Diverting stomata (DS) have been shown to mitigate the clinical impact of anastomotic leakage (AL) but not without complications, and their routine use remains a matter of international debate. The objective of this study was to examine the association between stomata and the clinical consequences of AL.
This was a nationwide retrospective cohort study including all patients suffering from AL after low anterior resection from 2001 to 2010.
Four thousand sixty-three patients were treated in the period of whom 581 (11.9%) developed AL. In case of AL, patients without a diverting stoma had a slightly higher 90-day mortality rate (13.5% versus 8.7%, p = 0.089). Patients suffered more complications due to AL, both surgical (52% versus 28%, p < 0.001) and non-surgical (48% versus 35%, p = 0.004) with a higher Clavien-Dindo score. Twenty percent of patients developed stoma-related complications prior to stoma reversal. Mortality related to stoma reversal was 2.4%. Factors associated with a risk of a permanent stoma were age (HR 1.04, 95% CI 1.01–1.08), blood transfusion during primary surgery (HR 2.35, 95% CI 1.16–4–78), conserved anastomosis after AL (HR 0.019, 95% CI 0.009–0.04), and a diverting stoma fashioned at the index operation (HR 0.50, 95% CI 0.26–0.97).
The use of diverting stomata during low anterior resection mitigates the clinical impact of AL. However, this benefit needs to be balanced against the risk of stoma-related complications, seen in 20%, and mortality with stoma reversal (2.4%). Where practical, the decision to divert should be made pre-operatively in a multidisciplinary setting.
This is a preview of subscription content,to check access.
Access this article
Globocan. (2012). Estimated cancer incidence, mortality and prevalence worldwide in 2012. (2012) Available from: http://globocan.iarc.fr/Default.aspx. Globocan.
Eriksen MT, Wibe A, Norstein J, Haffner J, Wiig JN, the Norwegian Rectal Cancer Group (2005) Anastomotic leakage following routine meosrectal excision for rectal cancer in a national cohort of patients. Color Dis 7:51–57
Yeh CY, Changchien CR, Wang JY, Chen JS, Chen HH, Chiang JM, Tang R (2005) Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients. Ann Surg 241:9–13
Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectalexcision. Am J Surg 179:92–96
Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M (1998) Risk factors for anastomotic leakage after resection of rectal cancer see comment. Br J Surg 85:355–358
Peeters KC, Tollenaar RA, Marijnen CA et al (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92:211–216
Marusch F, Koch A, Schmidt U, Geiler S, Dralle H, Saeger HD, Wolff S, Nestler G, Pross M, Gastinger I, Lippert H (2002) Value of a protective stoma in low anterior resections for rectal cancer. Dis Colon Rectum 45:1164–1171
Hallbook O, Pahlman L, Krog M et al (1996) Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 224:58–65
Matthiessen P, Hallbook O, Andersson M, Rutegard J, Sjodahl R (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Color Dis 6:462–469
Branagan G, Finnis D (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 48:1021–1026
Merkel S, Wang WY, Schmidt O, Dworak O, Wittekind CH, Hohenberger W, Hermanek P (2001) Locoregional recurrence in patients with anastomotic leakage after anterior resection for rectal carcinoma. Color Dis 3:154–160
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 doublestapling technique anastomosis for rectal cancer. Am J Surg 202:259–226
Law WL, Chu KW (2004) Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 240:260–268
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
den Dulk M, Smit M, Peeters K, Kranenbarg EM, Rutten HJ, Wiggers T, Putter H, van de Velde C, Dutch Colorectal Cancer Group (2007) A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol 8:297–303
Pokorny H, Herkner H, Jakesz R, Herbst F (2005) Mortality and complications after stoma closure. Arch Surg 140(10):956–960
Mengual-Ballester M, García-Marín JA, Pellicer-Franco E, Guillén-Paredes MP, García-García ML, Cases-Baldó MJ, Aguayo-Albasini JL (2012 Jul) Protective ileostomy: complications and mortality associated with its closure. Rev Esp Enferm Dig 104(7):350–354
Wong KS, Remzi FH, Gorgun E, Arrigain S, Church JM, Preen M, Fazio VW (2005) Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 48(2):243–250
Flikier-Zelkowicz B, Codina-Cazador A, Farrés-Coll R, Olivet-Pujol F, Martín-Grillo A, Pujadas-de PM (2008) Morbidity and mortality associated with diverting ileostomy closures in rectal cancer surgery. Cir Esp 84(1):16–19
Chow A (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Color Dis 24:711–723
DCCG. DCCG Årsrapport 2017. DCCG Årsrapport 2017
Augestad KM, Lindsetmo RO, Stulberg JJ, Reynolds H, Champagne B, Senagore AJ, Delaney CP, (IRCSG)., International Rectal Cancer Study Group (2012 Oct) System-based factors influencing intraoperative decision-making in rectal cancer by surgeons: an international assessment. Color Dis 14(10):679–688
Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM (2009 May) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Color Dis 24(5):569–576
Multicenter analysis of risk factors for anastomotic leakage after middle and low rectal cancer resection without diverting stoma: a retrospective study . International Journal of Colorectal Disease. 2017;32:1431–1437.
Blok RD, Stam R, Westerduin E, Borstlap WAA, Hompes R, Bemelman WA, Tanis PJ (2018 Aug) Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer. Eur J Surg Oncol 44(8):1220–1225
Ihnát P, Guňková P, Peteja M, Vávra P, Pelikán A, Zonča P (2016 Nov) Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 30(11):4809–4816
The authors extend their thanks to Claus Anders Bertelsen, M.D., PhD, for contributing to the conception of the study and acquisition of data.
Conflicts of interest
The authors declare that they have no conflicts of interest.
The study has received ethical approval from a local Ethics Committee prior to the study being undertaken. Regional Ethical Committee: De Videnskabsetiske Komiteer for Region, Hovedstaden, Regionsgården, Kongens Vænge 2, 3400 Hillerød.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Schlesinger, N.H., Smith, H. The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study. Int J Colorectal Dis 35, 1903–1910 (2020). https://doi.org/10.1007/s00384-020-03625-8