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Defunctioning stoma in low anterior resection of the rectum for cancer: Aspects of stoma reversal, anastomotic leakage, anorectal function, and cost-effectiveness
Örebro University, School of Medical Sciences.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Rectal cancer is a common malignancy treated with surgical resection and curative intent in the majority of cases. One treatment option is low anterior resection (LAR) with preserved bowel continuity, often involving the formation of a temporary defunctioning stoma (DS).

The general aim of this thesis was to improve understanding of the role of DS in rectal cancer surgery with regard to timing of stoma reversal and development of anastomotic leakage (AL), impact on long-term anorectal function (AF), as well as aspects of cost-effectiveness.

Study I addressed the timing of stoma reversal following LAR. We found that 19% of reversed patients were reversed within 4 months of LAR, while 81% of reversals were delayed. In 58% of delayed reversals the delay was due to low priority on surgical waiting lists.

Studies II-IV were based on 234 patients randomized to receive a DS or no DS following LAR. Study II compared patients with AL following LAR diagnosed during the initial hospital stay (early leakage, EL) with patients diagnosed after hospital discharge (late leakage, LL). LL was more common in females, and originated more frequently from the transverse stapler line. EL was more common in males, and originated more frequently from the circular stapler line. Study III assessed AF 5 years after LAR with regard to whether patients initially had a DS or no DS. We found no difference in AF between the two randomized groups. When comparing with a 1-year follow-up in the same patient cohort, there were no further changes in AF over time. Study III assessed necessary healthcare resources and cost within 5 years of LAR, depending on whether patients initially had a DS or no DS. The overall cost analysis revealed a higher cost for patients randomized to DS, regardless of the cost-savings associated with a reduced frequency of anastomotic leakage.

Place, publisher, year, edition, pages
Örebro: Örebro university , 2016. , 56 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 143
Keyword [en]
rectal cancer, low anterior resection, defunctioning stoma, stoma reversal, anastomotic leakage, anorectal function, costs, resources
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-49021ISBN: 978-91-7529-139-0 (print)OAI: oai:DiVA.org:oru-49021DiVA: diva2:910029
Public defence
2016-05-27, Universitetssjukhuset, Bomanssonsalen, Södra Grev Rosengatan, Örebro, 09:15 (English)
Opponent
Supervisors
Available from: 2016-03-08 Created: 2016-03-08 Last updated: 2017-10-17Bibliographically approved
List of papers
1. When are defunctioning stomas in rectal cancer surgery really reversed?: Results from a population-based single center experience
Open this publication in new window or tab >>When are defunctioning stomas in rectal cancer surgery really reversed?: Results from a population-based single center experience
2013 (English)In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 102, no 4, 246-250 p.Article in journal (Refereed) Published
Abstract [en]

Background and Aims: This study assessed the timing of reversal of defunctioning stoma following low anterior resection of the rectum for cancer and risk factors for a defunctioning stoma becoming permanent in patients who were not reversed.

Material and Methods: Patients who underwent low anterior resection with defunctioning stoma during a 12-year period were assessed with regard to timing of stoma reversal. Delayed reversal was defined as > 4 months after low anterior resection. Patients with a defunctioning stoma that was never reversed were assessed regarding risk factors for permanent stoma.

Results: A total of 134 patients were analyzed. Of 106 stoma reversals, 19% were reversed within 4 months of low anterior resection, while 81% were reversed later than 4 months. In 58% of these patients, the delay was to due to low medical priority given to this procedure. The other main reasons for delayed stoma reversal were nonsurgical complications (20%), symptomatic anastomotic leakage following low anterior resection (12%), and postoperative adjuvant chemotherapy (10%). Of all patients, 21% (28/134) ended up with a permanent stoma. Risk factors for a defunctioning stoma becoming permanent were stage IV cancer (P < 0.001) and symptomatic anastomotic leakage following low anterior resection (P < 0.001).

Conclusion: Four in five patients experienced a delayed stoma reversal, in a majority because of the low priority given to this surgical procedure.

Place, publisher, year, edition, pages
Sage Publications, 2013
Keyword
Rectal cancer, low anterior resection of the rectum, defunctioning stoma, temporary stoma, stoma reversal, permanent stoma, risk factors
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-50041 (URN)10.1177/1457496913489086 (DOI)000335584100006 ()24056133 (PubMedID)2-s2.0-84902682473 (Scopus ID)
Available from: 2016-04-29 Created: 2016-04-29 Last updated: 2017-11-30Bibliographically approved
2. Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities?
Open this publication in new window or tab >>Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities?
Show others...
2013 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 15, no 3, 334-340 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim of the study was to compare patients with symptomatic anastomotic leakage following low anterior resection of the rectum (LAR) for cancer diagnosed during the initial hospital stay with those in whom leakage was diagnosed after hospital discharge.

