Risk Factors For Nonclosure Of A Temporary Stoma Following Anterior Resection Of Rectal Cancer

Objective: In clinic,it is found that some patients with rectal cancer can not be returned by temporary stoma after anterior rectal resection,which leads to the formation of permanent stoma.Permanent stoma will affect the quality of life of patients and bring additional pain and financial burden.It is of great significance to identify high-risk patients with permanent stoma as soon as possible.In this study,to explore the independent risk factors and prevention measures related to permanent stoma following anterior resection,which can be used as a reference for the identification and intervention of high-risk patients.Methods: A retrospective case-control study was utilized.In strict accordance with the inclusion,exclusion and rejection criteria,the clinical,surgical,pathological and follow-up data of rectal cancer patients treated in Sichuan Cancer Hospital from October 2013 to October 2018 were collected.SPSS was used for statistical description and analysis.Univariate analysis was performed first,and then statistically significant variables were included in logistic regression analysis to obtain the independent risk factors of permanent stoma.Results: A total of 223 patients were enrolled in this study.The temporary stoma includes the preventive stoma established during anterior rectal resection and the salvage stoma due to postoperative complications such as intestinal obstruction and anastomotic fistula et al.Permanent stoma refers to a temporary stoma that cannot be returned or stoma was made again for some reason after stoma was returned.87.4%(195/223)patients received stoma closure surgery successfully,while 12.6%(28/223)of them suffered permanent stoma.The median lasting time of temporary stoma was 156.5 days(112.25 to 211).Twentyeight of the stoma located in the transverse colon and 195 in the terminal ileum.Prophylactic stoma was 87.9%(196/223)and therapeutic stoma was 11.7%(28/223).The reasons for permanent stoma were anastomotic stricture(n=10,35.7%),anastomotic fistula(n=8,28.6%),local recurrence(n=5,17.8%),peritoneal metastasis(n=3,10.7%),adhesive bowel obstruction(n=1,3.6%),radiation proctitis(n=1,3.6%).About 80%(8/10)of the patients who formed permanent stoma due to rectal stenosis received radiotherapy,and 40%(4/10)had anastomotic leakage.75%(6/8)of patients with anastomotic fistula received radiotherapy,and 37.5% had complicated the rectal stenosis.The reasons for primary permanent stoma were anastomotic stricture(n=7,58.4%),anastomotic fistula(n=2,25.0%),local recurrence(n=5,17.8%),peritoneal metastasis(n=3,10.7%),adhesive bowel obstruction(n=1,3.6%),radiation proctitis(n=1,3.6%).The reasons for secondary permanent stoma anastomotic fistula(n=5,31.3%),local recurrence(n=4,25.0%),anastomotic stricture(n=3,18.8%).In univariate analysis,age,type of anastomosis,neoadjuvant chemoradiation,local recurrence,anastomotic leakage and rectal stricture were all related to permanent stoma(P<0.05).Multivariate logistic analyses showed that neoadjuvant chemoradiotherapy(OR=3.556,95%CI: 1.227-10.308,P=0.019),local recurrence(OR=16.849,95% CI: 3.130-90.698,P=0.001),anastomotic leakage(OR=6.078,95%CI: 2.090-17.674,P=0.001)and rectal stricture(OR= 8.788,95%CI:3.008-25.677,P<0.001)were independent risk factors of permanent stoma.Conclusion: In this study,12.6% patients suffered permanent stoma.The reasons for permanent stoma were anastomotic stricture,anastomotic fistula,local recurrence.Multivariate logistic analyses showed that neoadjuvant chemoradiotherapy,local recurrence,anastomotic leakage and rectal stricture were independent risk factors of permanent stoma.The rectal stenosis found in this study was tubular stenosis at the anastomotic site and the upper colorectum,accompanied by intestinal fibrosis and weakened peristalsis.After the closure of the stoma,serious intestinal obstruction is easily formed due to colorectal stenosis and weakened rectal function.The anastomotic leakage combined with long-term chronic pelvic infection and radiation intestinal injury may lead to the formation of the chronic sinus,the rectal stenosis,and even re-rupture of the anastomotic site.Neoadjuvant chemoradiotherapy can cause intestinal and peripheral tissue fibrosis,vascular reduction and stenosis at incisal margin.Neoadjuvant chemoradiotherapy increased the difficulty and time of operation,and increased postoperative complications.All the above reasons together lead to the formation of permanent stoma.Therefore,for the patients with the above risk factors,individual intervention measures should be taken to avoid the occurrence of permanent stoma.The patients with anastomotic leakage and rectal stricture should be intervened as soon as possible.Oncological safety should never be compromised.