAR in a single institute. The risk factors for AL and the DI-related morbidity were assessed.

Results

DI was performed in 226 patients (54.2%). The incidence rates of symptomatic AL showed no significant difference between patients with and without DI (8.4% vs. 10.0%, p = 0.612). AL requiring a surgical intervention was relatively lower in patients with DI than in those without DI (1.8% vs. 4.7%, p = 0.097). DI construction was an independent risk factor for AL requiring a surgical intervention (OR 3.47, p = 0.041), as was the serum albumin level (p = 0.003), and being male was a relative risk factor (p = 0.058). Focusing on sex, the rate of AL requiring a surgical intervention was significantly different in male (1.7 and 7.9%, p = 0.021) but not in female patients (1.9 and 1.1%, p = 1.000) with and without DI. The DI construction-related morbidity was 9.7%, and no patient required a reoperation. Of 226 patients with DI, 209 (92.5%) underwent stoma closure 118 days (median 30–509 days) after LAR. The stoma closure-related morbidity was 9.1% and 1 patient (0.5%) required a reoperation due to anastomotic leakage.

Conclusions

DI following laparoscopic LAR can decrease the risk of AL, requiring a surgical intervention, especially in male patients with malnutrition. However, due to DI-related morbidity, DI is not recommended in female patients.

Keywords

Laparoscopic low anterior resection Diverting ileostomy Anastomotic leakage Sex Stoma complication 

