Permanent Stoma Research Articles

(Babcock or Soave Baulieux) Procedure for Coloanal Anastomosis: 03 Cases

The Soave Baulieux procedure is a surgical technique for performing a coloanal anastomosis in cases of pathological colorectal conditions. A coloanal anastomosis is performed through a sleeve of rectal muscularis after a two-stage mucosectomy. In the first stage, the colonic tube is exteriorised through the anal canal, and a few days later a direct coloanal anastomosis is performed in the second stage. This is a salvage operation and its results are not well documented in the literature. This is a study of three (03) consecutive patients, hospitalised and operated on using the Babcock or Soave Baulieux technique at the Department of Visceral Surgery A of the Hassan II University Hospital in Fez, Morocco. The objectives of this study were to evaluate the indications, operative results, postoperative morbidity and mortality, and long-term functional results. Our study concerns three (03) patients with colorectal cancer. In 66.7% of cases, the decision to perform the Soave Baulieux technique was taken preoperatively to avoid other complications related to the low colorectal anastomosis. After the operation, 66.7% of patients had a simple post-operative course and only one patient (33.3%) was re-operated after a complication (necrosis of the anastomosis from the distal segment to the anus). Only one patient had a permanent stoma. Quality of life and functional results were satisfactory in 66.7% of our patients.

Machine learning model for prediction of permanent stoma after anterior resection of rectal cancer: A multicenter study

BackgroundThe conversion from a temporary to a permanent stoma (PS) following rectal cancer surgery significantly impacts the quality of life of patients. However, there is currently a lack of practical preoperative tools to predict PS formation. The purpose of this study is to establish a preoperative predictive model for PS using machine learning algorithms to guide clinical practice. MethodsIn this retrospective study, we analyzed clinical data from a total of 655 patients who underwent anterior resection for rectal cancer, with 552 patients from one medical center and 103 from another. Through machine learning algorithms, five predictive models were developed, and each was thoroughly evaluated for predictive performance. The model with superior predictive accuracy underwent additional validation using both an independent testing cohort and the external validation cohort. The Shapley Additive exPlanations (SHAP) approach was employed to elucidate the predictive factors influencing the model, providing an in-depth visual analysis of its decision-making process. ResultsEight variables were selected for the construction of the model. The support vector machine (SVM) model exhibited superior predictive performance in the training set, evidenced by an AUC of 0.854 (95 % CI:0.803–0.904). This performance was corroborated in both the testing set and external validation set, where the model demonstrated an AUC of 0.851 (95%CI:0.748–0.954) and 0.815 (95%CI:0.710–0.919), respectively, indicating its efficacy in identifying the PS. ConclusionsThe model(https://yangsu2023.shinyapps.io/psrisk/) indicated robust predictive performance in identifying PS after anterior resection for rectal cancer, potentially guiding surgeons in the preoperative stratification of patients, thus informing individualized treatment plans and improving patient outcomes.

Long-term restoration of bowel continuity after rectal cancer resection and the influence of surgical technique: A nationwide cross-sectional study.

Literature on nationwide long-term permanent stoma rates after rectal cancer resection in the minimally invasive era is scarce. The aim of this population-based study was to provide more insight into the permanent stoma rate with interhospital variability (IHV) depending on surgical technique, with pelvic sepsis, unplanned reinterventions and readmissions as secondary outcomes. Patients who underwent open or minimally invasive resection of rectal cancer (lower border below the sigmoid take-off) in 67 Dutch centres in 2016 were included in this cross-sectional cohort study. Among 2530 patients, 1470 underwent a restorative resection (58%), 356 a Hartmann's procedure (14%, IHV 0%-42%) and 704 an abdominoperineal resection (28%, IHV 3%-60%). Median follow-up was 51 months. The overall permanent stoma rate at last follow-up was 50% (IHV 13%-79%) and the unintentional permanent stoma rate, permanent stoma after a restorative procedure or an unplanned Hartmann's procedure, was 11% (IHV 0%-29%). A total of 2165 patients (86%) underwent a minimally invasive resection: 1760 conventional (81%), 170 transanal (8%) and 235 robot-assisted (11%). An anastomosis was created in 59%, 80% and 66%, with corresponding unintentional permanent stoma rates of 12%, 24% and 14% (p = 0.001), respectively. When corrected for age, American Society of Anesthesiologists classification, cTNM, distance to the anorectal junction and neoadjuvant (chemo)radiotherapy, the minimally invasive technique was not associated with an unintended permanent stoma (p = 0.071) after a restorative procedure. A remarkable IHV in the permanent stoma rate after rectal cancer resection was found. No beneficial influence of transanal or robot-assisted laparoscopy on the unintentional permanent stoma rate was found, although this might be caused by the surgical learning curve. A reduction in IHV and improving preoperative counselling for decision-making for restorative procedures are required.

