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Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer – A prediction model

Published:December 22, 2022DOI:https://doi.org/10.1016/j.ejso.2022.12.008

      Abstract

      Introduction

      In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS.

      Materials and methods

      Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T0) and after resection, in patients having a stoma in situ (T1). These risk factors were used to construct a web-based prediction tool.

      Results

      Of 2099 patients included in the study (T0), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T1), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T0 and T1 population. Other predictors at T0 were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T1, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T0 and an AUC of 0.81 for T1.

      Conclusions

      PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.

      Keywords

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      References

        • Arezzo A.
        • Passera R.
        • lo Secco G.
        • et al.
        Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials.
        Gastrointest Endosc. 2017; 86: 416-426https://doi.org/10.1016/j.gie.2017.03.1542
        • Veld J.V.
        • Amelung F.J.
        • Borstlap W.A.A.
        • et al.
        Changes in management of left-sided obstructive colon cancer: national practice and guideline implementation.
        J Natl Compr Cancer Netw. 2019; 17: 1512-1520https://doi.org/10.6004/jnccn.2019.7326
        • van Ommeren
        • Olijve S.J.
        • Burbach J.P.M.
        • Furnée E.J.B.
        • et al.
        Risk factors for non-closure of an intended temporary defunctioning stoma after emergency resection of left-sided obstructive colon cancer.
        Int J Colorectal Dis. 2020; 35https://doi.org/10.1007/s00384-020-03559-1
        • Öistämö E.
        • Hjern F.
        • Blomqvist L.
        • Falkén Y.
        • Pekkari K.
        • Abraham-Nordling M.
        Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction.
        World J Surg Oncol. 2016; 14https://doi.org/10.1186/s12957-016-0994-2
        • Arezzo A.
        • Passera R.
        • lo Secco G.
        • et al.
        Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials.
        Gastrointest Endosc. 2017; 86: 416-426https://doi.org/10.1016/j.gie.2017.03.1542
        • Amelung F.J.
        • van ’t Hullenaar C.P.D.
        • Verheijen P.M.
        • Consten E.C.J.
        Dubbelloops ileostoma versus colostoma: wat verdient de voorkeur?.
        Ned Tijdschr Geneeskd. 2017; : 161
      1. Schlesinger NH, Smith H. The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study. doi:10.1007/s00384-020-03625-8/Published.

