Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France.
Biometrics Unit, Montpellier Cancer Institute, Montpellier, France.
Ann Surg Oncol. 2022 Apr;29(4):2514-2524. doi: 10.1245/s10434-021-11197-2. Epub 2022 Jan 7.
Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA).
In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded.
Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p = 0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p = 0.064), disease-free survival was 67.0% and 55.8%, respectively (p = 0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p = 0.084). The long-term, stoma-free rate was 89.1% overall.
Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.
预防性造口术（DS）可以降低吻合口相关并发症（AL）的发生率。自 2010 年以来，我们对低位直肠结肠吻合术（LCRA）采用了个体化、高度选择性的 DS 管理。
共 433 例直肠癌患者接受了相同的标准化手术。非造口术（NS）管理用于无手术困难、结肠准备良好且吻合质量良好的患者。在所有其他情况下，都使用 DS。术后随访期间测量 C 反应蛋白。根据性别、年龄、体重指数、肿瘤位置和美国麻醉医师协会评分，采用倾向评分匹配调整初始人群的不平衡。记录术后 30 天内 AL 的发生率、5 年总生存率、局部无复发生存率和无病生存率。
吻合术主要为超低位，腹腔镜或机器人手术均可完成。AL 的总体发生率为 13.4%，两组之间无显著差异（DS 组 12.2%，NS 组 14.6%；p=0.575）。NS 组的手术时间、出血量和住院时间明显较低。总的二次造口率为 11.4%。病理结果相似，R0 切除率为 98%。NS 组和 DS 组的中位随访时间分别为 5.5 年，总生存率分别为 84.9%和 73.4%（p=0.064），无病生存率分别为 67.0%和 55.8%（p=0.095），局部无复发生存率分别为 95.2%和 88.7%（p=0.084）。总的长期无造口率为 89.1%。
对 LCRA 进行个体化 DS 似乎是安全的，并且可以在术后发病率方面提供潜在的益处，同时 NS 患者的长期肿瘤学结果相同。应开展前瞻性、多中心研究来验证这种方法。
