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MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
MCC 2011 - Slide 20
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  • 1. Stomata in rectal cancer surgery G.L. Beets Department of Surgery University Hospital Maastricht The Netherlands
  • 2.
    • Routine vs selective deviating stoma
    • Bowel prep
    • Ileostomy vs colostomy
    • Timing of closure
    • Technical issues
  • 3. Goal of deviating stoma
    • Decrease morbidity & mortality of anastomotic leakage
    • Decrease incidence of anastomotic failure
    • Decrease severity of anastomotic failure
  • 4. Morbidity of diverting stoma
    • Second procedure
    • Stoma related
      • Quality of life issues
      • Stoma appliance problems
      • Hernia
      • Prolaps
      • Dehydration
  • 5. Diverting stoma?
    • Cochrane review, Montedori 2010
    • 6 RCT, 648 pts, anterior resection for rectal cancer
    • Diverting stoma
      • less anastomotic leakage: 6% vs 20%
      • less urgent reoperations: 4% vs 16%
      • no significant difference mortality
  • 6. Diverting stoma?
  • 7. Does it make sense to create a diverting stoma and omit MBP?
  • 8. MBP evidence – colorectal
    • Guenaga et al. Cochrane 2009
      • 13 trials – 4776 pts
    • Slim et al. Ann Surg 2009
      • 14 trials – 4859 pts
    • No difference in
      • anastomotic leakage (4.2% - 3.4%)
      • infections: (extra)abdominal/pelvic/wound
      • extra-abd non-infectious complications
      • reoperations
      • death
  • 9. MBP evidence - rectal
    • Guenaga review: 275 ‘LAR’ (9% leak)
    • Slim review: 415 ‘rectal’ anastomoses
    • “ Numbers too low to draw any conclusion”
    • Van ‘t Sant et al. Ann Surg 2010
      • subgroup analysis POCON trial
      • 449 ‘LAR’: no difference in outcome
      • preop RT 11%, div stoma 11%, leak 7%
  • 10. Greccar III trial Brettagnol et al. Ann Surg 2010
    • French multicenter trial
    • 178 pts with rectal cancer
    • 71% preop RT, 81% div stoma, leak 11%
    • MBP: senna and povidone I enema (?)
    • Prim endpoint: 30 d postop morbidity
    • Sec endpoint: mortality, infections, hospital stay, discomfort, etc..
  • 11. Greccar III trial
  • 12. Greccar III trial
  • 13. Low rectal anastomosis:
    • Solid evidence that diversion prevents morbidity
    • Some evidence that MBP is beneficial
  • 14. Surgeons at the bar
  • 15. Surgical bar talk
    • Suture technique
      • 1 layer – 2 layer, suture material
      • end/end – side/end …. hand vs staple
    • Purse string with appendectomy
    • Nasogastric tube
    • Mechanical bowel preparation (MBP)
    • Diverting colostomy/ileostomy
  • 16.  
  • 17.
    • Guenaga et al. Cochrane 2008
      • 5 trials, 344 pts
    • Rondelli et al. Int J Colorect Dis 2009
      • 5 trials, en 7 observ comparative, 1529 pts
  • 18. Assessment
    • General outcome
      • Leak rate, hospital stay, interval, …
    • Stoma outcome
      • Hernia, stenosis, prolaps, …
    • Stoma closure
      • Time, complications, hernia, …
    • Stoma functioning
      • Skin irritation, patient QoL, ..
  • 19. General outcome
    • Wound infections
    • Anastomotic leakage
    • Reoperation rate
    • Mortality
    • No significant differences
  • 20. Stoma outcome
    • Stoma prolaps: colo 19% - ileo 2%
      • no difference in:
    • Parastomal hernia
    • Stoma retraction
    • Parastomal fistula
  • 21.  
  • 22. Stoma closure
        • No difference in:
    • Leak rate
    • Postop obstruction
    • Incisional hernia
      • colo 5/51 vs ileo 0/52 (non sign.)
  • 23. Stoma functioning
    • no difference:
    • Leaking appliance (45%!!)
    • Skin irritation
    • Ileus
  • 24. Other reports
    • More episodes SBO after ileostomy
    • More wound infections/hernia after colostomy
    • Colostomy easier to fashion/close?
    • Ileostomy more dehydration
  • 25. Review Rondelli
    • 5 RCT+7 comparative, 1529 pts
    • Ileostomy more
      • Dehydration
      • Long term SBO
    • Colostomy more
      • Stoma prolaps
      • Wound infections
  • 26. Conclusion ileostomy vs colostomy
    • Comparable
    • Each has its own
      • Advantages
      • Disadvantages
  • 27. Timing of closure
    • Textbook: 6 – 12 weeks
      • After healing of anastomosis
        • Endoscopy?
        • Contrast X-ray enema?
      • After adjuvant chemotherapy?
    • Early closure
    • Persistent sinus?
  • 28. Early closure
    • Bakx 2003 DCR.
      • feasible in 18/27 pts
    • Menegaud 2002 Eur J Surg
      • feasible in 14/36 pts
    • Krand 2008 Hepatogastroenterology
      • RCT 25 vs 25 pts: closure feasible in 22/25
  • 29. techniques
    • Aanleggen
      • Brug, fasciahechting, everterend
    • Opheffen
      • Sluiten, resectie
      • Huid open of sluiten.
  • 30.  
  • 31.  
  • 32.  
  • 33.  
  • 34.  
  • 35.  
  • 36.  
  • 37. Close the skin or not?
  • 38. Purse string
  • 39. ‘ Gun-sight’ Lim et al DCR 2010
  • 40. Conclusion
    • Diverting stoma?
      • yes
    • MBP?
      • probably yes
    • Ileostomy – colostomy?
      • take your pick
    • Timing of closure
      • traditional 6-12 weeks
  • 41.  
  • 42. Maastricht University Medical Center

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