Defunctioning Stoma and Anastomotic Leak Rate after Total Mesorectal Excision with Coloanal Anastomosis in the Context of PROCARE
K. Beirens, F. Penninckx, on behalf of PROCARE*
*The PROCARE steering group consists of delegates from all Belgian scientific organisations involved in the treatment of rectum cancer, i.e. the Belgian Section of Colorectal Surgery, a section of the Royal Belgian Society of Surgery (Bertrand C., De Coninck D., Duinslaeger M., Kartheuser A., Penninckx F., Van de Stadt J., Vaneerdeweg W.), the Belgian Society of Surgical Oncology (Claeys D.), the Belgian Group for Endoscopic Surgery (Burnon D.), the Belgian Society of Radiotherapy – Oncology (Haustermans K., Scalliet P., Spaas Ph.), the Belgian Society of Pathology and the Digestive Pathology Club (Demetter P., Jouret-Mourin A., Sempoux C.), the Belgian Society of Medical Oncology (Demey W, Humblet Y., Van Cutsem E.), the Belgian Group for Digestive Oncology (Laurent S., Van Cutsem E., Van Laethem J. L.), the Royal Belgian Society of Radiology (Danse E., Op de Beeck B., Smeets P), the Société Royale Belge de Gastro-entérologie (Melange M., Rahier J.), the Vlaamse Vereniging voor Gastro-enterologie (Cabooter M., Pattyn P., Peeters M.), the Belgian Society of Gastro-intestinal Endoscopy (Buset M.). Are also represented : the Belgian Professional Surgical Association (Haeck L., Mansvelt B.), the Foundation Belgian Cancer Registry (Van Eycken E.) and the RIZIV/INAMI (Dercq J.-P., Thijs A.). Penninckx F. chairs the PROCARE Steering Group. Beirens K. is a
senior researcher at the Belgian Cancer Registry.
Abstract. Background : Anastomotic leakage (AL) after total mesorectal excision is a major adverse event. Construction of a defunctioning stoma (DS) reduces the morbidity of AL. This study aims to illustrate the AL rate and its related morbidity with and without primary stoma formation in the context of a Belgian project, PROCARE.
Methods : Between January 2006 and March 2011, 1912 patients who underwent elective TME with colo-anal anastomosis for invasive rectal adenocarcinoma up to 15 cm above the anal verge were registered. A primary DS was constructed in 1183 patients (62%). Early clinical AL rate, AL-related re-operation rate, length of stay (LoS), inhospital mortality were analysed.
Results : In patients without leak, mortality was 1.1% and the mean LoS was 14.7 days. AL occurred in 6.5%, varying from 0%-25% between participating centres. In patients with AL, mortality was 4.8% (p < 0.001). In the presence of a primary DS, AL rate was 4.3%, requiring re-operation under narcosis in 78% with no mortality, resulting in a mean LoS of 30.4 days. In the absence of a primary DS, AL rate was 10.2%, requiring re-operation under narcosis in 93% with a mortality of 8.1% and a mean LoS of 33.4 days. Analysis per centre showed a weak relation between percentage of DS construction and AL rate.
Conclusion : Construction of a primary DS significantly reduced the incidence of early AL, re-operation rate, and mortality. Although technical aspects of colo-anal anastomosis are of paramount importance, construction of a DS at primary surgery has to be considered by those teams with high early AL rate and/or high AL related mortality.
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