Method: Forty-five patients undergoing LAR (n=234) entered into a randomized multicentre trial (NCT 00636948), who developed symptomatic anastomotic leakage, were identified. A comparison was made between patients diagnosed during the initial hospital stay on median postoperative day 8 (early leakage, EL; n=27) and patients diagnosed after hospital discharge at median postoperative day 22 (late leakage, LL; n=18). Patient characteristics, operative details, postoperative course and anatomical localization of the leakage were analysed.

Results: Leakage from the circular stapler line of an end-to-end anastomosis was more common in EL, while leakage from the stapler line of the efferent limb of the J-pouch or side-to-end anastomosis tended to be more frequent in LL (P=0.057). Intra-operative blood loss (P=0.006) and operation time (P=0.071) were increased in EL compared with LL. On postoperative day 5, EL performed worse than LL with regard to temperature (P=0.021), oral intake (P=0.006) and recovery of bowel activity (P=0.054). Anastomotic leakage was diagnosed most often by a rectal contrast study in EL and by CT scan in LL. The median initial hospital stay was 28days for EL and 10days for LL (P<0.001).

Conclusion: The present study has demonstrated that symptomatic anastomotic leakage can present before and after hospital discharge and raises the question of whether early and late leakage after LAR may be different entities.

Keyword
Symptomatic anastomotic leakage, early leakage, late leakage, low anterior resection of the rectum, postoperative course, hospital stay
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-50042 (URN)10.1111/j.1463-1318.2012.03195.x (DOI)000315519300022 ()22889325 (PubMedID)2-s2.0-84874375872 (Scopus ID)
Available from: 2016-04-29 Created: 2016-04-29 Last updated: 2017-11-30Bibliographically approved
3. Evaluation of Long-term Anorectal Function After Low Anterior Resection: A 5-Year Follow-up of a Randomized Multicenter Trial
Open this publication in new window or tab >>Evaluation of Long-term Anorectal Function After Low Anterior Resection: A 5-Year Follow-up of a Randomized Multicenter Trial
2014 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 57, no 10, 1162-1168 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Anorectal function after rectal surgery with low anastomosis is often impaired. Outcome of long-term anorectal function is poorly understood but may improve over time.

OBJECTIVE: We evaluated anorectal function 5 years after low anterior resection for cancer with regard to whether patients had a temporary stoma at initial resection. The objective of this study was to assess changes in anorectal function over time by comparing the results with anorectal function 1 year after rectal resection.

DESIGN: This study was a secondary end point of a randomized, multicenter controlled trial.

SETTINGS: The study was conducted at 21 Swedish hospitals performing rectal cancer surgery from 1999 to 2005.

PATIENTS: Patients included were those operated on with low anterior resection.

INTERVENTIONS: Patients were randomly assigned to receive or not receive a defunctioning stoma.

MAIN OUTCOME MEASURES: We evaluated anorectal function in patients who were initially randomly assigned to the defunctioning stoma or no stoma group, who had been free of stoma for 5 years, by means of using a standardized patient questionnaire. Questions addressed stool frequency, urgency, fragmentation of bowel movements, evacuation difficulties, incontinence, lifestyle alterations, and patient preference regarding permanent stoma formation. Results were compared with the same patient cohort at 1-year follow-up.

RESULTS: A total of 123 patients answered the bowel function questionnaire (65 in the no-stoma group and 58 in the stoma group). No differences were found between groups regarding the number of passed stools, need for medication to open the bowel, evacuation difficulties, incontinence, and urgency. General well-being was significantly better in the no-stoma group (p = 0.033). Comparison with anorectal function at 1 year showed no further changes over time.

LIMITATIONS: The study was based on a limited sample size (n = 123) and formed a secondary end point of a randomized trial.

CONCLUSIONS: Anorectal function was impaired for many patients, but the temporary presence of a defunctioning stoma after rectal resection did not affect long-term outcome. Anorectal function did not change between 1-year and 5-year follow-up.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2014
Keyword
Anorectal function, Defunctioning stoma, Long-term follow-up, Rectal cancer
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:oru:diva-37865 (URN)10.1097/DCR.0000000000000197 (DOI)000341970500002 ()25203371 (PubMedID)2-s2.0-84908303580 (Scopus ID)
Note

Funding Agency:

Örebro County Council (Örebro, Sweden)

Available from: 2014-10-22 Created: 2014-10-20 Last updated: 2017-12-05Bibliographically approved
4. Costs and Resource Use following Defunctioning Stoma in Low Anterior Resection: A long-term analysis of a randomized multicenter trial
Open this publication in new window or tab >>Costs and Resource Use following Defunctioning Stoma in Low Anterior Resection: A long-term analysis of a randomized multicenter trial
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-50045 (URN)
Available from: 2016-05-02 Created: 2016-04-29 Last updated: 2017-10-17Bibliographically approved

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