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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 11/2015

Open Access 01-10-2015 | Colorectal Cancer

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

Authors: Heleen S. Snijders, MD, Nicoline J. van Leersum, MD, Daan Henneman, PhD, Alexander C. de Vries, MD, PhD, Rob A. E. M. Tollenaar, MD, PhD, Anne M. Stiggelbout, PhD, Michel W. J. M. Wouters, MD, PhD, Jan Willem T. Dekker, MD, PhD

Published in: Annals of Surgical Oncology | Issue 11/2015

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Abstract

Background and Purpose

Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated.

Methods

Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction.

Results

Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals’ adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals’ adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates.

Conclusions

A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.
Literature
1.
Hüser N, Michalski CW, Erkan M, et al. Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg. 2008;248:52–60.CrossRefPubMed
2.
Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246:207–14.PubMedCentralCrossRefPubMed
3.
den Dulk M, Marijnen CA, Collette L, et al. Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg. 2009;96:1066–75.CrossRef
4.
Peeters KC, Tollenaar RA, Marijnen CA, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92:211–16.CrossRefPubMed
5.
Snijders HS, Wouters MW, van Leersum NJ, et al. Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol. 2012;38:1013–19.CrossRefPubMed
6.
Koperna T. Cost-effectiveness of defunctioning stomas in low anterior resections for rectal cancer: a call for benchmarking. Arch Surg. 2003;138:1334–38.CrossRefPubMed
7.
Matthiessen P, Hallbook O, Andersson M, Rutegard J, Sjodahl R. Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis. 2004;6:462–69.CrossRefPubMed
8.
Saha AK, Tapping CR, Foley GT et al. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis. 2009;11:866–71.CrossRefPubMed
9.
Nastro P, Knowles CH, McGrath A, Heyman B, Porrett TR, Lunniss PJ. Complications of intestinal stomas. Br J Surg. 2010;97:1885–89.CrossRefPubMed
10.
den Dulk DM, Smit M, Peeters KC, et al. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol. 2007;8:297–303.CrossRef
11.
Harris DA, Egbeare D, Jones S, Benjamin H, Woodward A, Foster ME. Complications and mortality following stoma formation. Ann R Coll Surg Engl. 2005;87:427–31.PubMedCentralCrossRefPubMed
12.
Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database Syst Rev. 2004;2:CD004323.
13.
Floodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg. 2013;102:246–50.CrossRefPubMed
14.
Dikken JL, Wouters MW, Lemmens VE, et al. Influence of hospital type on outcomes after oesophageal and gastric cancer surgery. Br J Surg. 2012;99:954–63.CrossRefPubMed
15.
Elferink MA, Wouters MW, Krijnen P, et al. Disparities in quality of care for colon cancer between hospitals in the Netherlands. Eur J Surg Oncol. 2010;36(Suppl 1):S64–73.CrossRefPubMed
16.
Goossens-Laan CA, Visser O, Wouters MW, et al. Variations in treatment policies and outcome for bladder cancer in the Netherlands. Eur J Surg Oncol. 2010;36(Suppl 1):S100–07.CrossRefPubMed
17.
van Steenbergen LN, van de Poll-Franse LV, Wouters MW, et al. Variation in management of early breast cancer in the Netherlands, 2003–2006. Eur J Surg Oncol. 2010;36(Suppl 1):S36–43.CrossRefPubMed
18.
Wouters MW, Siesling S, Jansen-Landheer ML, et al. Variation in treatment and outcome in patients with non-small cell lung cancer by region, hospital type and volume in the Netherlands. Eur J Surg Oncol. 2010;36(Suppl 1):S83–92.CrossRefPubMed
19.
de Munck L, Visser O, et al. Variation between hospitals in surgical margins after first breast-conserving surgery in the Netherlands. Breast Cancer Res Treat. 2012;131:691–98.CrossRefPubMed
