Risk Factors For Permanent Temporary Stoma In Rectal Cancer Patients

Background:Rectal cancer is one of the most common digestive tract malignant tumors in China.Radical resection can improve the survival rate,reduce the local recurrence rate and improve the prognosis of patients.However,the occurrence of anastomotic leakage after operation still poses a great risk to the operators and the patients.In order to limit the incidence of anastomotic leakage and the consequences of anastomotic leakage,many surgeons choose to construct defunctioning stoma or salvage stoma.The initial decision of the surgeon is usually creating temporary stoma,which will be reversed after the risk period of anastomotic leakage has passed,but some patients’ temporary stomas can not be reversed as planned.Objective:Temporary stoma can limit the incidence of anastomotic leakage,mitigate the consequences of anastomotic leakage and improve prognosis of patients with anastomotic leakage.However,if the temporary stoma is not reversed within one year,it will be very likely to change into permanent stoma,which will affect the quality of life of patients and their mental health.The purpose of this study is to investigate the risk factors of turning temporary stoma into permanent stoma in rectal cancer patients undergoing anterior resection with temporary ostomy and to provide reference and basis for surgeons in clinical work.Methods:A case-control study was conducted to analyze the data of patients with rectal cancer who underwent anterior resection and temporary stoma in the Department of Gastrointestinal Surgery,China-Japan Union Hospital of Jilin University from January 2017 to August 2019.In this study,temporary stoma include defunctioning stoma(i.e.ostomy was made during operation)and salvage stoma(i.e.ostomy was made after operation due to anastomotic leakage or severe complications).A total of235 patients with rectal cancer were enrolled in the study,including 156 males and79 females.218 patients underwent defunctioning ostomy and 17 underwent salvage ostomy.There were 190 cases of ileostomy and 45 cases of transverse colostomy.The median follow-up period was 23(14-44)months.From September to October2020,telephone follow-up was conducted to investigate whether the stoma was reversed,the reasons for reversal failure,whether the tumor recurred and had metastasis.Permanent stoma was defined as that the stoma was still not reversed at the last follow-up.The risk factors of permanent stoma were analyzed by chi-square test or Fisher exact text,and the factors with P < 0.05 were included in the unconditional logistic regression analysis model for multivariate analysis.Results:A total of 235 cases were included in this study.A median follow-up time was23(14-44)months.During follow-up,6 cases had local recurrence and 12 cases had distant metastasis.Among the 235 patients with temporary stoma,143(60.9%)patients had stomas reversed.The mean time between stoma return and stoma operation time was 6.9 months,and the median interval time was 6(3-15)months.141 cases(64.7%)of defunctioning stoma patients reversed stomas,with an average interval time of 6.9(3-15)months;2 cases(11.8%)of salvage stoma patients reversed stomas with an average time of 6 months.The temporary stoma became permanent stoma in 92 cases(39.1%).Univariate analysis showed that the possible factors leading to become permanent stoma included preoperative anemia,abdominal surgery history,open surgery,salvage stoma,anastomotic leakage,Clavien-Dindo grade>2,transverse colostomy,pathological stage,postoperative chemoradiotherapy,local recurrence and distant metastasis(P < 0.05).Multivariate analysis showed that abdominal surgery history(OR= 4.614,95% CI: 1.862-11.433,P = 0.001),open surgery(OR= 62.399,95% CI: 6.888-564.188,P < 0.0001),preoperative anemia(OR = 11.293,95% CI: 2.792-45.672,P <0.0001),Postoperative pathological stage(OR = 2.017,95% CI: 1.312-3.100,P =0.001),postoperative chemoradiotherapy(OR = 5.691,95% CI: 2.227-14.546,P <0.0001),distant metastasis(OR = 46.002,95% CI: 4.187-505.359,P = 0.002)were independent risk factors of permanent stoma.Conclusion:Abdominal surgery history,open surgery,preoperative anemia,pathological stage,postoperative chemoradiotherapy,distant metastasis,temporary colostomy are risk factors for nonclosure of defunctioning stomas after low anterior resection in patients with rectal cancer.Surgeons should carefully evaluate the patient’s condition and make appropriate treatment decisions to reduce the risk of becoming permanent stoma and improve the quality of life of patients in order to avoid potential conflicts.