        • Gavriilidis P.
        • Azoulay D.
        • Taflampas P.
        Loop transverse colostomy versus loop ileostomy for defunctioning of colorectal anastomosis: a systematic review, updated conventional meta-analysis, and cumulative meta-analysis.
        Surg Today. 2019; 49https://doi.org/10.1007/s00595-018-1708-x
        • Kim M.J.
        • Kim Y.S.
        • Park S.C.
        • et al.
        Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy.
        Surgery. 2016; 159: 721-727https://doi.org/10.1016/j.surg.2015.09.011
        • Veld J.v.
        • Amelung F.J.
        • Borstlap W.A.A.
        • et al.
        Comparison of decompressing stoma vs stent as a bridge to surgery for left-sided obstructive colon cancer.
        JAMA Surg. 2020; 155: 206-215https://doi.org/10.1001/jamasurg.2019.5466
        • Amelung F.J.
        • Mulder C.L.J.
        • Verheijen P.M.
        • Draaisma W.A.
        • Siersema P.D.
        • Consten E.C.J.
        Acute resection versus bridge to surgery with diverting colostomy for patients with acute malignant left sided colonic obstruction: systematic review and meta-analysis.
        Surg Oncol. 2015; 24https://doi.org/10.1016/j.suronc.2015.10.003
        • Veld J.
        • Umans D.
        • van Halsema E.
        • et al.
        Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: a systematic review and meta-analysis.
        Crit Rev Oncol Hematol. 2020; 155https://doi.org/10.1016/j.critrevonc.2020.103110
        • Cirocchi R.
        • Arezzo A.
        • Sapienza P.
        • et al.
        Current status of the self-expandable metal stent as a bridge to surgery versus emergency surgery in colorectal cancer: results from an updated systematic review and meta-analysis of the literature.
        Medicina. 2021; 57https://doi.org/10.3390/medicina57030268
        • Kim S.
        • Kim M.H.
        • Oh J.H.
        • et al.
        Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function.
        Colorectal Dis. 2020; 22: 399-407https://doi.org/10.1111/codi.14898
        • Gessler B.
        • Haglind E.
        • Angenete E.
        Loop ileostomies in colorectal cancer patients-morbidity and risk factors for nonreversal.
        J Surg Res. 2012; 178: 708-714https://doi.org/10.1016/j.jss.2012.08.018
        • Mak J.C.K.
        • Foo D.C.C.
        • Wei R.
        • Law W.L.
        Sphincter-preserving surgery for low rectal cancers: incidence and risk factors for permanent stoma.
        World J Surg. 2017; 41https://doi.org/10.1007/s00268-017-4090-8
        • Jutesten H.
        • Draus J.
        • Frey J.
        • et al.
        High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer.
        Colorectal Dis. 2019; 21https://doi.org/10.1111/codi.14469
        • Borstlap W.A.A.
        • Deijen C.L.
        • den Dulk M.
        • et al.
        Benchmarking recent national practice in rectal cancer treatment with landmark randomized controlled trials.
        Colorectal Dis. 2017; 19https://doi.org/10.1111/codi.13644
        • Centers Dis Control Prev
        Prevention C for DC and defining adult overweight and obesity | overweight & obesity | CDC.
        (Published online, 1)
        https://www.cdc.gov/obesity/adult/defining.html
        Date: 2017
        Date accessed: March 23, 2021
        • Hosmer D.W.
        • Lemeshow S.
        • Sturdivant R.X.
        Applied logistic regression.
        Wiley, 2013https://doi.org/10.1002/9781118548387
        • Öistämö E.
        • Hjern F.
        • Blomqvist L.
        • Falkén Y.
        • Pekkari K.
        • Abraham-Nordling M.
        Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction.
        World J Surg Oncol. 2016; 14: 232https://doi.org/10.1186/s12957-016-0994-2
        • van Hooft J.E.
        • Bemelman W.A.
        • Oldenburg B.
        • et al.
        Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial.
        Lancet Oncol. 2011; 12: 344-352https://doi.org/10.1016/S1470-2045(11)70035-3
        • Zhou X.
        • Wang B.
        • Li F.
        • Wang J.
        • Fu W.
        Risk factors associated with nonclosure of defunctioning stomas after sphincter-preserving low anterior resection of rectal cancer: a meta-analysis.
        Dis Colon Rectum. 2017; 60 (554): 544https://doi.org/10.1097/DCR.0000000000000819
        • Li C.
        • Qin X.
        • Yang Z.
        • et al.
        A nomogram to predict the incidence of permanent stoma in elderly patients with rectal cancer.
        Ann Transl Med. 2021; 9 (342): 342https://doi.org/10.21037/atm-21-29
        • Pan H.D.
        • Peng Y.F.
        • Wang L.
        • et al.
        Risk factors for nonclosure of a temporary defunctioning ileostomy following anterior resection of rectal cancer.
        Dis Colon Rectum. 2016; 59: 94-100https://doi.org/10.1097/DCR.0000000000000520
        • Keller D.S.
        • Pedraza R.
        • Flores-Gonzalez J.R.
        • LeFave J.P.
        • Mahmood A.
        • Haas E.M.
        The current status of emergent laparoscopic colectomy: a population-based study of clinical and financial outcomes.
        Surg Endosc. 2016; 30: 3321-3326https://doi.org/10.1007/s00464-015-4605-z
        • Kryzauskas M.
        • Bausys A.
        • Degutyte A.E.
        • et al.
        Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery.
        World J Surg Oncol. 2020; 18: 205https://doi.org/10.1186/s12957-020-01968-8
        • Telem D.A.
        Risk factors for anastomotic leak following colorectal surgery.
        Arch Surg. 2010; 145: 371https://doi.org/10.1001/archsurg.2010.40
        • Venara A.
        • Hamel J.F.
        • Beyer-Berjot L.
        • et al.
        Link between postoperative ileus and anastomotic leakage: a structural equation modelling approach.
        Surg. Open Digestive Advan. 2021; 2100009https://doi.org/10.1016/j.soda.2021.100009
        • Vennix S.
        • Lips D.J.
        • di Saverio S.
        • et al.
        Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort.
        Surg Endosc. 2016; 30: 3889-3896https://doi.org/10.1007/s00464-015-4694-8
        • Boland P.A.
        • Kelly M.E.
        • Donlon N.E.
        • et al.
        Outcomes following colonic stenting for malignant left-sided bowel obstruction: a systematic review of randomised controlled trials.
        Int J Colorectal Dis. 2019; 34: 1625-1632https://doi.org/10.1007/s00384-019-03378-z
        • Tan L.
        • lin Liu Z.
        • ni Ran M.
        • et al.
        Comparison of the prognosis of four different treatment strategies for acute left malignant colonic obstruction: a systematic review and network meta-analysis.
        World J Emerg Surg. 2021; 16: 11https://doi.org/10.1186/s13017-021-00355-2
        • Veld J.v.
        • Amelung F.J.
        • Borstlap W.A.A.
        • et al.
        Decompressing stoma a s bridge to elective surgery is an effective strategy for left-sided obstructive colon cancer.
        Ann Surg. 2020; 272: 738-743https://doi.org/10.1097/SLA.0000000000004173
        • Kronborg O.
        Acute obstruction from tumour in the left colon without spread.
        Int J Colorectal Dis. 1995; 10: 1-5https://doi.org/10.1007/BF00337576
        • Wasserman M.
        • McGee M.
        Preoperative considerations for the ostomate.
        Clin Colon Rectal Surg. 2017; 30 (03): 157-161https://doi.org/10.1055/s-0037-1598155