The Effect of Stoma Site Marking on Stomal Complications: A Long-term Retrospective Study.

To identify the effect of stoma site marking on stoma-related complications. The study sample included 639 individuals with stomas who were followed up in a stomatherapy unit in Turkey between January 1, 2017, and June 20, 2021. Researchers collected patient data from nursing records. Data were evaluated using number, percentage, χ2, and logistic regression tests. Of the individuals with stomas, 60.6% (n = 387) were men, and 72.6% (n = 464) had a cancer diagnosis. Their mean age was 60.16 (SD, 14.81) years. The stoma site was marked preoperatively in of 67.1% of patients (n = 429), and 17.1% (n = 109) developed stoma-related complications. The complication rate was higher in individuals with unmarked stoma sites (25.7%; P = .000), emergency surgeries (25.0%; P = .006), colostomies (23.9%; P = .042), and permanent stomas (28.3%; P = .002). The three most common complications were peristomal skin problems (56.9%), mucocutaneous separation (13.8%), and edema (9.2%). The incidence of stoma-related complications in the postoperative period was higher in individuals with unmarked stoma sites. The authors recommend that stoma and wound care nurses mark the stoma site in individuals for whom stoma creation is planned.

Risk factors for decreased quality of life in patients with permanent colostomy

The purpose of the study: to identify risk factors for decreased quality of life in patients with permanent colostomy. The results of a survey of 114 patients with permanent stoma after radical surgical treatment of stage I–III rectal cancer were analyzed. The quality of life was assessed with EORTC QLQ-C30 questionnaire.Severe impact on the global health status (less than 50 points) was observed in 21 (18.4 %) respondents. The significant risk factors of impaired quality of life include the absence of preoperative stoma site marking (OR = 6.5, 95 %CI = 2.0–20.4; p = 0.002) and the lack of specialized stoma care service in the region of residence (OR = 4.6, 95 %CI = 1.6–13.1; p = 0.005). The emergency nature of the primary operation also had a significant negative impact on subsequent quality of life (OR = 6.1, 95 %CI = 1.8–20.1; p = 0.004). The employment had a positive effect on the quality of life of patients (OR = 0.2, 95 %CI = 0.07–0.9; p = 0.024). Conclusion. The quality of life of patients with a permanent colostomy after radical surgery for rectal cancer depends on several factors. The absence of preoperative stoma site marking, inaccessibility of the rehabilitation service for colostomy patients in the region, and surgery emergency negatively affect the quality of life of this category of patients.

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

BackgroundTemporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer.Materials and methodsWe conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer.ResultsA total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure.ConclusionWe identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.

Stoma care and diet in the community.

Community nurses are often the common link with people in the community with healthcare services. Community nurses are involved in the care of people living with a temporary or permanent stoma and might be asked specialist questions of which they may feel uncertain of appropriate responses. This article describes some basic facts about stoma as well as specialist dietary considerations; which can be used to improve symptoms such as constipation as well as how to prevent issues such as a food bolus obstruction. An increased understanding of stoma-related dietary needs among community nurses will likely improve care outcomes, as they will feel more equipped to offer tailored guidance and support.

