Time to contrast enema and ileostomy closure rates following low anterior resection: does laparoscopic surgery make a difference? A prospective cohort study.

Abstract

Dear Editor: Laparoscopic surgery for the management of low rectal cancer has been shown to be safe and offers an equivalent and in some series improved oncological result to traditional open surgery. Studies have looked at whether a de-functioning ileostomy is necessary in reducing the incidence of anastomotic leak after low rectal resections. The widely held belief now supports de-functioning ileostomy as standard practice with several studies suggesting reduced morbidity and incidence of clinically relevant anastomotic leaks. The decision for a de-functioning ileostomy is often governed by other factors including patient fitness, favourability of anastomosis, need for adjuvant chemotherapy, the presence of metastatic disease and other technical surgical aspects. Stoma reversal is often governed by various surgical, clinical and social factors. Usually it is performed after adjuvant chemotherapy is complete and anastomotic integrity has been proven with a contrast enema. However, metastatic disease, comorbidities and symptomatic anastomotic leaks are strong predictors of permanent stoma. Post-operative complications at the primary operation also have an influence on reversal surgery. Generally, fitter patients tend to have their stomas reversed earlier, whereas there is a subset of patients with multiple comorbidities in whom a decision is made early on a permanent stoma. Although studies have looked at the factors that influence risk of non-reversal and permanent stoma, there is little evidence to suggest what impact laparoscopic surgery as an independent factor may have on stoma reversal. The benefits of laparoscopic surgery as relates to quicker recovery, reduced length of hospital stay and post-operative morbidity are well known. However, there is sparse data evaluating the usefulness of laparoscopic surgery in reducing time to stoma reversal after anterior resection. It is also unknown as to how this impacts on permanent stoma rates. This may be an important factor when counselling and consenting patients pre-procedure. In a high volume colorectal centre, we aimed to assess the influence of laparoscopic surgery as an independent predictor of subsequent stoma reversal after low anterior resection in a cohort of comparable patients. The primary outcome measure was ileostomy reversal rates. Secondary outcomes included time to contrast enema, length of hospital stay, post-operative complications, readmission rates and post-operative mortality. Post-operative complications were defined as clinically significant requiring hospital admission, re-imaging or re-operation. Patients were followed-up over a 5-year period via validated questionnaires, telephone interviews and outpatient clinics. As most patients suitable for reversal surgery were likely to have it within the first 2 years, data analysis began after that time period. We used the student t test and Fisher’s test to analyse paired numerical and categorical variables, respectively, and the Kaplan–Meier to estimate the rates of persisting stoma between the groups. Odds ratios with 95 % confidence intervals were used to quantify ileostomy reversal rates and other outcome measures between the groups. In our observations, 50 patients (30 male) were included in the study; mean age was 66 (53–75). There were 30 laparoscopic and 20 open/laparoscopic converted. Fifteen (50 %) of the male patients had a laparoscopic procedure, 15 (75 %) had an open resection compared with five (25 %) of females having and open operation. Mean age was similar for both groups laparoscopic vs. open, 66 vs. 64. The groups were comparable * Joel Lambert joellambert@doctors.org.uk