Yaghoobi Notash Aidin, Sadeghian Ehsan, Sobhanian Ehsan, Behboudi Behnam, Ahmadi Tafti Seyed Mohsen, Moghimi Zahra, Keshvari Amir, Fazeli Mohammad Sadegh, Keramati Mohammad Reza
Tehran University of Medical Sciences, Tehran, Iran.
Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Middle East J Dig Dis. 2024 Oct;16(4):225-229. doi: 10.34172/mejdd.2024.396. Epub 2024 Oct 30.
Low anterior resection (LAR) is the gold standard for curative cancer treatment in the middle and upper rectum. In radically operated patients, the local recurrence rates with total mesorectal excision (TME) after 5 and 10 years was<10%, with 80% in 5 years survival. Anastomotic leakage (AL) affects 4%-20% of patients who underwent LAR. Based on some studies, there is a risk reduction of symptomatic AL after LAR and the need for reoperation in patients with a defunctioning stoma (DS), also known as diverting stoma. Ileostomy has many complications, such as skin irritation and leakage, dehydration, obstruction, and parastomal hernia. Considering the complications of defunctioning loop-ileostomy (DLI) we designed this study to evaluate noninserting stoma in a particular group of patients.
This retrospective cohort case series study utilized data of 20 patients with rectal adenocarcinoma with lesion>7 cm from anal verge in rectoscopy who underwent LAR after 28 sessions of chemoradiotherapy (CRT) and 6 weeks of rehabilitation. All of the patients matched our criteria, so DLI was not performed on any of them.
Among our 20 patients, four AL were happened (20%). C-reactive protein (CRP) on post-operation day (POD) six was valuable. Computed tomography (CT) scan was not used as a reliable modality in our study. In all patients with positive AL, magnetic resonance imaging (MRI) was useful and reported correctly, and direct vision of the anastomosis site by rigid rectoscopy was not safe enough to make decisions about it.
The leakage rate was not far from the average leakage rate in other studies. Then it seems it is possible to forget about defunctioning loop stoma (DLS) in safe cases to reduce the stoma complications. Due to our restricted case selection and our close observation protocol, we had no significant complications compared to other studies. According to this study, not inserting stoma in suitable cases with restricted protocol selection is possible, and the leakage rate is not higher in comparison with patients with stoma.
低位前切除术（LAR）是中高位直肠癌根治性治疗的金标准。在接受根治性手术的患者中，行全直肠系膜切除术（TME）后5年和10年的局部复发率<10%，5年生存率为80%。吻合口漏（AL）影响4%-20%接受LAR的患者。基于一些研究，行LAR后有症状的AL风险降低，并且对于行去功能化造口（DS）（也称为转流造口）的患者，再次手术的必要性降低。回肠造口术有许多并发症，如皮肤刺激和渗漏、脱水、梗阻和造口旁疝。考虑到去功能化袢式回肠造口术（DLI）的并发症，我们设计了本研究以评估特定患者组中不造口的情况。
这项回顾性队列病例系列研究利用了20例直肠腺癌患者的数据，这些患者在直肠镜检查中病变距肛缘>7 cm，在接受28个疗程的放化疗（CRT）和6周康复后行LAR。所有患者均符合我们的标准，因此均未行DLI。
在我们的20例患者中，发生了4例AL（20%）。术后第6天的C反应蛋白（CRP）很有价值。在我们的研究中，计算机断层扫描（CT）扫描不作为可靠的检查方式。在所有AL阳性的患者中，磁共振成像（MRI）很有用且报告正确，而通过硬性直肠镜直接观察吻合口部位并不足够安全以据此做出决策。
渗漏率与其他研究中的平均渗漏率相差不远。那么在安全的情况下似乎可以不进行去功能化袢式造口（DLS）以减少造口并发症。由于我们的病例选择受限且观察方案严密，与其他研究相比，我们没有明显的并发症。根据本研究，在合适的病例中，按照受限的方案选择不造口是可行的，并且与有造口的患者相比，渗漏率并不更高。