Examining How Religion is Addressed During Preoperative Stoma Counseling

IntroductionAn intestinal stoma creation is one of the most common surgical procedures. Despite benefits, a stoma can have serious effects on a patient's quality of life. Multiple dimensions of everyday life can be affected such as social life, body image, as well as ability to participate in some religious practices, with some faith groups being disproportionately affected. This study sought to understand the extent to which faith is addressed during these sessions given the integral role it plays for some patients. MethodsA survey was developed based on literature review and expert consultation. This was distributed to ostomy certified nursing staff, inflammatory bowel disease gastroenterologists and colorectal surgeons caring for patients requiring a permanent stoma at a high-volume academic institution. Follow-up semistructured interviews were conducted to delve deeper into themes identified in the surveys. ResultsThe overall survey response rate was 57%. Only 35% reported training on how stomas interface with religious practices. Religious services were either rarely or never present during preoperative counseling discussions. During interviews, it was noted that religious beliefs often impact after care but are not always discussed during preoperative sessions. Interviewees found these conversations to be difficult with minimal support or direction on how to navigate them. ConclusionsAlthough very important, health-care providers are not including faith-based issues surrounding stomas in perioperative counseling partly due to lack of training or awareness of existing support systems. As our population diversifies, understanding cultural and religious practices that influence care is increasingly important.

The significance of G8 and other geriatric assessments in urologic cancer management: A comprehensive review.

In urologic oncology, which often involves older patients, it is important to consider how to manage their care appropriately. Geriatric assessment (GA) is a method that can address the specific needs of older cancer patients. The GA encompasses various assessment domains, but these domains exhibit variations across the literature. Some of the common items include functional ability, nutrition, comorbidities, cognitive ability, psychosocial disorders, polypharmacy, social and financial support, falls/imbalance, and vision/hearing. Despite the diversity of domains, there is limited consensus on reliable measurement methods. This review discusses the role of GA in managing urologic cancer in unique scenarios, such as those necessitating temporary or permanent urinary catheters or stomas due to urinary diversion. A comprehensive GA is time and human-resource-intensive in real-world clinical practice. Hence, simpler tools such as the Geriatric-8 (G8), capable of identifying high-risk patients requiring a detailed GA, are also under investigation in various contexts. Therefore, we conducted a systematic literature review on the G8. Our findings indicate that patients with low G8 scores encounter difficulties with stoma self-care after urinary diversion and have higher risks of urinary tract infections and ileus after radical cystectomy. The utilization of G8 as a screening tool for urologic cancer patients may facilitate the delivery of appropriate and personalized treatment and care.

Rehabilitasi Respirasi pada Pasca Operasi Angkat Pita Suara

Laryngectomy is a surgery that involves the removal of components of the larynx and vocal cords, with a permanent stoma created in the neck. Voice, breathing, and eating functions will be impaired in the long term. After laryngectomy, people lose not only their voice and ability to communicate but also part of their personality. Voice rehabilitation becomes essential in treatment, focusing on acceptable voice production and aspiration prevention and improving the quality of life of larynx-impaired patients post vocal cord removal. Rehabilitation of laryngectomized patients is a current therapeutic challenge. A therapeutic respiratory rehabilitation was designed to meet patient expectations better.

Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer.

Previous treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre. Data regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer. Patients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60-1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34-4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36-1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32-5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival. Rectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location.

Risk factors for the failure of endoscopic balloon dilation to manage anastomotic stricture from colorectal surgery: retrospective cohort study.

An anastomotic stricture after colorectal surgery is principally managed by endoscopic balloon dilation (EBD). Although this intervention is effective, however, subsequent procedures or surgical interventions are often required. This study aimed to assess the long-term outcomes of EBD for anastomotic stricture arising from colorectal cancer surgery. We analyzed 173 patients who received curative surgery for colorectal cancer at our hospital between January 2000 and December 2022 and had undergone EBD to manage anastomotic stricture. The medical records of these cases were retrospectively reviewed to assess the outcomes and risk factors for restenosis and permanent stoma. Of the 173 study patients, 41 (23.7%) presented with restenosis with a median time to recurrence of 49 [37-150] days. The restenosis group was significantly younger (55.6years versus 60.8years), with a more prominent rectal location (80.5% versus 57.6%), a higher incidence of hand-sewn anastomosis (24.4% versus 5.3%), and a higher percentage of neoadjuvant radiotherapy (34.1% versus 5.3%, P < 0.001). Multivariable analysis indicated neoadjuvant radiotherapy (adjusted HR 2.48; 95% CI 1.03-5.95) and cerebral vascular disease (adjusted HR 6.97; 95% CI 2.15-22.54) as independent prognostic factors for restenosis. Fourteen patients (8.1%) required a permanent stoma due to treatment failure. All cases needing a permanent stoma were male (14 patients, 100%, P = 0.007) and this group had a higher rate of neoadjuvant radiotherapy, adjuvant chemotherapy, and hand-sewn anastomosis. Patients receiving neoadjuvant radiotherapy are most prone to restenosis after an EBD intervention to manage an anastomotic stricture. Neoadjuvant radiotherapy is also a strong risk factor for requiring a permanent stomas due to treatment failure.

