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Colostomy Vs Tube Cecostomy for Protection of a Low Anastomosis in Rectal Cancer

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Colostomy Vs Tube Cecostomy for Protection of a Low Anastomosis in Rectal Cancer ORIGINAL ARTICLE Colostomy vs Tube Cecostomy for Protection of a Low Anastomosis in Rectal Cancer Joerg Tschmelitsch, MD; Heinz Wykypiel, MD; Rupert Prommegger, MD; Ernst Bodner, MD Background: Symptomatic anastomotic leakage is the Main Outcome Measures: Clinical anastomotic leak- most important surgical complication following rectal age rate, reoperation rate for anastomotic leaks/fistulas, resection with intestinal anastomosis. Therefore, the rou- postoperative mortality, permanent colostomy rate, and tine use of a protective stoma is suggested by several median hospital stay. authors. In our department 2 different techniques are performed to protect the anastomosis. Patients receive Results: The rate of anastomotic leaks (C/I, 16%; TC, either a loop colostomy/ileostomy (C/I) or a tube 17%), fecal peritonitis (C/I, 0%; TC, 10%), reoperation cecostomy (TC). for anastomotic leaks/fistulas (C/I, 0%; TC, 13%), per- manent colostomies (C/I, 0%; TC, 7%), and postopera- Hypothesis: No significant difference is noted be- tive mortality (C/I, 5%; TC, 0%) did not differ signifi- tween C/I and TC for protection of a low anastomosis cantly in both groups. Median hospital stay was regarding clinical anastomotic leakage rate, reoperation significantly reduced in patients with TC (C/I, 28 days; rate for anastomotic leaks/fistulas, postoperative mor- TC, 15 days). tality, and permanent colostomy rate. By avoiding a sec- ond operation (for colostomy closure), median hospital Conclusion: In our patients with low resections for rec- stay should be significantly reduced. tal cancer, a C/I for protection of the anastomosis did not improve outcome significantly as compared with a TC. Design: A retrospective review during 1985 to 1997. With a properly fashioned TC and adequate postopera- tive management a second operation (for colostomy clo- Setting: Tertiary care center sure) can be avoided and the overall hospital stay is sig- nificantly reduced. Patients: One hundred fifty-eight patients who had un- dergone anterior resections for rectal cancer were stud- ied. Protective C/Is were used in 19 patients; a TC was fashioned in 30 patients. Arch Surg. 1999;134:1385-1388 N PATIENTS with rectal cancer a neoadjuvant radiochemotherapy.8 In these radical resection is the corner- patients routine use of a protective stoma stone of treatment. Symptomatic is suggested by several authors.1,2,4,5 anastomotic leakage is the most important surgical complication See Invited Critique Ifollowing rectal resection with intestinal at end of article anastomosis. The clinical leakage rate after anterior resection varies from 1% to 19 %.1-5 Concerns about the routine use of de- The mortality rate and risk of permanent functioning colostomies are the morbid- stoma after clinical leakage are 6% to 22%,6-13 ity and mortality associated with their and 10% to 100%, respectively.8-12 closure10,14,15 and the prolonged overall Fecal diversion seems to offer pro- hospitalization and convalescence.16 tection against the complications of anas- In our department 2 different tech- tomotic dehiscence. Proponents of the niques are performed for defunctioning an defunctioning colostomy maintain that it anastomosis. Patients receive either a loop is impossible to predict which anastomo- colostomy/ileostomy (C/I) or a tube ce- From the Department of sis will leak although the probability seems costomy (TC). Surgery, University of greatest for the lowest anastomoses,2 af- The aim of this retrospective study Innsbruck, Innsbruck, Austria. ter total mesorectal excision,4 and after was to review our results after C/I as com- ARCH SURG/ VOL 134, DEC 1999 WWW.ARCHSURG.COM 1385 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 PATIENTS AND METHODS Hand-sewn anastomoses were carried out using in- terrupted 3-0 polyglactin sutures in an inverting double- layer technique. One hundred fifty-eight patients (94 men, 64 women; mean Perianastomotic drainage was routinely performed. [SD] age, 66 [11] years) had anterior resections for rectal Some patients received preoperative radiotherapy or ra- cancer performed in our department between 1985 and diochemotherapy. 