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Long term aspects of defunctioning stoma following low anterior resection for rectal cancer
Örebro University, School of Medical Sciences.ORCID iD: 0000-0002-2813-2019
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In Sweden, more than 2 000 individuals are diagnosed with rectal cancer each year. Surgery is the main curative treatment, and involves removal of the tumor with the surrounding mesorectum in adefined anatomical plane. Intestinal continuity is restored by anastomosing the colon to the rectalstump at the pelvic floor. Leakage of the anastomosis is a potentially life-threatening complication, and is most common in low anastomoses located at the pelvic floor. A temporary defunctioning loop stoma (DS) reduces both the rate of leakage and the severity when leakage occurs despite DS. The use of DS has increased substantially in Sweden over the last 15 years, especially in low anastomoses at the level of the pelvic floor. The purpose of this thesis was to increase the understanding of different aspects of DS and its impact on anorectal function, long-term survival, cancer recurrence, timing of stoma reversal, and the risk of having a permanent stoma.

In Paper I, the LARS score questionnaire was used to assess anorectal function among patients who had participated in a Swedish nationwide randomized trial. Those who had a DS (n=116) were compared to those without DS (n=118). After a median follow-up time of 12 years, patients with DS had a poorer bowel function than those without DS in terms of incontinence for gas and loose stools. No differences were found with regard to fecal incontinence, defragmentation, and urgency. Women and patients who had received preoperative radiotherapy had poorer anorectal function. Impaired anorectal function was associated with lower self-perceived health.

In Paper II, a cohort of 110 patients from Örebro Region, Sweden, was investigated with regard to whether or not the DS was reversed within a 4-month period. Only 25% had their stoma reversed within this timeframe. Moreover, a third of the patients had a delayed stoma closure without any identifiable medical reason. This was an improvement compared to a previous study from the same region, which found that 58% of patients operated between 1995 and 2007 had a delayed stoma reversal without any identifiable medical reason. The most common cause for delayed DS reversal in our study was adjuvant chemotherapy (38%).

In Paper III, the impact of DS on long-term survival and local and distant cancer recurrence was investigated in a nationwide population-based study cohort operated with low anterior resection (LAR) between 1995 and 2010 (n=4130), retrieved from the Swedish Colorectal Cancer Registry. Patients with a DS at LAR (n=2163) had an increased survival rate during the first 3 years afterindex surgery in comparison with those without a DS. Beyond 3 years of follow-up, no difference was noted between the two groups. There were no differences regarding either local cancer recurrence or distant metastases between patients with and without DS.

In Paper IV, the risk of having a permanent stoma beyond 5 years after rectal cancer surgery was evaluated in 232 patients (excluding mortality within 90 days; n=2) previously randomized to DS or no DS. After a median follow-up of 15 years, 25% (57/232) had a permanent stoma. Of these, 23% (13/57) had their permanent stoma constructed at median 10 years after the index surgery. The incidence of permanent stoma was numerically lower in the group originally randomized to DS, but this difference was not statistically significant. Anastomotic leakage was the most common riskfactor for ending up with a permanent stoma.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2020. , p. 84
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 206
National Category
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-78812ISBN: 978-91-7529-319-6 (print)OAI: oai:DiVA.org:oru-78812DiVA, id: diva2:1380784
Public defence
2020-03-06, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:00 (English)
Opponent
Supervisors
Available from: 2019-12-19 Created: 2019-12-19 Last updated: 2020-02-04Bibliographically approved
List of papers
1. Does a Defunctioning Stoma Impair Anorectal Function After Low Anterior Resection of the Rectum for Cancer?: A 12-Year Follow-up of a Randomized Multicenter Trial
Open this publication in new window or tab >>Does a Defunctioning Stoma Impair Anorectal Function After Low Anterior Resection of the Rectum for Cancer?: A 12-Year Follow-up of a Randomized Multicenter Trial
2017 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 60, no 8, p. 800-806Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Anorectal function after low anterior resection of the rectum for cancer is often impaired, and long-term outcome has not frequently been reported.

OBJECTIVE: We evaluated anorectal function 12 years after rectal resection with regard to whether patients had a defunctioning temporary stoma at the initial rectal resection.

DESIGN: An exploratory cross-sectional investigation of a previously randomized study population.

