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Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital

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1 Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital
TME: to divert or not? Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital

2 Line of transection in conventional rectal surgery
The mesorectum in rectal cancer: the clue to pelvic recurrence Heald et al. Br J Surg 1982; 69: 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

3 The Basingstoke experience of TME, 1978-1997 Heald et al
The Basingstoke experience of TME, Heald et al. Arch Surg 1998; 133: 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%

4 Leakage rate after TME Karanjia et al. Br J Surg 1994; 81:1224-26.
P=0.03 Karanjia et al. Br J Surg 1994; 81: Defunctioning colostomy group has significantly lower risk of major leakage (p=0.03) The overall leakage rate was the same between the two groups

5 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?

6 Stoma or no stoma: results from RCTs
2 RCTs identified: Graffner at el. Dis Colon Rectum 1983; 26: 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: 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

7 Risk factors Author Year Number of patients (stoma rate%)
Leakage rate in stoma gp. Leakage rate in no stoma gp Risk factors for leakage Karanjia 1998 N=219 (71%) 6.5% 11% No stoma Sigmoid for anastomosis Rullier N=272 (41%) 18% 8% Male sex Level of anastomosis Obesity Law 2000 176 TME (52%) 4.8% 16.1% Men Marusch 2002 75 hosp N=482 (30.7%) 2% 6.9% Pakkastie 1994 134 (7%) 10%

8 Risk factors Risk factors of anastomotic leakage identified:
Makela at el. Dis Colon Rectum 2003;46: Case-control study 44 patients were identified with anastomotic leakage that required surgery Risk factors of anastomotic leakage identified: Malnutrition Hypoabluminaemia Wt loss> 5 kg Medical illness Use of alcohol Bowel preparation ASA Contamination Level of anastomosis Incomplete donuts Blood transfusion OT time >120 mins

9 Type of defunctioning system
Loop ileostomy (LI) Loop transverse colostomy (LTC) Caecostomy Transanal tube/ intracolonic device

10 Loop ileostomy vs. loop colostomy
Author Year No. of patient LI/LTC (total) Results Khoury 1986 32/29(61) LI functions faster Rullier 2001 107/60 (167) LI Stoma related morbidity and risk of re-operation lower Willaims 23/24(47) Wound infection after closure more common in TLC Edwards 34/36(70) Overall cx rate increases in TLC. Gooszen 1998 37/39(76) Overall cx more common in LI Law 2002 42/38(80) More IO and prolonged ileus in LI

11 Tube caecostomy vs. loop transverse colostomy
Tschmelitsch et al. Arch Surg 1999; 134: Loop colostomy Tube caecostomy P value No. of patients 19 30 Leakage rate 16% 17% >0.05 Re-operation rate 0% 10% Overall hospital stay 28 15 <0.05

12 Transanal tube/intracolonic device
Coloshield Patrascu at el. 2004 Ravo at el (coloshield) 38 patients and 10 patients respectively No major complication reported

13 Long term survival: affects by diversion stoma and early closure?
Experimental carcinogenesis is enhanced at colorectal anastomosis Inhibited by proximal faecal diversion Promoted by the closure of a defunctioning stoma Meleagros et al. BJS 1995; 82: Dukes’ B P<0.01

14 Timing of closure Early closure is possible
But how many patient can have early closure? Advantage and disadvantage? Any logistic problem in our hospital? Author year Stoma No. complication Mortality Lewis 1982 Transverse colostomy 60 4 leak 1 IO 6 wound 1(MI) Bakx 2003 Loop ileostomy 27 2 wound 1 line sepsis

15 Techniques and complications of ileostomy closure
Phang et al. Am J Surg 1999; 177, 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

16 Cost-effectiveness of defunctioning stomas
Koperna Arch Surg 2003; 138: Cost analysis study 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

17 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: 59 with defunctioning stoma 5/59 not closed (8%) 2 metastatic disease, 2 anastomotic stricture, 1 patient choice

18 Summary 3-17% Re-operation 3-16% Yes Depends on surgeon preferences
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? ???

19 Selective defunctioning
Some surgeons rarely performed stoma (stoma rate <10%) with reasonably low leakage rate (3-8%) (Machado 2002, Grabham 1995, Mealy 1992)


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