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High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Kirurgi.
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2017 (Engelska)Ingår i: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 19, nr 12, s. 1067-1075Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

AIM: Fashioning a defunctioning stoma is common when performing an anterior resection for rectal cancer in order to avoid and mitigate the consequences of an anastomotic leakage. We investigated the permanent stoma prevalence, factors influencing stoma outcome and complication rates following stoma reversal surgery.

METHOD: Patients who had undergone an anterior resection for rectal cancer between 2007 and 2013 in the northern healthcare region were identified using the Swedish Colorectal Cancer Registry and were followed until the end of 2014 regarding stoma outcome. Data were retrieved by a review of medical records. Multiple logistic regression was used to evaluate predefined risk factors for stoma permanence. Risk factors for non-reversal of a defunctioning stoma were also analysed, using Cox proportional-hazards regression.

RESULTS: A total of 316 patients who underwent anterior resection were included, of whom 274 (87%) were defunctioned primarily. At the end of the follow-up period 24% had a permanent stoma, and 9% of patients who underwent reversal of a stoma experienced major complications requiring a return to theatre, need for intensive care or mortality. Anastomotic leakage and tumour Stage IV were significant risk factors for stoma permanence. In this series, partial mesorectal excision correlated with a stoma-free outcome. Non-reversal was considerably more prevalent among patients with leakage and Stage IV; Stage III patients at first had a decreased reversal rate, which increased after the initial year of surgery.

CONCLUSION: Stoma permanence is common after anterior resection, while anastomotic leakage and advanced tumour stage decrease the chances of a stoma-free outcome. Stoma reversal surgery entails a significant risk of major complications.

Ort, förlag, år, upplaga, sidor
2017. Vol. 19, nr 12, s. 1067-1075
Nyckelord [en]
Defunctioning stoma, diverting stoma, faecal diversion, permanent stoma
Nationell ämneskategori
Kirurgi
Identifikatorer
URN: urn:nbn:se:umu:diva-142563DOI: 10.1111/codi.13771ISI: 000416856200006PubMedID: 28612478OAI: oai:DiVA.org:umu-142563DiVA, id: diva2:1162432
Tillgänglig från: 2017-12-04 Skapad: 2017-12-04 Senast uppdaterad: 2019-11-12Bibliografiskt granskad
Ingår i avhandling
1. Permanent stoma after anterior resection for rectal cancer: prevalence and mechanisms
Öppna denna publikation i ny flik eller fönster >>Permanent stoma after anterior resection for rectal cancer: prevalence and mechanisms
2019 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

While sphincter-saving surgery constitutes standard treatment for rectal cancer, anterior resection still harbours a significant risk of a permanent stoma in the long run. Although anastomotic leakage plays a major role in this surgical dilemma, the exact mechanisms are not known, while surveys indicate a stoma-free outcome is essential for a majority of patients. To address this issue, the overall aim of the present thesis was to investigate the permanent stoma prevalence in patients undergoing anterior resection for rectal cancer in Sweden, and to identify plausible mechanisms that impede prospects of a stoma-free outcome.

In a population-based cohort, chart review of patients who had anterior resection for rectal cancer in the Northern healthcare region in Sweden between 2007 and 2013 showed that 75 out of 316 (24%) patients ended up with a permanent stoma. Of 274 patients (87%) primarily defunctioned with a stoma, 229 underwent stoma closure, 21 (9%) of whom suffered major complications that required return to theatre or worse. A permanent stoma was shown to be more common among patients with anastomotic leakage and an advanced tumour stage.

A registry-based method to estimate nationwide stoma outcome after anterior resection for rectal cancer was developed, using data from the Swedish Colorectal Cancer Registry and the National Patient Registry. With a chart-reviewed cohort as reference, stoma outcome was assessed with a positive predictive value of 85.1%, and a negative predictive value of 100.0%. In patients operated in Sweden between 2007 and 2013, the registry-based method determined that 942 out of 4768 (19.8%) had a permanent stoma, while stoma rates varied substantially between different healthcare regions.

In a 1:1 matched case-control study of 82 patients who had curative resection for non-disseminated colorectal cancer, a subgroup analysis of 34 patients with rectal cancer displayed biomarker aberrations in serum measured preoperatively in those with anastomotic leakage. Compared to complication-free controls, 15 proteins related to inflammation were elevated, of which two (C-X-C motif chemokine 6, and C-C motif chemokine 11) remained significant after adjustment for multiple testing.

Based on a cohort of 4529 patients who had anterior resection, tumour height served as a proxy to determine the extent of mesorectal excision, while long-term stoma outcome was classified using a previously validated registry-based method. Defunctioning stomas significantly decreased chances of a stoma-free outcome, especially in patients undergoing partial mesorectal excision; for these patients, faecal diversion was also least beneficial in terms of reducing anastomotic leakage.

In conclusion, every fifth patient undergoing anterior resection for rectal cancer in Sweden eventually ends up with a permanent stoma. Although construction of a defunctioning stoma decreases the risk of symptomatic anastomotic leakage, subsequent takedown surgery carries a substantial risk of major complications, while chances of a long-term stoma-free outcome become significantly reduced. To facilitate selective use of faecal diversion, novel markers to identify high-risk anastomoses prior to surgery have been identified, but require validation in larger prospective settings. Anterior resection without a defunctioning stoma should be considered in appropriately informed patients for whom a stoma-free outcome is of importance. In particular, this holds true for patients eligible for partial mesorectal excision, where anastomotic dehiscence is less frequent and the advantageous effects of a defunctioning stoma are limited.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet, 2019. s. 79
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2059
Nyckelord
rectal cancer, anterior resection, permanent stoma, defunctioning stoma, mesorectal excision, biomarkers
Nationell ämneskategori
Kirurgi
Forskningsämne
kirurgi
Identifikatorer
urn:nbn:se:umu:diva-165134 (URN)978-91-7855-136-1 (ISBN)
Disputation
2019-12-06, Hörsal B, Unod T9, Norrlands universitetssjukhus, Umeå, 13:00 (Svenska)
Opponent
Handledare
Forskningsfinansiär
Knut och Alice Wallenbergs Stiftelse, 52103/7003487Cancerforskningsfonden i NorrlandSvenska läkaresällskapetVästerbottens läns landsting
Tillgänglig från: 2019-11-15 Skapad: 2019-11-12 Senast uppdaterad: 2019-11-14Bibliografiskt granskad

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Holmgren, KlasKverneng Hultberg, DanielHaapamäki, Markku M.Rutegård, JörgenRutegård, Martin

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