MCC 2011 - Slide 20

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MCC 2011 - Slide 20

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

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