Skip to main content
Download PDF

Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study

BMC Surgery volume 23, Article number: 167 (2023) Cite this article

Abstract

Background

Anterior resection (AR) is considered the gold standard for curative cancer treatment in the middle and upper rectum. The goal of the sphincter-preserving procedure, such as AR, is vulnerable to anastomotic leak (AL) complications. Defunctioning stoma (DS) became the protective measure against AL. Often a defunctioning loop-ileostomy is used, which is associated with substantial morbidity. However, not much is known if the routine use of DS reduces the overall incidence of AL.

Methods

Elective patients subjected to AR in 2007–2009 and 2016-18 were recruited from the Swedish colorectal cancer registry (SCRCR). Patient characteristics, including DS status and occurrence of AL, were analyzed. In addition, independent risk factors for AL were investigated by multivariable regression.

Results

The statistical increase of DS from 71.6% in 2007–2009 to 76.7% in 2016–2018 did not impact the incidence of AL (9.2% and 8.2%), respectively. DLI was constructed in more than 35% of high-located tumors ≥ 11 cm from the anal verge. Multivariable analysis showed that male gender, ASA 3–4, BMI > 30 kg/m2, and neoadjuvant therapy were independent risk factors for AL.

Conclusion

Routine DS did not decrease overall AL after AR. A selective decision algorithm for DS construction is needed to protect from AL and mitigate DS morbidities.

Peer Review reports

Introduction

Anterior resection (AR) is considered the gold standard for the curative treatment of cancer in the middle and upper rectum [1]. The widespread use of total mesorectal excision (TME) and neoadjuvant therapy have improved oncological outcomes and survival [2]. Anastomotic leakage (AL) is a dreaded complication affecting 4–20% of patients undergoing AR [2, 3]. Several risk factors for AL have been described, e.g., male gender, smoking, excess alcohol, overweight, advanced ASA class, diabetes mellitus, pulmonary, renal, vascular diseases, tumor size, neoadjuvant therapy, and anastomotic height from the anal verge [3,4,5]. Meta-analysis and randomized controlled trials have shown a risk reduction of symptomatic AL after low anterior resection and the need for reoperation in patients with a defunctioning stoma (DS) [6, 7]. Following studies detected a mitigating role of DS in AL complications rather than a decline in overall AL incidence [2, 8]. DS is frequently fashioned as a defunctioning loop-ileostomy (DLI) and more seldom as a loop colostomy [6, 7]. Around 70–80% of AR patients are protected with DS in the UK and Holland, respectively [9, 10]. According to the Swedish colorectal cancer registry (SCRCR), around 600 ARs are performed annually in Sweden [11]. Since most DS are fashioned as DLI, DS will hereafter be named DLI [12, 13].

DLI becomes permanent in about 25% of the cases. The local and systemic physiological changes due to DLI can vary from minor symptoms of skin irritation and leakage (59%) to significant issues like dehydration, obstruction, and parastomal hernia (25%) [14]. One-third of DLI patients risk dehydration in the first six weeks, and half of them require admission for electrolytes correction, possibly putting adjuvant chemotherapy at stake [15]. DLI also impairs health-related quality of life [16]. Delayed DLI closure has been associated with impaired bowel function and major low anterior resection syndrome (LARS) [17, 18]. In addition, about 40% of patients encounter surgical complications, most commonly small bowel obstruction and wound sepsis, during the DLI reversal procedure [14, 19].

This study aimed to evaluate whether the frequency of AL has decreased as the usage of DLI has increased and, as a secondary outcome, investigate risk factors for AL. We hypothesized that the lack of clear indications for DLI leads to increased DLI usage without reducing AL.

Materials and methods

This study is a population-based retrospective cohort study of patients subjected to rectal cancer surgery in Sweden. The SCRCR is a nationwide registry including rectal cancer patients since 1995 in Sweden with high validity and coverage [20]. We encompassed all rectal cancer patients undergoing AR during two intervals, 2007–2009 and 2016–2018. The criteria for exclusion were age < 18-year-old, emergency surgery, microscopically non-radical resection, and unregistered DLI status. Eligible patients were divided into two groups based on the time for index surgery. We expected patients in the latter group (2016–2018) to be more exposed to DLI than the early cohort (2007–2009) since RECTODES trial results were released in August 2007. Thus, the latter group would be more protected against AL. Each group was further divided into having DLI at the index surgery or not. To be noted, the variable DLI was firstly introduced in the registry in 2007. Patients were discussed at a multidisciplinary team conference.

Definitions

Rectal cancer was defined as adenocarcinoma within ≤ 15 cm from the anal verge measured with rigid sigmoidoscopy.

According to the International Study Group of Rectal Cancer (ISREC), AL after AR for rectal cancer is defined as a communication between the two cavities (intra- and extraluminal compartments) manifested as a defect in the anastomosis (anastomotic staple or suture line), the presence of a presacral pelvic abscess or a rectovaginal fistula [21] and divided into three grades. AL was reported by different colorectal surgeons in the SCRCR; hence, the validity of the AL definition may vary. In addition, all grades of AL are represented.