SETTINGS: Twenty-one Swedish hospitals performing rectal cancer surgery during a 5-year period participated in the trial.

PATIENTS: Patients operated on with low anterior resection for cancer were included.

INTERVENTIONS: Patients were randomly assigned to receive or not receive a temporary defunctioning stoma.

MAIN OUTCOME MEASURES: We evaluated anorectal function 12 years after low anterior resection in patients who were initially randomly assigned to temporary stoma or not, by means of using the low anterior resection syndrome score questionnaire, which assesses incontinence for flatus, incontinence for liquid stools, defecation frequency, clustering, and urgency. Self-perceived health status was evaluated by the EQ-5D-3L questionnaire.

RESULTS: Eighty-nine percent (87/ 98) of the patients responded to the questionnaires, including 46 with and 41 without an initial temporary stoma. Patient demography was comparable between the groups. No differences regarding major, minor, and no low anterior resection syndrome categories were found between the groups. The stoma group had increased incontinence for flatus (p = 0.03) and liquid stools (p = 0.005) and worse overall low anterior resection syndrome score (p = 0.04) but no differences regarding frequency, clustering, and urgency.

LIMITATIONS: The study was limited by its sample size (n = 98) based on a previously randomized trial population (n = 234).

CONCLUSIONS: After low anterior resection for cancer, the incidence of the categories major, minor, and no low anterior resection syndrome were comparable in the stoma and the no-stoma groups. Incontinence for flatus and liquid stools was more commonly reported by patients who were randomly assigned to temporary stoma, as compared with those without, which may indicate an association between temporary stoma and impaired anorectal function.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2017
Keywords
Anorectal function, Defunctioning stoma, Low anterior resection, Low anterior resection syndrome score, Rectal cancer
National Category
Gastroenterology and Hepatology Surgery
Identifiers
urn:nbn:se:oru:diva-59306 (URN)10.1097/DCR.0000000000000818 (DOI)000405418100010 ()28682965 (PubMedID)2-s2.0-85024847647 (Scopus ID)
Available from: 2017-08-25 Created: 2017-08-25 Last updated: 2020-02-04Bibliographically approved
2. Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience
Open this publication in new window or tab >>Reversal of defunctioning stoma following rectal cancer surgery: are we getting better? A population-based single centre experience
2019 (English)In: ANZ journal of surgery, ISSN 1445-1433, E-ISSN 1445-2197, Vol. 89, no 4, p. 403-407Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR).

METHODS: All patients operated with LAR and a primary DS during a 9-year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent.

RESULTS: In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre-operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health-related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post-operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%.

CONCLUSION: One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider.

Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2019
Keywords
Defunctioning stoma, low anterior resection, rectal cancer
National Category
Cancer and Oncology Surgery
Identifiers
urn:nbn:se:oru:diva-72878 (URN)10.1111/ans.14990 (DOI)000465103800023 ()30806006 (PubMedID)2-s2.0-85062339107 (Scopus ID)
Note

Funding Agency:

Örebro County Council, Örebro, Sweden  OL-693821

Available from: 2019-03-04 Created: 2019-03-04 Last updated: 2020-02-04Bibliographically approved
3. Defunctioning stoma and oncological outcome after low anterior resection for rectal cancer: findings from a Swedish nation-wideregister-based study
Open this publication in new window or tab >>Defunctioning stoma and oncological outcome after low anterior resection for rectal cancer: findings from a Swedish nation-wideregister-based study
(English)Manuscript (preprint) (Other academic)
National Category
Surgery Cancer and Oncology
Identifiers
urn:nbn:se:oru:diva-79754 (URN)
Available from: 2020-02-04 Created: 2020-02-04 Last updated: 2020-02-04Bibliographically approved
4. What is the risk of permanent stoma beyond five years after low anterior resection for rectal cancer? A 15-year follow-up of arandomized trial
Open this publication in new window or tab >>What is the risk of permanent stoma beyond five years after low anterior resection for rectal cancer? A 15-year follow-up of arandomized trial
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Cancer and Oncology Surgery
Identifiers
urn:nbn:se:oru:diva-79755 (URN)
Available from: 2020-02-04 Created: 2020-02-04 Last updated: 2020-02-04Bibliographically approved

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