Abstract
Background: The use of a protective defunctioning stoma in rectal cancer surgery has been reported to reduce the rates of reoperation for anastomotic leakage, as well as mortality after surgery. However, a protective defunctioning stoma is not often used in cases other than low rectal cancer because of the need for stoma closure later, and hesitation by patients to have a stoma. We outline a novel and patient-friendly procedure with an excellent cosmetic outcome. This procedure uses the umbilical fossa for placement of a defunctioning ileostomy followed by a simple umbilicoplasty for ileostomy closure. Patients and Methods: This study included a total of 20 patients with low rectal cancer who underwent a laparoscopic low anterior resection with defunctioning ileostomy (10 cases with a conventional ileostomy in the right iliac fossa before March 2012, and 10 subsequent cases with ileostomy at the umbilicus) at the Jikei University Hospital in Tokyo from August 2011 to January 2013. The clinical characteristics of the two groups were compared: operative time, blood loss, length of hospital stay and postoperative complications of the initial surgery, as well as the stoma closure procedure. Results: There were no differences between the groups in the median operative time for initial surgery (248 min vs. 344 min), median blood loss during initial surgery (0 ml vs. 115 ml), and median hospital stay after initial surgery (13 days vs. 16 days). Complication rates after the initial surgery were similar. There were no differences between the groups in median operative time for stoma closure (99 min vs. 102 min), median blood loss during stoma closure (7.5 ml vs. 10 ml), and median hospital stay after stoma closure (8 days in both groups). Complications after stoma closure such as wound infection and intestinal obstruction were comparable. Thus, no significant differences in any factor were found between the two groups. Conclusion: The transumbilical protective defunctioning stoma is a novel solution to anastomotic leakage after laparoscopic rectal cancer surgery, with patient-friendliness as compared to conventional procedures in light of the cosmetic outcome.
Major advancements have been achieved in rectal cancer surgery over the past 20 years due to the development of devices, the introduction of laparoscopy which allows for enhanced and magnified views inside the pelvis, and improvement of automatic anastomotic devices. Anastomotic leakage, however, remains a serious complication which not only increases perioperative morbidity and mortality but also negatively affects the long-term outcome (1, 2). The rate of anastomotic leakage ranges between 3.5% and 13.7%, with an average of approximately 10% (3-16). While various measures have been advocated to reduce anastomotic leakage, such as additional suturing of anastomoses (17) and use of fibrin glue (18), most of them are not reproducible. Although the introduction of automatic anastomotic devices has enabled surgeons to perform very low anastomoses, findings indicate that the rate of anastomotic leakage did not actually decrease (19). Creating defunctioning stoma has frequently been reported to reduce the rate of reoperation due to anastomotic leakage (4-9, 20-23) and is considered effective in reducing such a complication. However, since this procedure requires for stoma care and later stoma closure, it is not widely used except for patients who require a very low anastomosis, or those with major complications. Defunctioning stoma should be used more widely in light of the reduced rate of anastomotic leakage found in patients with rectal cancer. Another reason for the low incidence of stoma placement in rectal surgery is reluctance of patients.
In this study, we advocate the transumbilical placement of a defunctioning stoma during laparoscopic low anterior resection. At the time of stoma closure, we worked with plastic surgeons to perform simple umbilicoplasty, making the entire operation a patient-friendly procedure with an excellent cosmetic outcome. We performed this novel procedure in 10 patients and compared their clinical features with those of the conventional defunctioning stoma created in the right iliac fossa.
Patients and Methods
This study included patients who underwent low anterior resection for rectal cancer at the Jikei University Hospital in Tokyo between May 2011 and January 2013. All patients underwent preoperative examinations, including colonoscopy, chest computed tomography (CT) scan, and abdominal CT or magnetic resonance imaging (MRI) scan. Patients diagnosed with stage II or stage III rectal cancer under the TNM classification in the preoperative examinations were treated with 40 Gy of preoperative radiation and evaluated again by imaging studies at one month after the radiotherapy. Curatively-treated patients who were diagnosed with node-positive disease were excluded from the study since such patients were routinely treated with lateral lymph node dissection at our Institution. Patients with a tumor lying close to the dentate line who were treated with abdominoperineal or intersphincteric resection were also excluded. After such exclusions, 20 patients treated with laparoscopic low anterior resection (LAR) and defunctioning ileostomy were studied. A total of 10 patients who were operated on in or after March 2012 were treated with a transumbilical defunctioning stoma. Another 10 patients who underwent surgery before that period were treated with a defunctioning stoma in the right iliac fossa. Postoperatively, gastrografin enema examination was routinely carried out to ascertain the integrity of anastomosis. Ileostomy closure was performed for patients requiring postoperative adjuvant chemotherapy after they had undergone six to eight months of systemic chemotherapy. The defunctioning stoma of the umbilicus group (umbilical group) and the defunctioning stoma at the right iliac fossa group (conventional group) were compared in terms of operative time, blood loss, duration of their hospital stay and postoperative complications after the initial surgery, as well as after stoma closure.
Statistical analysis. All data are expressed as the median (range). The Mann-Whitney U-test and the chi-square test were used for continuous and categorical variables, respectively. Statistical Package for Social Sciences version 20.0 (SPSS Inc., Chicago, IL, USA) was used to assess the significance of differences between the groups. A p-value of less than 0.05 was considered significant.
Results
Patient background. Table I shows patient and tumor data for the two groups. There were no significant differences in any factor between the two groups.
Initial surgery. No significant difference in the median operative time, blood loss, hospital stay, or postoperative complications was found between the two groups (Table II).
Patients' characteristics by site of defunctioning stoma.