DLI is an ileostomy that diverts bowel contents and protects the newly reconstructed colorectal anastomosis applied during the elective AR.

The partial mesorectal excision (PME) variable will be registered in 2022 after the study is completed and the colorectal anastomosis level is not enlisted in SCRCR. Tumor height from the anal verge is employed as a proxy for PME, with PME operations defined as tumors located 11 cm or higher from the anal verge.

Ethics

Ethical approval was obtained via the Swedish Ethical Review Authority (Diary number 2020 − 01082).

Statistical analysis

Statistical analyses were made using IBM SPSS version 26. Demographic characteristics were reported as medians with first and third interquartile range (IQR) when continuous and categorical variables as numbers and percentages. Mann-Whitney U test was applied for continuous variables, Fisher’s Exact or Chi-square tests for categorical variables. A two-sided p-value < 0.05 was considered statistically significant. Missing data were reported when exceeding 2% in a variable.

Risk factors for AL were identified using a binary logistic regression model for a univariable and multivariable analysis, including significant univariable variables and other clinically essential indicators like DLI, and index operation date .

Results

Study cohort

A total of 3948 AR procedures for rectal cancer were performed during 2007 to 2009 and 2016 to 2018. One hundred thirty-one patients were non-radically resected, 123 patients had missing data regarding resection margins, and six with unregistered DLI status were excluded resulting in 3688 included patients in the study cohort, Fig. 1.

Fig. 1
figure 1

Rectal cancer patients undergoing AR (2007-09) and (2016–2018) retrieved from SCRCR and divided into +/-DLI

SCRCR, Swedish Colorectal Cancer Registry, AR, anterior resection, DLI, defunctioning loop-ileostomy

Full size image

DLI patient characteristics and demographics are displayed in Table 1. Noteworthy, patients in the latter cohort (2016–2018) had more commonly high-located rectal tumor (≥ 11 cm from the anal verge) than the earlier cohort (37% vs. 35%; p < 0.001), and less low-located tumor (< 5 cm from the anal verge) (1.7 vs. 3.4%; p < 0.001). Additionally, less advanced tumor stage and less distant metastasis were found in the latter cohort.

Table 1 Comparison of patient characteristics with DLI after AR grouped according to the time (2007–2009) and (2016–2018)
Full size table

Compared to the former cohort, patients in the latter group comprised more patients with ASA 3–4 (19.5% vs. 14.1%; p < 0.001), BMI > 30 (17.6% vs. 12.3%; p < 0.001), and had a longer hospital stay (8 vs. 7 days; p < 0.001). Throughout the research period, the neoadjuvant therapy was either a short course of 5 × 5 Gy or radio-chemotherapy 2 × 25 Gy with radiosensitizing capecitabine, with the latter group receiving less neoadjuvant therapy (63% vs. 72%; p < 0.001). Moreover, fewer patients in the latter group were treated with adjuvant therapy (17% compared to 39%; p < 0.001). Perioperatively, the latter cohort more frequently underwent minimally invasive anterior resection and high ligation of the inferior mesenteric artery. The characteristics of the PME and TME groups are shown in Supplement Tables 1 and 2.

Defunctioning loop-ileostomy, anastomotic leakage, and risk factors

Although more than two-thirds of the patients, 71.6% (1345/1879), were diverted by DLI (2007–2009), the diversion rate increased further to 76.7% (1387/1809) (p < 0.001) in the latter group (2016–2018), shown in Table 2.

There was no significant reduction in AL incidence over 11 years despite the expansion in DLI usage (9.2% (124/1879) in 2007–2009 compared to 8.2% (114/1809) in 2016–2018) (p = 0.35). The number of reoperations for AL was unchanged (4% (58/1345) vs. 3% (46/1387), respectively). Comparisons between +/-DLI in the subgroups TME and PME are shown in supplement Tables 1 and 2. The AL rate did not differ between + DLI and -DLI; however, the non-stoma groups needed more reoperations for AL than the + DLI group. This was not significant in the TME group in the latter cohort due to few cases.

Table 2 Incidence of AL related to DLI over twelve year-period (2007–2009) and (2016–2018)
Full size table

The study cohort was divided into +/-AL, and AL risk factors were analyzed (Table 3). Patients with AL had as many DLI as patients without AL (72% compared to 74%, p = 0.36). In a univariable analysis, AL was significantly related to the male sex, ASA class, BMI, and neoadjuvant therapy.

Male gender, ASA class 3–4, BMI 30 or above, and neoadjuvant therapy remained risk factors for AL in the multivariable analysis (Table 3). DLI and surgery date, on the other hand, had no influence on the incidence of AL.

