Abstract
To investigate the conflicting consequences of faecal diversion on stoma outcomes and anastomotic leakage in anterior resection for rectal cancer, including interaction effects determined by the extent of mesorectal excision. Anterior resections between 2007 and 2016 were identified using the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine stoma outcome 2years after surgery. Tumour distance from the anal verge constituted a proxy for extent of mesorectal excision [total mesorectal excision (TME): ≤10cm; partial mesorectal excision (PME): 13-15cm]. With confounder-adjusted probit regression, the total effect of defunctioning stoma on permanent stoma, and the interaction effect of extent of mesorectal excision, were estimated together with the indirect effect through anastomotic leakage. Baseline risks, risk differences (RDs) and relative risks (RRs) were reported. The main study cohort included 4529 patients. Defunctioning stomas influenced the absolute permanent stoma risk (TME: RD 0.11 [95% CI 0.09-0.13]; PME: RD 0.15 [95% CI 0.13-0.16]). The baseline risk was higher in TME, with a resulting greater RR in PME (2.23 [95% CI 1.43-3.02] vs 4.36 [95% CI 3.05-5.68]). The indirect reduction in permanent stoma rates, due to the alleviating effect of faecal diversion on anastomotic leakage, was small (TME: 0.89 [95% CI 0.81-0.96]; PME: 0.96 [95% CI 0.91-1.00]). In anterior resection for rectal cancer, defunctioning stomas may reduce chances of a stoma-free outcome. Considering leakage reduction benefits, consequences of routine diversion in TME might be fairly balanced, while this seems questionable in PME.
Highlights
Sphincter-preserving surgery is considered standard treatment for cancer of the mid-and upper rectum, the long-term permanent stoma prevalence after anterior resection amounts to 20%–25% [1, 2]
While confounder- adjusted total risk differences were similar between total mesorectal excision (TME) and partial mesorectal excision (PME) (TME: RD 0.11 [95% confidence intervals (CIs): 0.09–0.13]; PME: RD 0.15 [95% CI: 0.13–0.16]), patients in the former group had a higher baseline risk of a permanent stoma outcome (TME: baseline risks (BRs) 0.09 [95% CI: 0.08–0 .10]; PME: BR 0.04 [95% CI: 0.03–0 .06])
For estimates concerning the protective effect of a defunctioning stoma on anastomotic leakage, only patients who could not be classified regarding mesorectal excision were excluded, while operations on patients in 2016 and those deceased within 90 days of surgery remained
Summary
Sphincter-preserving surgery is considered standard treatment for cancer of the mid-and upper rectum, the long-term permanent stoma prevalence after anterior resection amounts to 20%–25% [1, 2]. Anastomotic leakage is a major driver of this phenomenon [1, 2], while 20% of defunctioning stomas, originally fashioned to mitigate the consequences of a potential leak, are left in place or converted to end-colostomies [1, 3–5] and might add to the high stoma rate in themselves. Their protective effects are at times clearly advantageous [6], the morbidity of defunctioning stomas [7, 8], and subsequent takedown surgery [2, 9], can be profound. Routine use of defunctioning stomas seems to rather delay the leakage diagnosis [13], with less leaks acknowledged during the postoperative period and a decrease in reported leakage rates as a result
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