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Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Purpose

The purpose of this study was to determine the risk factors for the development of a permanent stoma in laparoscopic intersphincteric resection (LS-ISR) for ultralow rectal adenocarcinoma and to develop and validate a prediction model to predict the probability of permanent stoma after surgery.

Methods

A primary cohort consisting of 301 consecutive patients who underwent LS-ISR was enrolled in this study. Multivariable logistic regression analysis was used to identify risk factors and develop the nomogram. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort contained 91 consecutive patients from January 2012 to January 2019.

Results

The permanent stoma rate was 11.3% (34/301) in the primary cohort and 18.7% (17/91) in the validation cohort. Multivariable analysis revealed that nCRT (OR, 3.195; 95% CI, 1.169-8.733; P=0.024), ASA score of 3 (OR, 5.062; 95% CI, 1.877-13.646; P=0.001), distant metastasis (OR, 14.645; 95% CI, 3.186-67.315; P=0.001), and anastomotic leakage (OR, 11.308; 95% CI, 3.650-35.035; P<0.001) were independent risk factors for permanent stoma, and a nomogram was established. The AUCs of the nomogram were 0.842 and 0.858 in the primary and validation cohorts, respectively. The calibration curves showed good calibration in both cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful.

Conclusion

We developed and validated a nomogram for ultralow rectal adenocarcinoma patients who underwent LS-ISR, and the nomogram could help surgeons identify which patients are at a higher risk of a permanent stoma after surgery.

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References

Author names in bold designate shared co-first authorship.

  1. West N, Finan P, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 2008;26:3517-3522.

    Article  Google Scholar 

  2. Monastyrska E, Hagner W, Jankowski M, Głowacka I, Zegarska B, Zegarski W. Prospective assessment of the quality of life in patients treated surgically for rectal cancer with lower anterior resection and abdominoperineal resection. Eur J Surg Oncol 2016;42:1647-1653.

    Article  CAS  Google Scholar 

  3. Denost Q, Adam J, Rullier A, Buscail E, Laurent C, Rullier E. Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 2014;260:993-999.

    Article  Google Scholar 

  4. Laurent C, Paumet T, Leblanc F, Denost Q, Rullier E. Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach. Colorectal Dis 2012;14:35-41; discussion 2-3.

    Article  CAS  Google Scholar 

  5. Park J, Choi G, Jun S, Hasegawa S, Sakai Y. Laparoscopic versus open intersphincteric resection and coloanal anastomosis for low rectal cancer: intermediate-term oncologic outcomes. Ann Surg 2011;254:941-946.

    Article  Google Scholar 

  6. Zhang B, Zhao K, Liu Q, Yin S, Zhuo G, Zhao Y, Zhu K, Ding J. Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis? Int J Colorectal Dis 2017;32:587-590.

    Article  Google Scholar 

  7. Chopra S, Mrak K, Hünerbein M. The effect of endoscopic treatment on healing of anastomotic leaks after anterior resection of rectal cancer. Surgery 2009;145:182-188.

    Article  Google Scholar 

  8. Vermeer T, Orsini R, Daams F, Nieuwenhuijzen G, Rutten H. Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment. Eur J Surg Oncol 2014;40:1502-1529.

    Article  CAS  Google Scholar 

  9. Yang J, Chen Q, Jindou L, Cheng Y. The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis. J Surg Oncol 2020;121:1283-1297.

    Article  CAS  Google Scholar 

  10. Jung SH, Yu CS, Choi PW, Kim DD, Park IJ, Kim HC, Kim JC. Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 2008;51:902-908.

    Article  Google Scholar 

  11. Xiao C, Zhou M, Yang X, Xiao F, Liu X, Guo Y, Li X, Cao H, Luo J. Novel nomogram with microvascular density in the surgical margins can accurately predict the risk for anastomotic leakage after anterior resection for rectal cancer. J Surg Oncol 2019;120:1412-1419.

  12. Martin S, Heneghan H, Winter D. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 2012;99:603-612.

    Article  CAS  Google Scholar 

  13. Lee S, Kim D, Lim S. Robotic versus laparoscopic intersphincteric resection for low rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2018;33:1741-1753.

    Article  Google Scholar 

  14. Yokota M, Ito M, Nishizawa Y, Kobayashi A, Saito N. The Impact of Anastomotic Leakage on Anal Function Following Intersphincteric Resection. World J Surg 2017;41:2168-2177.

    Article  Google Scholar 

  15. Ahmad N, Abbas M, Khan S, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. Int J Colorectal Dis 2020.

  16. Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, Lippert H. Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 2005;92:1137-1142.

    Article  CAS  Google Scholar 

  17. Zhou X, Wang B, Li F, Wang J, Fu W. Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis. Dis Colon Rectum 2017;60:544-554.

