Presentation on theme: "TME: to divert or not? Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital."— Presentation transcript:
TME: to divert or not? Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital
The mesorectum in rectal cancer: the clue to pelvic recurrence Heald et al. Br J Surg 1982; 69: 613-616. Isolated tumour deposits can be found within the mesorectum up to 3-4 cm distal to the main tumour Line of transection in conventional rectal surgery
The Basingstoke experience of TME, 1978-1997 Heald et al. Arch Surg 1998; 133: 894-898. TME: the new gold standard in rectal cancer surgery 519 patients with rectal cancer with operation 405 curative resections, the local recurrence rate was 3% at 5 years and 4% at 10 years Disease-free survival in this group was 80% at 5 years and 78% at 10 years Anastomotic leak rate: 6.5% clinical and 5.5% radiological Temporary stomas were constructed in 73%
Leakage rate after TME Karanjia et al. Br J Surg 1994; 81:1224-26. Defunctioning colostomy group has significantly lower risk of major leakage (p=0.03) The overall leakage rate was the same between the two groups N=219 P=0.03
Concerns and controversies Leakage rate? Consequences of leakage? Does protective stoma prevent major complication? What are the risk factors for leakage? Which type of stoma is better? Does protective stoma affect survival? What should be the timing of stoma closure? Is stoma cost effective? How many patients will end up with permanent stoma?
Stoma or no stoma: results from RCTs 2 RCTs identified: Graffner at el. Dis Colon Rectum 1983; 26: 87-90. 50 patients included, with overall leakage rate 8% No significant difference in all parameters including leakage rate Pakkasite at el. Eur J Surg 1997; 163: 929-33. 38 patients included, with overall leakage rate 24% No significant difference in major and overall leakage rate No stoma group has significantly higher reoperatively rate for leakage Covering stoma does not reduce anastomotic leakage rate but can reduce most of the severe infective consequences of leakage
Risk factors AuthorYear Number of patients (stoma rate%) Leakage rate in stoma gp. Leakage rate in no stoma gp Risk factors for leakage Karanjia1998 N=219 (71%) 6.5%11% No stoma Sigmoid for anastomosis Rullier1998 N=272 (41%) 18%8% Male sex Level of anastomosis Obesity Law2000 176 TME (52%) 4.8%16.1% No stoma Men Marusch2002 75 hosp N=482 (30.7%) 2%6.9%No stoma Pakkastie1994 134 (7%) 11%10%Level of anastomosis
Makela at el. Dis Colon Rectum 2003;46: 653-60. Case-control study 44 patients were identified with anastomotic leakage that required surgery Risk factors Risk factors of anastomotic leakage identified: MalnutritionHypoabluminaemia Wt loss> 5 kgMedical illness Use of alcoholBowel preparation ASAContamination Level of anastomosisIncomplete donuts Blood transfusionOT time >120 mins
Type of defunctioning system Loop ileostomy (LI) Loop transverse colostomy (LTC) Caecostomy Transanal tube/ intracolonic device
Loop ileostomy vs. loop colostomy AuthorYear No. of patient LI/LTC (total) Results Khoury198632/29(61) LI functions faster Rullier2001107/60 (167) LI Stoma related morbidity and risk of re- operation lower Willaims198623/24(47) Wound infection after closure more common in TLC Edwards200134/36(70) Overall cx rate increases in TLC. Gooszen199837/39(76) Overall cx more common in LI Law200242/38(80) More IO and prolonged ileus in LI
Tube caecostomy vs. loop transverse colostomy Loop colostomyTube caecostomyP value No. of patients1930 Leakage rate16%17%>0.05 Re-operation rate0%10%>0.05 Overall hospital stay 2815<0.05 Tschmelitsch et al. Arch Surg 1999; 134: 1385-88.
Transanal tube/intracolonic device Patrascu at el. 2004 Ravo at el. 1984 (coloshield) 38 patients and 10 patients respectively No major complication reported Coloshield
Long term survival: affects by diversion stoma and early closure? P<0.01 Dukes B Meleagros et al. BJS 1995; 82: 21-25. Experimental carcinogenesis is enhanced at colorectal anastomosis Inhibited by proximal faecal diversion Promoted by the closure of a defunctioning stoma
Timing of closure AuthoryearStomaNo.complicationMortality Lewis1982Transverse colostomy 604 leak 1 IO 6 wound 1(MI) Bakx2003Loop ileostomy 271 IO 2 wound 1 line sepsis 0 Early closure is possible But how many patient can have early closure? Advantage and disadvantage? Any logistic problem in our hospital?
Techniques and complications of ileostomy closure Phang et al. Am J Surg 1999; 177, 463-6. 339 patient with LI closure 65%: enterotomy suture 20%: resection with handsewn anastomosis 15%: stapled anastomosis IO rate significantly lower in enterotomy suture group Leakage rate no significant difference between groups
Cost-effectiveness of defunctioning stomas Cost drivers: Anastomotic leak and Defunctioning stomas Leakage rate of 16.5% necessary to balance the overall cost of stoma Conclusion: should keep low stoma rate and low leakage rate for LAR : 10% stoma rate and 10% leakage rate Cost LAR no stoma Overall n=51 10391 LAR no stoma no leak 8400 LAR with stoma n= 19 13985 LAR with leakage 42250 Koperna Arch Surg 2003; 138: 1334-1338 Cost analysis study
Incidence and causes of permanent stoma after anterior resection Some patient had no stoma closed General health Age Complications Anastomotic stricture Disease factors Local Systemic recurrence Bailey et al. Colorectal disease 2003; 5: 331-334. 59 with defunctioning stoma 5/59 not closed (8%) 2 metastatic disease, 2 anastomotic stricture, 1 patient choice
Summary Clinical leakage rate? 3-17% Consequences of leakage? Re-operation 3-16% Does protective stoma prevent major complication? Yes Which type of stoma is better? Depends on surgeon preferences Is stoma cost effective? Stoma is expensive if leakage rate is low How many patients will end up with permanent stoma? ???
Selective defunctioning Some surgeons rarely performed stoma (stoma rate <10%) with reasonably low leakage rate (3-8%) (Machado 2002, Grabham 1995, Mealy 1992)