20.
Paul-Shaheen P, Clark JD, Williams D. Small area analysis: a review and analysis of the North American literature. J Health Polit Policy Law. 1987;12:741–809.CrossRefPubMed
21.
McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982;307:1310–14.CrossRefPubMed
22.
van der Sanden GA, Coebergh JW, Schouten LJ, Visser O, van Leeuwen FE. Cancer incidence in The Netherlands in 1989 and 1990: first results of the nationwide Netherlands cancer registry. Coordinating Committee for Regional Cancer Registries. Eur J Cancer. 1995;31A:1822–29.CrossRefPubMed
23.
Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.CrossRefPubMed
24.
Snijders HS, van den Broek CB, Wouters MW, et al. An increasing use of defunctioning stomas after low anterior resection for rectal cancer. Is this the way to go? Eur J Surg Oncol. 2013;39:715–20.CrossRefPubMed
25.
Sebag-Montefiore D, Stephens RJ, Steele R, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet. 2009;373:811–20.PubMedCentralCrossRefPubMed
26.
Chang JS, Keum KC, Kim NK, et al. Preoperative chemoradiotherapy effects on anastomotic leakage after rectal cancer resection: a propensity score matching analysis. Ann Surg. 2014;259:516–21.CrossRefPubMed
27.
Poon RT, Chu KW, Ho JW, Chan CW, Law WL, Wong J. Prospective evaluation of selective defunctioning stoma for low anterior resection with total mesorectal excision. World J Surg. 1999;23:463–67.CrossRefPubMed
28.
Eriksen MT, Wibe A, Norstein J, Haffner J, Wiig JN. Anastomotic leakage following routine mesorectal excision for rectal cancer in a national cohort of patients. Colorectal Dis. 2005;7:51–7.CrossRefPubMed
29.
Lefebure B, Tuech JJ, Bridoux V, et al. Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer. Int J Colorectal Dis. 2008;23:283–88.CrossRefPubMed
30.
Fielding LP, Stewart-Brown S, Blesovsky L, Kearney G. Anastomotic integrity after operations for large-bowel cancer: a multicentre study. Brit Med J. 1980;281(6237):411–14.
31.
Enker WE, Merchant N, Cohen AM, et al. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg. 1999;230:544–52.PubMedCentralCrossRefPubMed
32.
Dekker JW, Liefers GJ, de Mol van Otterloo JC, Putter H, Tollenaar RA. Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score. J Surg Res. 2011;166:e27–34.CrossRefPubMed
33.
Messaris E, Sehgal R, Deiling S, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55:175–80.CrossRefPubMed
34.
Chun LJ, Haigh PI, Tam MS, Abbas MA. Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure. Dis Colon Rectum. 2012;55:167–74.CrossRefPubMed
35.
Gastinger I, Marusch F, Steinert R, Wolff S, Koeckerling F, Lippert H. Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg. 2005;92:1137–42.CrossRefPubMed
36.
Pakkastie TE, Ovaska JT, Pekkala ES, Luukkonen PE, Jarvinen HJ. A randomised study of colostomies in low colorectal anastomoses. Eur J Surg. 1997;163:929–33.PubMed
37.
Snijders HS, Bakker IS, Dekker JW, et al. High 1-year complication rate after anterior resection for rectal cancer. J Gastrointest Surg. 2014;18:831–38.CrossRefPubMed
38.
Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG. Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy. Br J Surg. 1998;85:76–9.CrossRefPubMed
Metadata
Title
Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?
Authors
Heleen S. Snijders, MD
Nicoline J. van Leersum, MD
Daan Henneman, PhD
Alexander C. de Vries, MD, PhD
Rob A. E. M. Tollenaar, MD, PhD
Anne M. Stiggelbout, PhD
Michel W. J. M. Wouters, MD, PhD
Jan Willem T. Dekker, MD, PhD
Publication date
01-10-2015
Publisher
Springer US
Published in
Annals of Surgical Oncology / Issue 11/2015
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-015-4385-7

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