  18. Chi P, Huang S, Lin H, Lu X, Huang Y, Jiang W, Xu Z, Chen Z, Sun Y, Ye D. Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome. Ann Surg Oncol 2015;22:944-951.

    Article  Google Scholar 

  19. Klink C, Lioupis K, Binnebösel M, Kaemmer D, Kozubek I, Grommes J Neumann UP, Jansen M, Willis S. Diversion stoma after colorectal surgery: loop colostomy or ileostomy? Int J Colorectal Dis 2011;26:431-436.

  20. Zeman M, Czarnecki M, Chmielarz A, Idasiak A, Grajek M, Czarniecka A. Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients. World J Surg Oncol 2020;18:207.

    Article  Google Scholar 

  21. Huang Y, Liang C, He L, Tian J, Liang C, Chen X, Ma Z, Liu Z. Development and Validation of a Radiomics Nomogram for Preoperative Prediction of Lymph Node Metastasis in Colorectal Cancer. J Clin Oncol 2016;34:2157-2164.

  22. Lo S, Ma J, Scolyer R, Haydu L, Stretch J, Saw R, Nieweg O, Shannon K, Spillane A, Ch'ng S, Mann G, Gershenwald J, Thompson J, Varey A. Improved Risk Prediction Calculator for Sentinel Node Positivity in Patients With Melanoma: The Melanoma Institute Australia Nomogram. J Clin Oncol 2020:JCO1902362.

  23. Maurichi A, Miceli R, Eriksson H, Newton-Bishop J, Nsengimana J, Chan M, Hayes A, Heelan K, Adams D, Patuzzo R, Barretta F, Gallino G, Harwood C, Bergamaschi D, Bennett D, Lasithiotakis K, Ghiorzo P, Dalmasso B, Manganoni A, Consoli F, Mattavelli I, Barbieri C, Leva A, Cortinovis U, Espeli V, Mangas C, Quaglino P, Ribero S, Broganelli P, Pellacani G, Longo C, Del Forno C, Borgognoni L, Sestini S, Pimpinelli N, Fortunato S, Chiarugi A, Nardini P, Morittu E, Florita A, Cossa M, Valeri B, Milione M, Pruneri G, Zoras O, Anichini A, Mortarini R, Santinami M. Factors Affecting Sentinel Node Metastasis in Thin (T1) Cutaneous Melanomas: Development and External Validation of a Predictive Nomogram. J Clin Oncol 2020;38:1591-1601.

    Article  Google Scholar 

  24. Serenari M, Han K, Ravaioli F, Kim S, Cucchetti A, Han D, Odaldi F, Ravaioli M, Festi D, Pinna A, Cescon M. A nomogram based on liver stiffness predicts postoperative complications in patients with hepatocellular carcinoma. J Hepatol 2020.

  25. Han S, Rivera G, Tammemägi M, Plevritis S, Gomez S, Cheng I, Wakelee H. Risk Stratification for Second Primary Lung Cancer. J Clin Oncol 2017;35:2893-2899.

    Article  Google Scholar 

  26. Kastrinos F, Uno H, Ukaegbu C, Alvero C, McFarland A, Yurgelun M, Kulke M, Schrag D, Meyerhardt J, Fuchs C, Mayer R, Ng K, Steyerberg E, Syngal S. Development and Validation of the PREMM Model for Comprehensive Risk Assessment of Lynch Syndrome. J Clin Oncol 2017;35:2165-2172.

    Article  CAS  Google Scholar 

  27. Cadrin-Tourigny J, Bosman L, Nozza A, Wang W, Tadros R, Bhonsale A, Bourfiss M, Fortier A, Lie ØH, Saguner A, Svensson A, Andorin A, Tichnell C, Murray B, Zeppenfeld K, van den Berg M, Asselbergs F, Wilde AAM, Krahn A, Talajic M, Rivard L, Chelko S, Zimmerman S, Kamel I, Crosson J, Judge D, Yap S, van der Heijden J, Tandri H, Jongbloed J, Guertin M, van Tintelen J, Platonov P, Duru F, Haugaa K, Khairy P, Hauer R, Calkins H, Te Riele A, James C. A new prediction model for ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy. Eur Heart 2019;40:1850-1858.

  28. Lee C, Huh J, Park Y, Cho Y, Kim H, Yun S, Lee W, Chun H. Risk factors of permanent stomas in patients with rectal cancer after low anterior resection with temporary stomas. Yonsel Med 2015;56:447-453.

    Article  Google Scholar 

  29. Kuryba A, Scott N, Hill J, van der Meulen J, Walker K. Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service. Colorectal Dis 2016;18:O199-205.

    Article  CAS  Google Scholar 

  30. Kim M, Kim Y, Park S, Sohn D, Kim D, Chang H, Oh J. Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy. Surgery 2016;159:721-727.