1997. A C/I was used in 19 patients (group 1). A TC was fashioned in 30 patients (group 2). The technique used was C/I and TC at the surgeon’s discretion. Anastomotic protection by ei- ther technique was performed on a selective basis where The C/Is were performed in the usual technique. For a TC there was a particular concern about the anastomosis (eg, the cecum is mobilized and a double row of concentric difficulty in dissection, incomplete doughnuts, or tension purse-string sutures is placed into the lateral cecal wall. A on the anastomosis). small incision is made within the inner purse-string and a Routine contrast enema was not performed after the op- 34F or 36F Pezzer mushroom catheter (Rusch AG, Kernen eration. Anastomotic leakage was suspected if the patient had i. R., Germany) with enlarged tip openings in the bulge of fever; leukocystosis; persistent ileus; gas, pus, or fecal dis- the mushroom is then inserted into the lumen using an ob- charge from the drain; pelvic abscess; or peritonitis. In these turator. The inner purse-string suture is then tied, fol- cases a water-soluble contrast enema was performed. lowed by the outer purse string. A generous purse-string Patients and tumor characteristics, clinical anasto- suture must be made, with enough tissue invaginated around motic leak rates, reoperation rates, postoperative mortal- the TC to prevent leakage. ity, permanent colostomy rates, and median hospital stay A small stab incision is then made in the lateral were documented (Table 1 and Table 2). abdominal wall and the distal end of the catheter is drawn through. The incision site in the cecum (exit of the cath- SURGICAL PROCEDURE eter from the colon) is approximated to the inner abdomi- nal wall (where the catheter exits the abdominal wall) and Resection and Anastomosis extraperitonealized by fixing the mobilized cecal wall around the catheter to the inner abdominal wall. This can The day before the operation, bowel lavage with 3 to 4 L easily be accomplished with 3 to 4 interrupted sutures of polyethylene glycol was carried out. All patients re- (Figure). ceived perioperative antibiotic prophylaxis. A midline ab- A skin suture tied around the catheter at its exit from dominal incision was performed. The inferior mesenteric the abdominal wall is desirable. The catheter is immedi- artery was ligated at its origin either flush with the aorta ately attached to gravity drainage and allowed to stay open. or just below the ascending left colic artery. The descend- After 24 hours gentle irrigation through the catheter (to ing colon and the splenic flexure were mobilized in most keep it open) may be started. In the first 3 to 4 postopera- low anterior resections to achieve anastomosis without ten- tive days, parenteral nutrition is administered. The next 2 sion. The sigmoid colon was transected. The mesorectum to 3 days patients are given a liquid diet. and the lateral perirectal tissue were removed with the speci- On day 11 or 12, after the TC has served its purpose, men, and a distal margin of clearance of at least 1.5 cm was the tube can be withdrawn easily. Although it is not essen- always obtained. tial, an obturator may be inserted through the cutoff cath- Anastomoses were either hand sewn or stapled. eter, thereby stretching out the mushroom bulge, and thus For stapled anastomoses the double-stapling tech- lessening the discomfort of removal. Drainage of feces nique was performed. through the catheter site is minimal and usually stops en- A linear stapler was used to divide the distal rectum tirely within a few hours. The small stab incision is al- (Autosuture TA 55; US Surgical Corp, Norwalk, Conn; or lowed to heal by secondary intention. RL60; Ethicon, Somerville, NJ). A purse-string suture was placed in the proximal segment, and the anastomosis was STATISTICAL ANALYSIS completed by passing the circular stapler per anum. The end-to end anastomosis (US Surgical Corp), Premium Differences between both treatment groups were exam- curved end-to-end anastomosis (US Surgical Corp), or in- ined by means of frequency tables or medians and ranges. traluminal (Ethicon) staplers were used for circular sta- Nonparametric tests (x2 for nominal data, Mann-Whitney pling. The tissue doughnuts were carefully inspected for test for ordinal data) were used for statistical compari- completeness. sons. P,.05 was considered to be statistically significant. pared with TC for the clinical anastomotic leakage rate, ing rectal resections. Leakage rate in the nondefunc- reoperation rate for anastomotic leaks/fistulas, postop- tioned patients was 8% (9 of 109 patients). erative mortality, permanent colostomy rate, and me- In defunctioned patients clinical anastomotic leaks dian hospital stay. occurred in 3 (16%) of 19 patients in group 1 (C/I) and in 5 (17%) of 30 patients in group 2 (TC). RESULTS Patients and tumor characteristics were compa- rable in groups 1 and 2 (Table 1). The rate of clinical anastomotic leakage was 11% (17 of In all patients with clinical leaks in group 1, heal- 158 patients) in the overall population of patients hav- ing of the anastomotic leak occurred spontaneously af- ARCH SURG/ VOL 134, DEC 1999 WWW.ARCHSURG.COM 1386 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 1. Characteristics of Study Population* Table 2. Results of Group 1 and Group 2 for Anastomotic Protection in Rectal Cancer* Group 1† Group 2† (n = 19) (n = 30) Group 1 Group 2 (n = 19) (n = 30) Male/female 11/8 19/11 Mean age (SD), y 65.4 (11.2) 67.2 (12.1) Anastomotic leakage 3 (16) 5 (17) Tumor stage Fecal peritonitis 0 (0) 3 (10) T1 + T2 8 (42) 9 (30) Reoperation for anastomotic leakage/fistula 0 (0) 4 (13) T3 + T4 11 (58) 21 (70) Permanent colostomy 0 (0) 2 (7) Quality of resection Complications after colostomy closure 2 (10) .
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