Introduction
Many patients who undergo resection for colorectal cancer, in particular those with severe comorbidities, neo-adjuvant chemoradiation, and/or low anastomosis, receive a defunctioning stoma to reduce the clinical consequences of anastomotic complications. In the emergency setting and especially in the case of malignant bowel obstruction, anastomotic healing might be impaired because of distension of the bowel [
1]. For patients with left-sided obstructive colon cancer, the various treatment modalities are available, including colonic stenting, diversion with a stoma only or “blowhole,” resection with end-colostomy, and resection with primary anastomosis with or without diverting stoma.
In the case of resection with primary anastomosis and a diverting stoma, most of the stomas created in these circumstances are intended to be temporary; however, 21–35% of these stomas will never be reversed [
2,
3]. Generally, these temporary stomas are loop ileostomies. The morbidity related to loop ileostomies can be considerable, including a high-output stoma, causing dehydration and readmission [
4]. Since end colostomies are associated with less serious complications, these stomas may be preferred in the subgroup of patients who have a high risk of non-closure.
Several studies have been published to identify risk factors associated with non-closure of stomas that were intended to be temporary in case of colorectal cancer resection. These risk factors include age, peri- or postoperative complications, comorbidity, and tumor stage [
5‐
8]. However, the majority of these studies concern data on procedures performed for rectal cancer. Less is known about risk factors for non-closure of an intended temporary stoma in the case of (emergency) resection for (left-sided) colon cancer [
9]. Moreover, many studies focus on postoperative factors as predictors for non-closure of the stoma, such as anastomotic leakage and other complications [
5], whereas few studies focus on preoperative factors, which are the only factors that are useful to estimate the preoperative risk of non-closure of an intended temporary stoma.
This study aims to identify independent preoperative predictors for non-closure of an intended temporary defunctioning stoma that was constructed following emergency resection for a left-sided obstructive colon cancer (LSOCC) with primary anastomosis, in order to aid clinical decision-making and, in addition, to assist informing patients on their individual probability that their stoma could potentially be reversed in the future or not.
Discussion
Patients with anemia, impaired renal function and/or metastatic disease at presentation had a significantly higher risk that their intended temporary defunctioning stoma was not reversed after emergency resection for LSOCC with primary anastomosis. In contrast, the type of temporary stoma, i.e., ileo- or colostomy, BMI, sex, age, or ASA-score, did not affect the rate of stoma reversal.
This study revealed a high non-closure rate of defunctioning stomas as approximately one-third of defunctioning stomas was not reversed. However, this is comparable with the percentages reported in the literature [
3]. To the best of our knowledge, this is the first study identifying risk factors of non-closure of an intended temporary stoma in case of LSOCC, and, in addition, the first study only focusing on preoperative parameters. The results of the current study can contribute to clinical decision-making in patients who undergo an emergency left-sided colon resection for obstruction. When one or even more of the identified risk factors for non-closure are present, the operating surgeon should consider creating an end-colostomy instead of a primary anastomosis with loop ileostomy, as the latter has a higher risk of high output and consequently dehydration which often leads to readmission [
4]. The preoperative presence of these risk factors can assist in counseling patients about the potential risk of non-closure of a temporary stoma and in shared decision-making with regard to the choice of stoma type. In addition, one can also consider the prevention of an emergency resection. Initial decompression might prevent postoperative mortality and non-closure of a stoma, especially in the elderly patients [
2,
15]. Such a bridging strategy can be accomplished by using a colonic stent or just a defunctioning stoma. Resection can be scheduled in an elective setting after the bowel distention has been restored.
A low hemoglobin level and impaired renal function are both expressions of a poor physical condition and/or a longer course of the disease. This might explain a four times higher risk of non-closure of a stoma in patients with one of these risk factors. Duration of symptoms prior to presentation also provides information about the length of disease. Therefore, we also expected this variable to be significantly associated with a lower stoma reversal rate. However, duration of symptoms was not identified as an independent predictor of non-closure of the stoma in the current study. The reason for this might be the unreliably reporting of this factor as a result of the retrospective design of the study. In addition, symptoms usually develop gradually and duration of symptoms is a subjective measurement obtained from patients in an acute phase of their disease. Metastatic disease at presentation was associated with a six times higher risk of non-closure of the stoma. This could at least partly be explained by a shorter survival of patients with stage IV disease. Furthermore, patients with metastatic disease often undergo systemic therapy that interferes with surgical interventions, patients might be less motivated to have their stoma reversed due to the associated risks of surgery during systemic therapy, and surgeons might be less willing to reverse the stoma in the palliative setting. In addition, one should avoid an ileostomy and consider performing a Hartmann’s procedure in the case of metastatic disease, as chemotherapy could lead to high stoma output in patients with an ileostomy.
Other factors that are normally taken into account when choosing between a defunctioning stoma and end-colostomy, such as age and ASA-score, were not identified as independent predictors of non-closure of the stoma in the current study. Therefore, it seems not justifiable to base one’s decision on these factors, despite the fact that previous studies have shown age to be a predictive factor for non-reversal of a defunctioning stoma in rectal cancer surgery [
9]. In addition, BMI was also not found to be associated with non-closure of the stoma in this study, despite our clinical impression that patients with obesity generally have a more complicated postoperative course and therefore are less likely to have their stoma reversed. This might be well explained by the relatively low number of patients with obesity in this cohort.