    Article  Google Scholar 

  31. Chiu A, Chan H, Brown C, Raval M, Phang P. Failing to reverse a diverting stoma after lower anterior resection of rectal cancer. Am J Surg 2014;207:708-711; discussion 11.

    Article  Google Scholar 

  32. Abe S, Kawai K, Nozawa H, Hata K, Kiyomatsu T, Tanaka T, Nishikawa T, Otani K, Sasaki K, Kaneko M, Murono K, Emoto S, Watanabe T. Use of a nomogram to predict the closure rate of diverting ileostomy after low anterior resection: A retrospective cohort study. Int J Surg 2017;47:83-88.

    Article  Google Scholar 

  33. Hendry P, Hausel J, Nygren J, Lassen K, Dejong C, Ljungqvist O, Fearon KC. Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg 2009;96:197-205.

    Article  CAS  Google Scholar 

  34. Qu H, Liu Y, Bi D. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc 2015;29:3608-3617.

    Article  Google Scholar 

  35. Sparreboom C, van Groningen J, Lingsma H, Wouters M, Menon A, Kleinrensink G, Jeekel J, Lange J, Dutch ColoRectal Audit group. Different Risk Factors for Early and Late Colorectal Anastomotic Leakage in a Nationwide Audit. Dis Colon Rectum 2018;61:1258-66.

  36. Pan H, Peng Y, Wang L, Li M, Yao Y, Zhao J, Zhan T, Gu J. Risk Factors for Nonclosure of a Temporary Defunctioning Ileostomy Following Anterior Resection of Rectal Cancer. Dis Colon Rectum 2016;59:94-100.

  37. Qin Q, Ma T, Deng Y, Zheng J, Zhou Z, Wang H et al. Impact of Preoperative Radiotherapy on Anastomotic Leakage and Stenosis After Rectal Cancer Resection: Post Hoc Analysis of a Randomized Controlled Trial. Dis Colon Rectum 2016;59:934-942.

    Article  Google Scholar 

  38. Da Silva G, Berho M, Wexner S, Efron J, Weiss E, Nogueras J, Vernava A, Connor J, Gervaz P. Histologic analysis of the irradiated anal sphincter. Dis Colon Rectum 2003;46:1492-1497.

    Article  Google Scholar 

  39. Dinnewitzer A, Jäger T, Nawara C, Buchner S, Wolfgang H, Öfner D. Cumulative incidence of permanent stoma after sphincter preserving low anterior resection of mid and low rectal cancer. Dis Colon Rectum 2013;56:1134-1142.

    Article  Google Scholar 

  40. Mak J, Foo D, Wei R, Law W. Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma. World J Surg 2017;41:2912-2922.

    Article  Google Scholar 

  41. Lindgren R, Hallböök O, Rutegård J, Sjödahl R, Matthiessen P. 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. Dis Colon Rectum 2011;54:41-47.

    Article  Google Scholar 

  42. Cui Y, Sun S, Li Z, Wang W. Safety, Survival, and Efficacy of Preserving Left Colonic Artery in Rectal Cancer Surgery: A Meta-Analysis and Review. J Laparoendosc Adv Surg Tech A 2019;29:1405-1413.

    Article  Google Scholar 

  43. Liu J, Gong Y, He M, Zeng X, Liu Y. Clinical Effect of Preservation or Nonpreservation of Left Colic Artery in Total Mesorectal Excision under Laparoscopy: A Meta-analysis. Gastroenterol Res Pract 2020;2020:1958573.

    PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to thank all the patients who participated in this study and the nurses who collected the data at Peking University First People’s Hospital and the Third People’s Hospital of Datong.

Funding

This study was supported by grants from the National Natural Science Foundation of China (No. 81272710) and Wu Jieping’s Foundation Special for Clinical Research (No. 320.6750.2021-04-2).

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Author notes

  1. Junguang Liu and Lijun Zheng contributed equally to this work.

Authors and Affiliations

  1. Department of General Surgery, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China

    Junguang Liu, Shuai Zuo, Junling Zhang, Yuanlian Wan, Xin Wang & Jianqiang Tang

  2. Department of General Surgery, the Third People’s Hospital of Datong, Datong, 037001, China

    Lijun Zheng & Song Ren

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  1. Junguang Liu
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Junguang Liu, Lijun Zheng, Xin Wang, and Jianqiang Tang. The first draft of the manuscript was written by Junguang Liu, Xin Wang, and Jianqiang Tang, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Xin Wang or Jianqiang Tang.

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All work was carried out in compliance with the Ethical Principles for Medical Research Involving Human Subjects outlined in the Helsinki Declaration in 1975 (revised in 2000).

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Liu, J., Zheng, L., Ren, S. et al. Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection. J Gastrointest Surg 25, 3218–3229 (2021). https://doi.org/10.1007/s11605-021-04982-7

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