The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study

Abstract

Background

Diverting stomata (DS) have been shown to mitigate the clinical impact of anastomotic leakage (AL) but not without complications, and their routine use remains a matter of international debate. The objective of this study was to examine the association between stomata and the clinical consequences of AL.

Methods

This was a nationwide retrospective cohort study including all patients suffering from AL after low anterior resection from 2001 to 2010.

Results

Four thousand sixty-three patients were treated in the period of whom 581 (11.9%) developed AL. In case of AL, patients without a diverting stoma had a slightly higher 90-day mortality rate (13.5% versus 8.7%, p = 0.089). Patients suffered more complications due to AL, both surgical (52% versus 28%, p < 0.001) and non-surgical (48% versus 35%, p = 0.004) with a higher Clavien-Dindo score. Twenty percent of patients developed stoma-related complications prior to stoma reversal. Mortality related to stoma reversal was 2.4%. Factors associated with a risk of a permanent stoma were age (HR 1.04, 95% CI 1.01–1.08), blood transfusion during primary surgery (HR 2.35, 95% CI 1.16–4–78), conserved anastomosis after AL (HR 0.019, 95% CI 0.009–0.04), and a diverting stoma fashioned at the index operation (HR 0.50, 95% CI 0.26–0.97).

Conclusion

The use of diverting stomata during low anterior resection mitigates the clinical impact of AL. However, this benefit needs to be balanced against the risk of stoma-related complications, seen in 20%, and mortality with stoma reversal (2.4%). Where practical, the decision to divert should be made pre-operatively in a multidisciplinary setting.

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Acknowledgments

The authors extend their thanks to Claus Anders Bertelsen, M.D., PhD, for contributing to the conception of the study and acquisition of data.

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Nis Hallundbæk Schlesinger has contributed to the conception of the study and to the acquisition, analysis, and interpretation of the data. He has drafted, revised, and approved the work and is accountable for all aspects of the work.

Henry Smith has contributed to the analysis and interpretation of the data. He has drafted, revised, and approved the work and is accountable for all aspects of the work.

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Correspondence to Nis Hallundbæk Schlesinger.

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The authors declare that they have no conflicts of interest.

Ethical approval

The study has received ethical approval from a local Ethics Committee prior to the study being undertaken. Regional Ethical Committee: De Videnskabsetiske Komiteer for Region, Hovedstaden, Regionsgården, Kongens Vænge 2, 3400 Hillerød.

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Schlesinger, N.H., Smith, H. The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study. Int J Colorectal Dis (2020). https://doi.org/10.1007/s00384-020-03625-8

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Keywords

  • Colorectal cancer
  • Anastomotic leakage
  • Diverting stoma