Previous studies reported complications from index surgery to be significantly associated with non-closure of stoma [
8,
9]. However, this is only known after the index surgery, whereas the decision of creating a stoma is taken before or during surgery. We therefore only focused on preoperative variables in the current study. Moreover, previous studies mainly focused on surgery for rectal cancer; none of these studies concerns colon cancer.
The current study has some limitations. First, the study design was retrospective, incorporating the risk of bias as well as some missing data, although the latter was limited for the included study population; for hemoglobin, 3.2% of the data was missing, for eGFR 4.5% and for CRP 7.1%. In 2.6% of patients, it was unknown whether they had metastasis at presentation or not. Although a prospective study design would be preferable, the current study design enabled us to collect a relatively large cohort of patients from a representative variety of hospitals, which is important as emergency left-sided colon resection with primary anastomosis and a defunctioning stoma is relatively rare. In addition, oncological follow-up regarding local recurrence or metachronic metastasis has not been taken into account in this analysis, whereas this might be an important factor in the (postoperative) decision whether to reverse a stoma or not. Lastly, intraoperative findings such as peritonitis, bowel perfusion, or advanced tumor stage could strengthen or weaken the model that estimates the risk of non-reversal in the current study. However, due to the retrospective design, these intraoperative data were not available for analysis in the current study.
In conclusion, hemoglobin < 7.5 mmol/L, eGFR ≤ 45 mL/min/1.73 m2, and metastatic disease at presentation were found to be independent preoperative predictors for non-closure of an intended temporary defunctioning stoma created during acute resection for left-sided obstructive colon cancer with primary anastomosis. These findings might support clinical decision-making on the type of stoma creation and might assist informing patients on their individual probability that their stoma could potentially be reversed in the future or not.
Acknowledgments
H Algera, G D Algie, CS Andeweg, FJ Amelung, TE Argillander, MNNJ Arron, K Arts, THJ Aufenacker, IS Bakker, M van Basten Batenburg, AJNM Bastiaansen, G L Beets, WA Bemelman, A van den Berg, B van de Beukel, RLGM Blom, B Blomberg, EG Boerma, FC den Boer, F ter Borg, WAA Borstlap, ND Bouvy, JE Bouwman, NDA Boye, ARM Brandt-Kerkhof, HT Bransma, A Breijer, WT van den Broek, MEE Bröker, JPM Burbach, ERJ Bruns, TA Burghgraef, ECJ Consten, RMPH Crolla, M Dam, L Daniels, JWT Dekker, A Demirkiran, KW van Dongen, SF Durmaz, A van Esch, JA van Essen, P Fockens, JW Foppen, AAW van Geloven, MF Gerhards, EA Gorter, WMU van Grevenstein, J van Groningen, IAJ de Groot-van Veen, HE Haak, JWA de Haas, P van Hagen, EE van Halsema, JTH Hamminga, K Havenga, M van Heinsbergen, B van den Hengel, E van der Harst, J Heemskerk, J Heeren, BHM Heijnen, L Heijnen, JT Heikens, M van Heinsbergen, DA Hess, N Heuchemer, C Hoff, W Hogendoorn, JE van Hooft, APJ Houdijk, N Hugen, B Inberg, TL Janssen, D Jean Pierre, WJ de Jong, ACHM Jongen, AV Kamman, JM Klaase, W Kelder, EF Kelling, R Klicks, GW De Klein, FWH Kloppenberg, JLM Konsten, LJER Koolen, V Kornmann, RTJ Kortekaas, A Kreiter, B Lamme, JF Lange, T Lettinga, D Lips, G Lo, F Logeman, YT van Loon, MF Lutke Holzik, CCM Marres, I Masselink, A Mearadji, G Meisen, AG Menon, JWS Merkus, DJLM de Mey, HCJ van der Mijle, DE Moes, CJL Molenaar, M J Nieboer, K Nielsen, GAP Nieuwenhuijzen, PA Neijenhuis, P Oomen, N van Oorschot, K Parry, KCMJ Peeters, T Paulides, I Paulusma, FB Poelmann, SW Polle, P Poortman, MH Raber, RJ Renger, BMM Reiber, R Roukema, WMJ de Ruijter, MJAM Russchen, HJT Rutten, J Scheerhoorn, S Scheurs, H Schippers, VNE Schuermans, HJ Schuijt, JC Sierink, PD Siersema, C Sietses, R Silvis, J van der Slegt, GD Slooter, M van der Sluis, P van der Sluis, N Smakman, D Smit, AB Smits, TC van Sprundel, DJA Sonneveld, C Steur, J Straatman, MC Struijs, HA Swank, AK Talsma, PJ Tanis, M Tenhagen, JAMG Tol, JL Tolenaar, L Tseng, JB Tuynman, MJF van Veen, J.V. Veld, SC Veltkamp, AWH van de Ven, L Verkoele, M Vermaas, HP Versteegh, L Verslijs, T Visser, D van Uden, WJ Vles, RJ de Vos tot Nederveen Cappel, HS de Vries, ST van Vugt, G Vugts, JA Wegdam, TJ Weijs, BJ van Wely, M Westerterp, HL van Westreenen, B Wiering, NAT Wijffels, AA Wijkmans, LH Wijngaarden, JHW de Wilt, M van de Wilt, DD Wisselink, F Wit, ES van der Zaag, DDE Zimmerman, TLR Zwols