Jacobs Journal of Surgery

Closure of Diverting Stoma after Rectal Cancer: Considerations about Times and Types

*Scabini S
Oncologic Surgical Unit, IRCCS San Martino IST, Italy

*Corresponding Author:
Scabini S
Oncologic Surgical Unit, IRCCS San Martino IST, Italy
Email:stefanoscabini@libero.it

Published on: 2014-04-17

Abstract

Protective colostomy after TME interventions in patients affected by rectal adenocarcinoma is the current standard of care. This is especially true in neoadjuvant treated patients, both after laparotomic resection and laparoscopic mini-invasive surgery.

Keywords

Introduction

Protective colostomy after TME interventions in patients affected by rectal adenocarcinoma is the current standard of care. This is especially true in neoadjuvant treated patients, both after laparotomic resection and laparoscopic mini-invasive surgery.

The reason for the colostomy approach lies in the inherent technical difficulty of sphincter saving procedures and the still dreaded fear of anastomotic leakage. This adverse event occurs with a frequency between 3 and 20%, in spite of methodological and technological advances occurred in the last few years.

As widely reported, a protection colostomy will not entirely prevent anastomotic leakage, but it often reduces the severity of such unwanted complication. Hence even in the case of leakage, protection colostomy will allow for a conservative approach avoiding re-intervention. Indeed, keeping a drainage catheter in the surgical bed until fecal material spill is no longer present is usually sufficient to preserve the anastomosis and lead to healing.

Yet, at least two questions remain without a definitive answer: what is more desirable between a protection colostomy and ileostomy? More important, when is a patient amenable to recanalization?

While a broad (but not universal) consensus exists on the answer to the first question, the second is a matter of debate for clinical as well as social, economic, and organizational reasons.

Ileostomy or colostomy? After anterior TME interventions, especially if conducted by laparoscopy, most surgeons will want to perform a right-sided ileostomy. This technique allows eliminating with high efficiency downstream stool transit. It is more easily performed (often by direct laparoscopic access), and it is, on average, easier to close upon colorectal anastomosis healing. There are negative aspects of ileostomy as well: if kept in place for long, it may lead to difficult-to-handle hydroelectrolytic imbalances (especially in frail, underweight or elderly patients).

Ileal fecal material qualitative and quantitative properties can lead to peristomal dermatitis, which is in itself difficult to control and cure. All these complications can become unmanageable if the patient develops an anastomotic fistula after the intervention, therefore necessitating keeping the ileostomy for longer. Ileostomy malfunctioning consequences in patients undergoing adjuvanttreatment are even more dangerous: the surgeon is sometimes compelled to find an interventional “window” between chemotherapy cycles, since hydroelectrolytic imbalances would put the patient’s life to risk. While preventing these dreadful adverse events, colostomy is more challenging from a technical point of view,especially during laparoscopy-based interventions. Upon colon-colon anastomosis, recanalization can be technically complex and burdened by greater risks, especially in elderly and vasculopathic patients. Colostomy, however, spares the aforementioned side effects, particularly in patients who, for various reasons (anastomotic leakage, delayed suture healing, substenotic healing needing mechanical dilation, etc.), will need a diversion stoma for a prolonged period.

Other issues are of relevance as well: we know from the available reports that there is inconsistency among the surgical community concerning the optimal timing for recanalization. Unforeseen issues commonly compel the surgeon to deviate from the planned management. Our experience concerns a high specialization level structure dedicated to colorectal surgery with more than 140 colic resections/year and three surgeons with high interventional volume (>30/year). We analyzed data from 118 patients affected by rectal cancer, undergoing protective bowel stoma construction after TME.

high interventional volume (>30/year). We analyzed data from 118 patients affected by rectal cancer, undergoing protective bowel stoma construction after TME. Fifty-four percent cases had undergone neoadjuvant treatment. Forty-six percent cases needed a protective stoma, due to either ultralow anastomoses or intraoperatory reasons calling for a more conservative approach. The personal experience of the operator, seldom in the very act of preparing the anastomosis, is often the main driver toward the construction of a protection stoma. This approach may attract criticisms (let us not forget we only have an“E” level evidence on such procedure), but it is a common experience for a surgeon to perform a technically flawless anastomosis (with excellent resection borders, negative hydropneumatic test and in a non-neoadjuvant treated patient) and then observe an anastomotic leakage! This kind of experiences demonstrates that there is still room for improvement in the topic of protection stomas and that a complete standardization of these procedures will always (provided this is the most desirable goal) be hampered by unpredictable variables occurring during the surgical act.

Surely, the laparoscopic approach has reduced the overall number of colostomies (in our experience we have assisted to a drop from 80% in the pre-laparoscopy era to less than 10%). Nowadays, we still construct protection colostomies in patients presenting with intraoperatory technical issues (positive hydropneumatic test or particularly challenging anastomoses), in those undergoing adjuvant treatment or in metabolically debilitated patients.

When should we proceed to recanalization? We can classify this intervention into early (within two weeks from intervention) and delayed recanalization (beyond eight weeks after intervention). For several Authors, early recanalization represents the current golden standard, with or without a Gastrografin enema (not everybody recommends it though).

Some considerations are due now: according to Sang only 77% of stomas are recanalized at some point [1], while a consistent proportion is not. Last, but not least, there are several factors delaying recanalization: i) incomplete certainty of a watertight anastomosis (intraoperatory issues come into play here), ii) need for adjuvant chemotherapy, iii) the development of complications that hamper a second intervention, iv) the patient’s will not to undergo it.

All these elements are evident in our experience. Taking into account all the protection stomas we constructed, we see that 14.4% of them become “functionally and irreversibly” permanent, mainly due to occurred comorbidities or disease progression (38% of cases) or patient’s preference (22%). When considering only ileostomies, this rate is lower (8.6%). Nevertheless, a proportion of patients will never undergo recanalization even in the latter case.

Hence, surgical timing is often just a planned act, hampered by real life factors by which the surgeon’s final decision cannot be separated. There is an abundant literature describing the advantages (and disadvantages) of early recanalization, which we have covered. Economical considerations must be finally taken into account when considering the choice of constructing a long term stoma, especially in a period of spending review for healthcare systems [2].

Indeed, not many reports exist which compare early vesus delayed recanalization. This is due, on the one hand, to the problem of designing a well-balanced study, and, on the other, to the ever too many confounding factors that occur in patients for which recanalization is planned.

Alves [3] andDanielsen [4] recruited 186 and 200 patients respectively. With all the limitations intrinsic to the heterogeneous populations analyzed, both Authors recognize some immediate advantages of early recanalization: fewer wound infection, better quality of life, fewer medical complications, and shorter hospitalization periods. On the long run, however, functional results are not significantly different.

As the Reader can infer from what summarized in the present Editorial, the dealt-with question is still subject to large discussion. This is especially true when considering all the peri- and post-interventional clinical, social, and economic issues which must be taken into consideration by a high-level colorectal surgery center.

In our opinion, larger and carefully designed studies are strongly needed to achieve higher levels of evidence for surgical procedures than those available nowadays. Such studies would be a good way to reach finally a “tailored” treat - ment rather than a “random” treatment, as it sometimes still seems.

References