Stoma closure. No significant difference in the median operative time, blood loss, hospital stay, or postoperative complications was found between the two groups (Table III).
Discussion
Operative procedures for colon cancer, such as LAR, that require an anastomosis at a site close to the anus are associated with higher incidence of anastomotic leakage compared with other colorectal anastomoses (24). A number of studies have reported the use of a defunctioning stoma as a means to reduce the rate of anastomotic leakage following LAR (4-9, 20-23). In a study by Tan et al. four randomized controlled trials and 21 non-randomized controlled trials were analyzed (6). According to that study, a lower clinical anastomotic leakage rate and lower reoperation rate were found in the randomized studies for the stoma group. Meta-analysis of the non-randomized studies showed lower clinical anastomotic leakage, reoperation and mortality rates in the stoma group. The same type of studies were also conducted by Hüser et al. (21), as well as Pata et al. (7), with similar results.
These studies on anastomotic leakage following LAR suggest that the use of a defunctioning stoma should be expanded based not only on surgeons' opinions but also a set of rules. Additionally, patient acceptance is another crucial factor in increasing the use of defunctioning stoma. The defunctioning stoma at the umbilicus we developed offers a major advantage in this regard.
While studies have reported on the use of umbilical incision to form a temporary stoma in children with anorectal malformations or Hirschsprung's disease (25-27), the use of umbilical fossa for ostomy in adult patients with rectal cancer is often difficult due to the large midline abdominal incision routinely placed for open colorectal procedures.
A photograph showing an ileostomy constructed at the umbilical site (A) and the same patient after reconstruction of the umbilicus following the closure of ileostomy (B).
Operative and postoperative results of the initial low anterior resection.
Laparoscopic surgery does not require a large midline incision and therefore enables construction of a stoma at the umbilical fossa. If a 4- to 7-cm incision is created at the umbilical fossa for extracting a tumor and then used for ostomy, the procedure will leave only 5-mm and 12-mm port incisions in the abdomen. This can be followed by stoma closure and simple umbilicoplasty, leaving nearly no operative scar on the abdomen (Figure 1A and B).
Traditionally, the ideal stoma site was located below the umbilicus, within the rectus muscle, away from scars, creases, bony prominences, umbilicus, or belt line, on the summit of the infraumbilical fat mound, and visible to the patient (28). Although our umbilical stoma technique does not meet many of these criteria, none of the 10 cases studied actually exhibited any major problems with stoma management, although some cases required for a slight modification in the placement of the ostomy pouch. We believe wound ostomy and continence nurses could play a very helpful role here. It is possible that the stoma was closed before any problems could arise since stoma closure was performed within one to three months after the initial surgery in many of the cases in this study. However, three out of 10 patients required adjuvant chemotherapy and lived with an umbilical stoma for about eight months. These three patients did not develop any major problems in the stoma site and completed their adjuvant chemotherapy. Although the use of the umbilical fossa for a permanent stoma may pose problems, such as parastomal hernia, since it is not a transrectus stoma, we considered that it would be acceptable as long as the stoma was temporary. If a tumor is large and requires a large incision, it will be too large for a stoma incision. In our study, however, we were able to construct a stoma without any problems even after creating an incision for extracting a tumor measuring 63 mm in diameter.
Operative and postopearative results of stomal closure.
Comparison of clinical data such as operative time and complications with a conventional stoma revealed that a transumbilical stoma was not inferior to a conventional stoma in the right iliac fossa. Instead, we found one case of abdominal incisional hernia at the stoma site in the conventional group.
While Chude et al. recommend that a defunctioning stoma be a routine procedure in LAR (23), it would be more realistic to increase the use of defunctioning stoma in patients who are at high risk for anastomotic leakage. The rate of anastomotic leakage can be significantly reduced by making defunctioning stoma a routine procedure in patients with predisposing factors for anastomotic leakage (4, 13, 14, 24), such as being male, with large tumor, anastomosis at a site close to the anus, preoperative comorbidity assessed on the basis of American Society of Anesthesiologists Score or the Charlson Comorbidity index (24), obesity, or intestinal obstruction.
One problem is that a very small number of patients cannot be treated with stoma closure after LAR due to the inability to maintain adequate anal function. It is still unknown what type of complications such patients may develop over the long run if an umbilical stoma is used as a permanent stoma. It may be necessary to consider the conventional stoma as an option in patients who cannot maintain normal anal function after LAR and who are likely to be treated with a permanent stoma. It is also necessary to take a closer look at the rate of abdominal incisional hernia after stoma closure.
While further study of a greater number of cases is still necessary, the present study suggests that the use of the umbilical site for a protective defunctioning stoma would be an acceptable alternative to the conventional ileostomy.
Conclusion
Protective defunctioning ileostomy at the umbilicus seems to be more acceptable for patients than conventional ileostomy because of better cosmetic results, which may widen the indication for constructing defunctioning ileostomy and lead to reduced incidence of anastomotic leakage after low rectal cancer surgery. Although further studies of a larger number of cases are necessary, a temporary umbilical ileostomy as a guardian for anastomosis might replace the conventional defunctioning stoma in the era of laparoscopic LAR.
Footnotes
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Author Disclosures
Drs. Ken Eto, Nobuo Omura, Koichiro Haruki, Yoshiko Uno, Masahisa Ohkuma, Shintaro Nakajima, Tadashi Anan, Makoto Kosuge, Tetsuji Fujita, Katsuhiro Ishida, and Katsuhiko Yanaga have no conflicts of interest or financial ties to disclose.
- Received September 9, 2013.
- Revision received October 11, 2013.
- Accepted October 15, 2013.
- Copyright© 2013 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
