Skip to main content
SpringerLink
Log in

Stoma bei tiefer anteriorer Resektion: Kontra

Stoma creation during low anterior resection: the cons

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

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.

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  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 95:693–698

    Article  CAS  PubMed  Google Scholar 

  2. Bakx R, Busch OR, Bemelman WA et al (2004) Morbidity of temporary loop ileostomies. Dig Surg 21:277–281

    Article  CAS  PubMed  Google Scholar 

  3. Bakx R, Busch OR, Van Geldere D et al (2003) Feasibility of early closure of loop ileostomies: a pilot study. Dis Colon Rectum 46:1680–1684

    Article  PubMed  Google Scholar 

  4. Bernell O, Lapidus A, Hellers G (2000) Risk factors for surgery and postoperative recurrence in Crohn’s disease. Ann Surg 231:38–45

    Article  CAS  PubMed  Google Scholar 

  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 52:1251–1258

    PubMed  Google Scholar 

  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 22:2643–2647

    Article  PubMed  Google Scholar 

  7. Chand M, Nash GF, Talbot RW (2008) Timely closure of loop ileostomy following anterior resection for rectal cancer. Eur J Cancer Care 17:611–615

    CAS  Google Scholar 

  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 55:1562–1567

    CAS  PubMed  Google Scholar 

  9. Stumpf M, Junge K, Wendlandt M et al (2009) Risk factors for anastomotic leakage after colorectal surgery. Zentralbl Chir 134:242–248

    Article  CAS  PubMed  Google Scholar 

  10. Duchesne JC, Wang YZ, Weintraub Sl et al (2002) Stoma complications: a multivariate analysis. Am Surg 68:961–966

    PubMed  Google Scholar 

  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 230:544–552

    Article  CAS  PubMed  Google Scholar 

  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 147:524–530

    Article  CAS  PubMed  Google Scholar 

  13. Giannakopoulos GF, Veenhof AA, Van Der Peet Dl et al (2009) Morbidity and complications of protective loop ileostomy. Colorectal Dis 11:609–612

    Article  CAS  PubMed  Google Scholar 

  14. Gooszen AW, Geelkerken RH, Hermans J et al (2000) Quality of life with a temporary stoma: ileostomy vs colostomy. Dis Colon Rectum 43:650–655

    Article  CAS  PubMed  Google Scholar 

  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 26:87–90

    Article  CAS  PubMed  Google Scholar 

  16. Hallbook O, Matthiessen P, Leinskold T et al (2002) Safety of the temporary loop ileostomy. Colorectal Dis 4:361–364

    Article  PubMed  Google Scholar 

  17. Huh JW, Kim HR, Kim YJ (2010) Anastomotic leakage after laparoscopic resection of rectal cancer: the impact of fibrin glue. Am J Surg 199:435–441

    Article  PubMed  Google Scholar 

  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 248:52–60

    Article  PubMed  Google Scholar 

  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 43:627–633

    Article  PubMed  Google Scholar 

  20. Koperna T (2003) Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer: a call for benchmarking. Arch Surg 138:1334–1339

    Article  PubMed  Google Scholar 

  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)

  22. Matthiessen P, Hallbook O, Andersson M et al (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469

    Article  CAS  PubMed  Google Scholar 

  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 246:207–214

    Article  PubMed  Google Scholar 

  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 227:179–186

    Article  CAS  PubMed  Google Scholar 

  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:CD006878

    PubMed  Google Scholar 

  26. Nugent KP, Daniels P, Stewart B et al (1999) Quality of life in stoma patients. Dis Colon Rectum 42:1569–1574

    Article  CAS  PubMed  Google Scholar 

  27. Pakkastie TE, Ovaska JT, Pekkala ES et al (1997) A randomised study of colostomies in low colorectal anastomoses. Eur J Surg Oncol 163:929–933

    CAS  Google Scholar 

  28. Paun BC, Cassie S, Maclean AR et al (2010) Postoperative complications following surgery for rectal cancer. Ann Surg 251:807–818

    Article  PubMed  Google Scholar 

  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):753–758

    Article  PubMed  Google Scholar 

  30. Phang PT, Hain JM, Perez-Ramirez JJ et al (1999) Techniques and complications of ileostomy takedown. Am J Surg 177:463–466

    Article  CAS  PubMed  Google Scholar 

  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):83

    Article  Google Scholar 

  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 23:1207–1212

    Article  PubMed  Google Scholar 

  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 52:662–668

    PubMed  Google Scholar 

  34. Suding P, Jensen E, Abramson MA et al (2008) Definitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg 143:907–911

    Article  PubMed  Google Scholar 

  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 96:462–472

    Article  CAS  PubMed  Google Scholar 

  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 209:114–118

    Article  PubMed  Google Scholar 

  37. Tsunoda A, Tsunoda Y, Narita K et al (2008) Quality of life after low anterior resection and temporary loop ileostomy. Dis Colon Rectum 51:218–222

    Article  PubMed  Google Scholar 

  38. Ulrich AB, Seiler C, Rahbari N et al (2009) Diverting stoma after low anterior resection: more arguments in favor. Dis Colon Rectum 52:412–418

    PubMed  Google Scholar 

  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 22:1818–1825

    Article  PubMed  Google Scholar 

  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 52:669–677

    PubMed  Google Scholar 

  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 135:143–148

    Article  PubMed  Google Scholar 

Download references

Interessenskonflikt

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

Author information

Authors and Affiliations

  1. Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland

    M.S. Kasparek &  K.-W. Jauch

Authors
  1. M.S. Kasparek
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K.-W. Jauch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to K.-W. Jauch.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kasparek, M., Jauch, KW. Stoma bei tiefer anteriorer Resektion: Kontra. Chirurg 81, 968–973 (2010). https://doi.org/10.1007/s00104-010-1929-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-010-1929-z

Schlüsselwörter

Keywords

Search

Navigation