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Permanent stoma after anterior resection for rectal cancer: prevalence and mechanisms
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
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.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 79
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2059
Keywords [en]
rectal cancer, anterior resection, permanent stoma, defunctioning stoma, mesorectal excision, biomarkers
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:umu:diva-165134ISBN: 978-91-7855-136-1 (print)OAI: oai:DiVA.org:umu-165134DiVA, id: diva2:1369420
Public defence
2019-12-06, Hörsal B, Unod T9, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Funder
Knut and Alice Wallenberg Foundation, 52103/7003487Cancerforskningsfonden i NorrlandSwedish Society of MedicineVästerbotten County CouncilAvailable from: 2019-11-15 Created: 2019-11-12 Last updated: 2019-11-14Bibliographically approved
List of papers
1. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study
Open this publication in new window or tab >>High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study
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2017 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 19, no 12, p. 1067-1075Article in journal (Refereed) 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.

Keywords
Defunctioning stoma, diverting stoma, faecal diversion, permanent stoma
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-142563 (URN)10.1111/codi.13771 (DOI)000416856200006 ()28612478 (PubMedID)
Available from: 2017-12-04 Created: 2017-12-04 Last updated: 2019-11-12Bibliographically approved
2. Anterior resection for rectal cancer in Sweden: validation of a registry-based method to determine long-term stoma outcome
Open this publication in new window or tab >>Anterior resection for rectal cancer in Sweden: validation of a registry-based method to determine long-term stoma outcome
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2018 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 57, no 12, p. 1631-1638Article in journal (Refereed) Published
Abstract [en]

Background: A permanent stoma after anterior resection for rectal cancer is common. Nationwide registries provide sufficient power to evaluate factors influencing this phenomenon, but validation is required to ensure the quality of registry-based stoma outcomes.

Methods: Patients who underwent anterior resection for rectal cancer in the Northern healthcare region of Sweden between 1 January 2007 and 31 December 2013 were reviewed by medical records and followed until 31 December 2014 with regard to stoma outcome. A registry-based method to determine nationwide long-term stoma outcomes, using data from the National Patient Registry and the Swedish Colorectal Cancer Registry, was developed and internally validated using the chart reviewed reference cohort. Accuracy was evaluated with positive and negative predictive values and Kappa values. Following validation, the stoma outcome in all patients treated with an anterior resection for rectal cancer in Sweden during the study period was estimated. Possible regional differences in determined stoma outcomes between the six Swedish healthcare regions were subsequently evaluated with the χ2 test.

Results: With 312 chart reviewed patients as reference, stoma outcome was accurately predicted through the registry-based method in 299 cases (95.8%), with a positive predictive value of 85.1% (95% CI 75.8%-91.8%), and a negative predictive value of 100.0% (95% CI 98.4%-100.0%), while the Kappa value was 0.89 (95% CI 0.82-0.95). In Sweden, 4768 patients underwent anterior resection during the study period, of which 942 (19.8%) were determined to have a permanent stoma. The stoma rate varied regionally between 17.8-29.2%, to a statistically significant degree (p = .001).

Conclusion: Using data from two national registries to determine long-term stoma outcome after anterior resection for rectal cancer proved to be reliable in comparison to chart review. Permanent stoma prevalence after such surgery remains at a significant level, while stoma outcomes vary substantially between different healthcare regions in Sweden.

Place, publisher, year, edition, pages
Taylor & Francis, 2018
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-152765 (URN)10.1080/0284186X.2018.1521988 (DOI)30306825 (PubMedID)2-s2.0-85054883319 (Scopus ID)
Available from: 2018-10-22 Created: 2018-10-22 Last updated: 2019-11-12Bibliographically approved
3. Preoperative biomarkers related to inflammation identify high-risk anastomoses in surgery for rectal cancer: an explorative study on patients with colorectal cancer
Open this publication in new window or tab >>Preoperative biomarkers related to inflammation identify high-risk anastomoses in surgery for rectal cancer: an explorative study on patients with colorectal cancer
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-165137 (URN)
Available from: 2019-11-11 Created: 2019-11-11 Last updated: 2019-11-14Bibliographically approved
4. Defunctioning stomas decrease chances of a stoma-free outcome after anterior resection for rectal cancer
Open this publication in new window or tab >>Defunctioning stomas decrease chances of a stoma-free outcome after anterior resection for rectal cancer
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-165138 (URN)
Available from: 2019-11-11 Created: 2019-11-11 Last updated: 2019-11-14Bibliographically approved

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