N18 The experience of the IBD patients with a permanent or temporary stoma: update of the literature

Abstract Background Surgery is indicated in selected patients with inflammatory bowel disease (IBD).Annually, 2000 (0.66%) of these individuals in the UK and an estimated 24,000 (1.5%) in the USA undergo surgery resulting in a permanent or temporary stoma. The audience of patients undergoing a stoma surgery is very broad and consists of not only elderly people, but also young adults, fertile or pregnant women.Fear of having a stoma is a major concern for people with IBD. And this aspect goes beyond the simple therapeutic aspect but it encroaches upon the psychological, occupational, relational, educational, financial and domestic area.This study aims to analyze the Quality of Life (QoL) outcomes of IBD patients with temporary or permanent stoma Methods To identify, evaluate and synthesis the lived experiences of IBD patients having a stoma, a meta-synthesis has been performed following the Sandelowski and Barroso guidelines (2007).Studies included: primary studies in English language, conducted using qualitative methodology that explore the subjective experience of IBD patients having a temporary or permanent stoma; studies that debated the experiences lived during the period of having a stoma; studies published from January 2013 to October 2023. The instrument Critical Appraisal Skills Program (CASP) has been used for the qualitative evaluation of the included studies (Image 1) Results Sixteen studies have been analyzed and the most of them involved more than one medical or research institution. The included studies described different areas of the perceived experience of 3046 IBD patients with a stoma. A total of 30 labels have been classified into 12 sub-themes, grouped in a total of five themes. (a) Surgery is a trigger for possible psychological disorders such as PTSD and (b) the positive perception of the stoma as an effective therapy in the management of IBD symptoms are the most frequent labels in the studies (Table 1) Conclusion The results of this study contributed to provide evidence about the experience of stoma-bearing IBD patients.Healthcare providers should offer improved interdisciplinary counselling earlier in the course of IBD so as to inform and enpower the patient and allow for shared decision-making. Patient information, education and support groups are crucial when managing IBD patients and optimizing patient-reported outcomes.This counts especially for young subjects that would be less prone to accept a stoma.Taken together, these findings provide further proof of the complex interplay between various psychological aspects.Our findings are consistent with previous research, which suggest, in terms of direction for psychological operations,that an increased focus in the educational and management of the disease is crucial

Intersphincteric resection of low rectal cancer: a retrospective study

Background The use of sphincter-saving resection without a permanent stoma in place of abdominoperineal resection (APR) has been one of the greatest advancements in the area of surgical therapy for low rectal cancer. Aim To assess the oncological and functional outcomes of inter-sphincteric resection of low rectal cancer in order to achieve radicality and a standard of living. Patients and methods At the hospitals affiliated with Menoufia University, a retrospective analysis was done. Forty patients with rectum cancer who were undergoing general surgery at Menoufia University Hospitals were the subject of this investigation. We comprised: older than 18 years old, sexes of both genders, low rectum and anal canal, with internal sphincter or rectal wall restriction on magnetic resonance imaging, differentiated tumour, tumour diameter of 1–5, and good continence. Results Mean operative time was 261.8 (±96.6 SD), the mean blood loss was 185.8 (±156.5 SD). Mean postoperative hospital stay was 11.2 (±4.1S D), the mean pain severity 1 h postoperatively was 5.5 (±1.0 SD), the mean 1 day postoperatively was 5.9 (±1.5 SD), the mean 5 day postoperatively was 3.3 (±1.2 SD), there were three with Anastomotic leakage, two with wound infection, two with hemorrhage, one with urinary tract infection, one with ileus. Regarding complications, mean score of micturition problems was 28.2 (±4.1 SD), the mean GIT symptoms was 32.2 (±3.1 SD), the mean weight loss was 5.5 (±1.0 SD), the mean CTX side effects was 13.9 (±1.5 SD), the mean body image was 70.3±6.2. Conclusion The intersphincteric resection approach improves the rate of sphincter preservation while maintaining oncological and functional results. Symptom-specific quality of life may be adversely affected by preoperative radiation.

Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis.

The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.

Long-Term Functional Outcomes and Multidisciplinary Management after Ileorectal Duhamel Pull-Through for Total Colonic Aganglionosis-20-Year Experience in a Tertiary Surgical Center.

Management of patients with total colonic aganglionosis (TCA) is challenging for pediatric surgeons. The purpose of this study was to review our institution's 20-year experience regarding long-term outcomes and multidisciplinary team management of these patients after an ileorectal Duhamel pull-through procedure. Retrospective review was conducted for all patients diagnosed with TCA in our tertiary institution. Data were collected on demographics, clinical presentation, complications, need for additional surgery, and long-term effects on bowel function. Of a total of 202 patients with Hirschsprung's disease, 13 were diagnosed with TCA (6.4%). Clinical presentation was variable. Eleven presented in neonatal period with distal bowel obstruction and two presented with constipation in early infancy. Ileorectal Duhamel pull-through was performed in all patients. Median follow-up was 13 years. Eleven are toilet trained, of whom five are fully continent. Six continue to have problems with bowel continence or constipation. One developed recurrent episode of Hirschsprung's associated enterocolitis. Two patients had stoma re-established. Patients experiencing difficulties in bowel function are jointly managed by a multidisciplinary team consisting of surgeons, gastroenterologists, pediatric psychologists, and clinical nurse specialists. TCA can be associated with significant long-term morbidity. Nearly half of the patients in this series have ongoing problems with bowel continence requiring a permanent stoma in some. Diligent follow-up coupled with inputs of a multidisciplinary team has greatly helped manage these complex patients in our institution.

Light and shadow of watch-and-wait strategy in rectal cancer: oncological result, clinical outcomes, and cost-effectiveness analysis.

The watch-and-wait (WW) strategy is a potential option for patients with rectal cancer who obtain a complete clinic response after neoadjuvant therapy. The aim of this study is to analyze the long-term oncological outcomes and perform a cost-effectiveness analysis in patients undergoing this strategy for rectal cancer. The data of patients treated with the WW strategy were prospectively collected from January 2015 to January 2020. A control group was created, matched 1:1 from a pool of 480 patients undergoing total mesorectal excision. An independent company carried out the financial analysis. Clinical and oncological outcomes were analyzed in both groups. Outcome parameters included surgical and follow-up costs, quality-adjusted life years (QALYs), and the incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). Forty patients were included in the WW group, with 40 patients in the surgical group. During a median follow-up period of 36months, metastasis-free survival (MFS) and overall survival (OS) were similar in the two groups. In the WW group, nine (22%) local regrowths were detected in the first 2years. The permanent stoma rate was slightly higher after salvage surgery in the WW group compared to the surgical group (48.5% vs 20%, p < 0.01). The cost-effectiveness analysis was slightly better for the WW group, especially for low rectal cancer compared to medium-high rectal cancer (ICER = - 108,642.1 vs ICER = - 42,423). The WW strategy in locally advanced rectal cancer offers similar oncological outcomes with respect to the surgical group and excellent results in quality of life and cost outcomes, especially for low rectal cancer. Nonetheless, the complex surgical field during salvage surgery can lead to a high permanent stoma rate; therefore, the careful selection of patients is mandatory.

Nonoperative management of the primary tumor in patients with unresectable stage IV colon cancer treated with systemic chemotherapy: Higher complication rates for left-sided colon tumors