Notes

Compliance with ethical standards

Disclosures

Shigeki Yamaguchi had fees for lectures from Covidien, Johnson & Johnson, and Olympus. Hiroki Shimizu, Toshimasa Ishii, Hiroka Kondo, Kiyoka Hara, Kenichi Takemoto, Shintaro Ishikawa, Takuhisa Okada, Asami Suzuki, and Isamu Koyama have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefGoogle Scholar
  2. 2.
    Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters W, Nelson H (2007) Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 246:655–662 (discussion 662-654) CrossRefGoogle Scholar
  3. 3.
    Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J, Haglind E, Pahlman L, Cuesta MA, Msika S, Morino M, Lacy A, Bonjer HJ (2009) Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 10:44–52CrossRefGoogle Scholar
  4. 4.
    Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet (London, England) 365:1718–1726CrossRefGoogle Scholar
  5. 5.
    Bagshaw PF, Allardyce RA, Frampton CM, Frizelle FA, Hewett PJ, McMurrick PJ, Rieger NA, Smith JS, Solomon MJ, Stevenson AR (2012) Long-term outcomes of the australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer: the Australasian Laparoscopic Colon Cancer Study trial. Ann Surg 256:915–919CrossRefGoogle Scholar
  6. 6.
    Kitano S, Inomata M, Mizusawa J, Katayama H, Watanabe M, Yamamoto S, Ito M, Saito S, Fujii S, Konishi F, Saida Y, Hasegawa H, Akagi T, Sugihara K, Yamaguchi T, Masaki T, Fukunaga Y, Murata K, Okajima M, Moriya Y, Shimada Y (2017) Survival outcomes following laparoscopic versus open D3 dissection for stage II or III colon cancer (JCOG0404): a phase 3, randomised controlled trial. Lancet Gastroenterol Hepatol 2:261–268CrossRefGoogle Scholar
  7. 7.
    Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, Peters WR Jr, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren SM, Pisters PW, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III Rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1346–1355CrossRefGoogle Scholar
  8. 8.
    Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, Davies L, Wilson K, Hague W, Simes J (2015) Effect of laparoscopic-assisted resection vs. open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363CrossRefGoogle Scholar
  9. 9.
    Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561CrossRefGoogle Scholar
  10. 10.
    Kuroyanagi H, Akiyoshi T, Oya M, Fujimoto Y, Ueno M, Yamaguchi T, Muto T (2009) Laparoscopic-assisted anterior resection with double-stapling technique anastomosis: safe and feasible for lower rectal cancer? Surg Endosc 23:2197–2202CrossRefGoogle Scholar
  11. 11.
    Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, Lim SB, Lee TG, Kim DY, Kim JS, Chang HJ, Lee HS, Kim SY, Jung KH, Hong YS, Kim JH, Sohn DK, Kim DH, Oh JH (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11:637–645CrossRefGoogle Scholar
  12. 12.
    van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218CrossRefGoogle Scholar
  13. 13.
    Ihnat P, Gunkova P, Peteja M, Vavra P, Pelikan A, Zonca P (2016) Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 30:4809–4816CrossRefGoogle Scholar
  14. 14.
    Watanabe T, Itabashi M, Shimada Y, Tanaka S, Ito Y, Ajioka Y, Hamaguchi T, Hyodo I, Igarashi M, Ishida H, Ishihara S, Ishiguro M, Kanemitsu Y, Kokudo N, Muro K, Ochiai A, Oguchi M, Ohkura Y, Saito Y, Sakai Y, Ueno H, Yoshino T, Boku N, Fujimori T, Koinuma N, Morita T, Nishimura G, Sakata Y, Takahashi K, Tsuruta O, Yamaguchi T, Yoshida M, Yamaguchi N, Kotake K, Sugihara K (2015) Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol 20:207–239CrossRefGoogle Scholar
  15. 15.
    Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Buchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351CrossRefGoogle Scholar
  16. 16.
    den Dulk M, Marijnen CA, Collette L, Putter H, Pahlman L, Folkesson J, Bosset JF, Rodel C, Bujko K, van de Velde CJ (2009) Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 96:1066–1075CrossRefGoogle Scholar
  17. 17.
    Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899CrossRefGoogle Scholar
  18. 18.
    Matthiessen P, Hallbook O, Andersson M, Rutegard J, Sjodahl R (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469CrossRefGoogle Scholar
  19. 19.
    Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818CrossRefGoogle Scholar
  20. 20.
    Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Kuroyanagi H, Yamaguchi T (2011) Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Am J Surg 202:259–264CrossRefGoogle Scholar
  21. 21.
    Park JS, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257:665–671CrossRefGoogle Scholar
  22. 22.
    Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, Kawamura J, Nagayama S, Sakai Y (2014) Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc 28:2988–2995CrossRefGoogle Scholar
  23. 23.
    Hanna MH, Vinci A, Pigazzi A (2015) Diverting ileostomy in colorectal surgery: when is it necessary? Langenbeck’s Arch Surg 400:145–152CrossRefGoogle Scholar
  24. 24.
    Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N (2015) Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients. J Am Coll Surg 220:186–194CrossRefGoogle Scholar
  25. 25.
    Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, Weihs D, Eberl T, Tschmelitsch J (2016) Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery 159:1129–1139CrossRefGoogle Scholar
  26. 26.
    Hamabe A, Ito M, Nishigori H, Nishizawa Y, Sasaki T (2017) Preventive effect of diverting stoma on anastomotic leakage after laparoscopic low anterior resection with double stapling technique reconstruction applied based on risk stratification. Asian J Endosc Surg 11:220CrossRefGoogle Scholar
  27. 27.
    Kim CW, Baek SJ, Hur H, Min BS, Baik SH, Kim NK (2016) Anastomotic Leakage after low anterior resection for rectal cancer is different between minimally invasive surgery and open surgery. Ann Surg 263:130–137CrossRefGoogle Scholar
  28. 28.
    Bandoh T, Shiraishi N, Yamashita Y, Terachi T, Hashizume M, Akira S, Morikawa T, Kitagawa Y, Yanaga K, Endo S, Onishi K, Takiguchi S, Tamaki Y, Hasegawa T, Mimata H, Tabata M, Yozu R, Inomata M, Matsumoto S, Kitano S, Watanabe M (2017) Endoscopic surgery in Japan: the 12th national survey (2012–2013) by the Japan Society for Endoscopic Surgery. Asian J Endosc Surg 10:345–353CrossRefGoogle Scholar
  29. 29.
    Zhu QL, Feng B, Lu AG, Wang ML, Hu WG, Li JW, Mao ZH, Zheng MH (2010) Laparoscopic low anterior resection for rectal carcinoma: complications and management in 132 consecutive patients. World J Gastroenterol 16:4605–4610CrossRefGoogle Scholar
  30. 30.
    Kang CY, Halabi WJ, Chaudhry OO, Nguyen V, Pigazzi A, Carmichael JC, Mills S, Stamos MJ (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71CrossRefGoogle Scholar
  31. 31.
    Shukla PJ, Pandey D (2005) Protective defunctioning stoma in low anterior resection for rectal carcinoma (Br J Surg 2005; 92: 1137-1142). Br J Surg 92:1565–1566CrossRefGoogle Scholar
  32. 32.
    Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214CrossRefGoogle Scholar
  33. 33.
    Lefebure B, Tuech JJ, Bridoux V, Costaglioli B, Scotte M, Teniere P, Michot F (2008) Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer. Int J Colorectal Dis 23:283–288CrossRefGoogle Scholar
  34. 34.
    Nastro P, Knowles CH, McGrath A, Heyman B, Porrett TR, Lunniss PJ (2010) Complications of intestinal stomas. Br J Surg 97:1885–1889CrossRefGoogle Scholar
  35. 35.
    Jafari MD, Halabi WJ, Jafari F, Nguyen VQ, Stamos MJ, Carmichael JC, Mills SD, Pigazzi A (2013) Morbidity of diverting ileostomy for rectal cancer: analysis of the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 79:1034–1039PubMedGoogle Scholar
  36. 36.
    Bulow S, Bulut O, Christensen IJ, Harling H (2006) Transanal stent in anterior resection does not prevent anastomotic leakage. Colorectal Dis 8:494–496CrossRefGoogle Scholar
  37. 37.
    Zhao WT, Hu FL, Li YY, Li HJ, Luo WM, Sun F (2013) Use of a transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer. World J Surg 37:227–232CrossRefGoogle Scholar
  38. 38.
    Hidaka E, Ishida F, Mukai S, Nakahara K, Takayanagi D, Maeda C, Takehara Y, Tanaka J, Kudo SE (2015) Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution. Surg Endosc 29:863–867CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Hiroki Shimizu
    • 1
  • Shigeki Yamaguchi
    • 1
    Email author
  • Toshimasa Ishii
    • 1
  • Hiroka Kondo
    • 1
  • Kiyoka Hara
    • 1
  • Kenichi Takemoto
    • 1
  • Shintaro Ishikawa
    • 1
  • Takuhisa Okada
    • 1
  • Asami Suzuki
    • 1
  • Isamu Koyama
    • 1
  1. 1.Department of Gastroenterological Surgery, Comprehensive Cancer CenterSaitama Medical University International Medical CenterHidakaJapan

Personalised recommendations