Loop ostomy following laparoscopic low anterior resection for rectal cancer after neoadjuvant chemoradiotherapy

The development of laparoscopic technique and neoadjuvant chemoradiotherapy helps surgeons to challenge the limited capacity for anus preservation after operations for low rectal cancer. The incidence of anastomotic leakage is particularly high if the anastomosis involves the anal canal or distal rectum. Though it remains controversial, ostomy is effective in preventing abdominal contamination, septic shock, and other complications in case of anastomotic leakage [1‐4]. This would be more pronounced for patients who have finished neoadjuvant chemoradiotherapy.

Both loop ileostomy (LI) and loop transverse colostomy (LTC) could achieve absolute fecal diversion and reduce the incidence of anastomotic leakage. In the literature published in English, some favor LI, whereas others prefer LTC [5‐8]. To the best of our knowledge, no dedicated study about ostomy following laparoscopic low anterior resection for rectal cancer after neoadjuvant chemoradiotherapy has been performed. Therefore, we designed a retrospective clinical study, collected the data in our center, and compared LI and LTC in patients with the same background.

A total of 186 patients were divided into two groups: LI group with 77 patients, and LTC group with 109 patients. Males (n = 123) comprised 66.1% of the patients, and 33.9% were females (n = 63). Mean age of the 186 patients was 59.5 ± 11.8 years (range 29–85 years). Mean body mass index (BMI) was 24.0 ± 2.4 kg/m². Sex distribution, mean ages and mean BMI in both groups were similar (p > 0.05). Patients with coronary disease (n = 72) comprised 38.7%, those with diabetes (n = 51) 27.4%, those with COPD (chronic obstructive pulmonary disease) (n = 14) 7.5%, those with cerebral infarction (n = 10) 5.4%, and those with renal insufficiency (n = 8) 4.3%. Distribution among both groups is shown in Table 1.

Anastomotic leakage is a serious complication after anterior resection for rectal cancer, especially for the patients with low colorectal or coloanal anastomosis. It is associated with additional medical cost, prolonged hospital stay and an increase in mortality of patients with rectal cancer [9, 10]. Though loop stoma for fecal diversion does not abolish the risk of anastomotic leakage and could influence patients’ life tremendously [11], it could decrease the severity of complications when anastomotic leakage occurs [2, 12]. LI and LTC are two major kinds of ostomy. Many studies have been carried out in the past several decades to analyze the better technique [5, 13‐15]. Different studies led to different conclusions because both techniques have several advantages. LI is easy to manage and produces less feculent odor [5, 13]. LTC has less complication, such as intestinal obstruction and ileus [16].

The present study only admitted patients who underwent laparoscopic low anterior resection for rectal cancer after neoadjuvant chemoradiotherapy. The patients were divided into two groups according to the different ostomy techniques. Gender and age distribution, BMI, and preexisting morbidities were similar in both groups. The complication rates were analyzed independently for the fecal diversion and stoma closure periods.

During the fecal diversion period, hospital stay was similar in both groups. Time to first defecation was significantly shorter in the LI group (p = 0.006). That was also observed in a previous study [5]. Bowel movement recovered more quickly in ileum than in colon because of abundant blood supply and liquid intestinal content. Dermatitis and electrolyte disturbance occurred significantly more in the LI group (p < 0.05). Both complications might be explained by the high flow capacity of small bowel feces. If the ileostomy output remains high, more serious complications such as dehydration and renal impairment would be expected [17‐21]. Parastomal hernia was more likely to be seen in the LTC group (p = 0.014). This might be caused by the larger fascial defect and heavier intestinal contents. The frequency of herniation was a remarkable drawback of LTC, some researchers even recommended LI to avoid this [22]. Stomal prolapse had been proved to be one of the most common complications after ostomy [23]. It occurred in about 2–22% of patients in one report [24]. In the present study, prolapse was only found in four patients. This might be attributed to the good fixation and appropriate length of loops.

During the stoma closure period, days until stoma reversal, hospital stay, duration of closure operation and time to first defecation showed no significant difference between both groups (p > 0.05). Bowel imaging before reversal, short ambulation time after surgery, and reasonable diet guide were possible reasons for the similar hospital stay and time to first defecation between both groups. There was a higher incidence of wound infection in the LTC group (p = 0.001). That might be attributed to more contaminated intestinal environment of transverse colon. Besides local wound infection, the incidence of systemic infection, such as sepsis, had been proved to be significantly reduced after ileostomy [25].

Though several patients suffered from severe complications such as necrosis and anastomotic leakage, the total rate of all complications was low. This shows that both stoma placement and closure are safe procedures. Most ostomates have physical, social, and psychological problems. Some of them have to accept low quality daily life [26]. The suitable stoma style should be chosen for each patient. According to our experience, LI and LTC had both advantages and disadvantages. LI had significantly high incidence of dermatitis, and electrolyte disturbance. Whereas, LTC had higher wound infection rate, higher incidence of parastomal hernia, and longer time to first defecation.

Though the present study compared LI and LTC in patients with the same background, it was a retrospective study. Patient-volume, registration information, and inspection items could not be designed beforehand. The comparison of life quality between two groups was lack of quantifiable index. Prospective, randomized, controlled and multi-center clinical trials are required for more supporting evidence, with greater reliability and persuasion.

Both stoma placement and closure are safe procedures. For its lower wound infection rate, lower incidence of parastomal hernia, and shorter time to first defecation, LI is recommended for all patients except those with potential electrolyte disturbance and sensitive skin.