IntroductionTreatment of the primary tumor in asymptomatic patients with unresectable colorectal metastases remains controversial. MethodsData from patients with synchronous stage IV colon cancer and an untreated primary tumor who started treatment aimed at metastatic disease at a specialized cancer center between 2014 and 2018 were analyzed retrospectively. Main outcome was primary tumor-related complications comparing left-sided and right-sided colon cancer. A competing-risk regression model was used to identify predictors of complications. ResultsOf 523 patients with metastatic colon cancer at presentation, 221 started treatment aimed at metastatic disease; these patients constituted the study cohort. The primary tumor was left-sided in 109 patients (49%) and right-sided in 112 patients (51%). In total, 46 patients (21%) developed a complication that required invasive intervention. Complications occurred more frequently in patients with left-sided tumors than in patients with right-sided tumors (29% vs 13%, P = 0.003). Eighteen patients (8%) underwent non-surgical intervention. Six patients (33%) failed non-surgical management and underwent surgery. Of 34 patients (15%) who underwent surgical intervention, 20 underwent an emergency colectomy and 14 underwent diversion with a permanent stoma. Overall, 10% of patients ended up with a permanent stoma. In competing-risk analysis, only left-sided primary tumor (hazard ratio 2.62; 95% CI 1.40–4.89; P = 0.003) was significantly associated with primary tumor-related complications requiring invasive intervention. ConclusionsPatients with asymptomatic metastatic left-sided tumors have a higher risk for primary tumor-related complications than patients with right-sided tumors. Close monitoring and early surgical rescue should be considered for patients with left-sided colon cancer who are managed nonoperatively.

Role and Morbidity of Protective Ileostomy after Anterior Resection for Rectal Cancer: One Centre Experience and Review of Literature

The creation of a protective stoma is considered a valid life-saving tool, significantly reducing the effects of anastomotic leakage in terms of related morbidity, mortality, and reoperation rate. The aim of this study was to evaluate the impact of a protective loop ileostomy in terms of short- and long-term postoperative morbidity, quantifying the stoma-related complications arising after stoma creation and stoma closure and the risk of permanent stoma. From January 2009 to January 2020, 149 patients with rectal cancer treated by anterior resection and protective ileostomy were enrolled in the study. A total of 113 (75.84%) patients were preoperatively treated with neoadjuvant radiochemotherapy. A clinically relevant anastomotic leak occurred in two patients (1.34%). The postoperative stoma complication rate was 6%. According to the Clavien classification, the stoma-related complication grade was I in seven patients (4.7%) and II in two patients (1.3%). A late stoma-related parastomal hernia occurred in one patient (0.67%). In 129 patients (86.57%), it was possible to close the stoma. Postoperative complications of stoma closure occurred in 12 patients (9.3%). The stoma closure complication grade was I in seven cases (5.43%), II in two cases (1.55%), and ≥3 in three cases (2.33%). Incisional hernia was the only late complication recorded in seven cases (5.42%). The permanent stoma rate was 13.43%. A protective ileostomy has a nonnegligible complication rate, but the rate of severe complications is low. Every effort should be made to clearly identify patients in whom the risk of anastomotic leakage justifies the stoma.

Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study

BackgroundThe surgical resection of rectal carcinoma is associated with a high risk of permanent stoma rate. Primary anastomosis rate is suggested to be higher in robot-assisted and transanal total mesorectal excision, but permanent stoma rate is unknown.MethodsPatients undergoing total mesorectal excision for MRI-defined rectal cancer between 2015 and 2017 in 11 centers highly experienced in laparoscopic, robot-assisted or transanal total mesorectal excision were included in this retrospective study. Permanent stoma rate, stoma-related complications, readmissions, and reoperations were registered. A multivariable regression analysis was performed for permanent stoma rate, stoma-related complications, and stoma-related reoperations.ResultsIn total, 1198 patients were included. Permanent stoma rate after low anterior resection (with anastomosis or with an end colostomy) was 40.1% in patients undergoing laparoscopic surgery, 21.3% in patients undergoing robot-assisted surgery, and 25.6% in patients undergoing transanal surgery (P < 0.001). Permanent stoma rate after low anterior resection with an anastomosis was 17.3%, 11.8%, and 15.1%, respectively. The robot-assisted and transanal techniques were independently associated with a reduction in permanent stoma rate in patients who underwent a low anterior resection (with anastomosis or with an end colostomy) (OR 0.39 [95% CI 0.25, 0.59] and OR 0.35 [95% CI 0.22, 0.55]), while this was not seen in patients who underwent a restorative low anterior resection. 45.4% of the patients who had a stoma experienced stoma-related complications, 4.0% were at least once readmitted, and 8.9% underwent at least one reoperation.ConclusionsThe robot-assisted and transanal techniques are associated with a lower permanent stoma rate in patients who underwent a low anterior resection.