Table 3 Univariable and multivariable analysis for anastomotic leakage risk factors
Full size table

Discussion

This study demonstrated a 5% increase in DLI construction between 2007 and 2009 and 2016–2018. Surprisingly, a high number of DLI (71.6%) was registered from 2007 to 2009, although RECTODES-trial was not reported until 2007 [6]. The increased usage of DLI did not reduce AL incidence nor reoperations due to AL. More than one-third of the DLI-patients in both periods had tumors located ≥ 11 cm from the anal verge.

AL is deemed one of the most feared surgical complications after sphincter-preserving surgery. Significant efforts to preclude its occurrence are conducted by minimizing modifiable risk factors and implementing protective measures, including DS. There are inconsistent results on how DS affects AL rates despite well-conducted randomized controlled trials, prospective multicentre studies, and meta-analyses [22, 23]. The present national study indicates that too many AR patients receive a DLI without a beneficial effect on AL, suggesting that the selection process is too blunt. Similarly, a comparison of the Dutch TME-trial in 1996–1999 to the Dutch Surgical Colorectal Audit in 2010 demonstrated significantly increased defunctioning rates from 57 to 70%, albeit AL remained stable (12% vs. 11%) [9].

Additionally, a Swedish regional study found an increase in DS construction from 15% (2002–2006) to 91% (2007–2011), while AL lingered around 10% [24]. The continuing RECTODES trial may have had an impact on clinical practice in both participating and non-participating hospitals. This impact might be attributed to many assumptions, such as DLI structure providing ultimate protection for AL or more frail patients being evaluated for operational care than previously. However, surgeons’ decision-making strategies vary widely, which is a subject for future survey studies. Moreover, the increase in DLI construction would raise the question if some patients would be better off with a permanent colostomy during index surgery and whether some low-risk patients should not be defunctioned, considering comorbidities-related DLI.

The interpretation of the results from RCTs advocating the protective role of DS must consider the circumstances that entail DS construction. In the case of the RECTODEStrial, several detrimental factors were considered. More than two-thirds of AR patients were not accepted for randomization. In our opinion, the most critical exclusion criterion was anastomosis level > 7 cm above the anal verge or resection with a PME procedure. However, in Sweden, a high proportion (25%) of AR patients have high-located tumors (≥ 11 cm from the anal verge), and about 34% subjected to PME were diverted with DLI in Sweden [24, 25]. This high proportion of PME is consistent with our findings which detected a diverting rate of 35% (2007–2009) and 37% (2016–2018).

Furthermore, the most frequent exclusion factor was intraoperative technical difficulties or intraoperative adverse events, which would create a selection bias and, consequently, decrease the external validity.

Blok RD et al. suggested a shift from routine to a highly selective defunctioning ileostomy (HS-DI) after laparoscopic and transanal TME. With a diversion rate of 8% compared to 90% in a historical group, the incidence of AL at 30 days and one year was similar in both groups [26]. Recently, the protocol of the first prospective randomized trial to assess a tailored policy in DS after TME has been presented using an Anastomotic Failure Observed Risk Score (AFOR score) [27].

The short- and long-term stoma-related morbidities for a DS are not negligible. The few weeks after hospital discharge carry a high risk of readmission (17%) due to dehydration by high-output stoma [28]. Moreover, the risk for chronic kidney injury (CKD) accompanying DLI is also time-related, as the incidence of severe CKD injury is higher during the first six months [29]. Stoma reversal is another eventful step that conveys a high rate of 18–40% complications which might require reoperation in 3–8% [30, 31]. Two Swedish population-based cohort studies have investigated the permanent stoma rate, and up to 26% of AR patients would have a permanent stoma. Although AL is one of the most prominent risk factors for the permanent stoma, constructing a defunctioning stoma has no more than negligible effect on maintaining a permanent one [25, 32].

This observational study is strengthened by a large sample representing the national population of this patient group and thus enhances its generalizability and external validity. It was unbiased in selecting all consecutive patients from two periods. However, this registry-based study is limited by unavailable variables. The possibility to explore the effect of DLI on attenuating AL severity and delaying its presentation is hampered by the lack in SCRCR of details on AL presentation and management such as diagnosis date, type of treatment (conservative, antibiotics, drainage, Endoscopic vacuum therapy), details on reoperation, stoma reversal, PME definition and missing data on adjuvant therapy. Another limitation is the unavailability of neoadjuvant treatment toxicity. Neoadjuvant toxicity could be studied for its potential effect on anastomotic healing.

Conclusion

This population-based study demonstrates an inefficient DLI role in diminishing the risk of AL in routine AR use. Other preventive measures are being studied, including ghost ileostomies, HS-DI, an AL-check list, and scheduled postoperative AL surveillance, including sigmoidoscopy, labs, and rectography. Thereby, an urge for a decision algorithm regarding selective criteria for DLI is called for to spare DLI usage in this complex patient group with multiple risk factors for AL. Noteworthy, there is a significant shift from open to laparoscopic approach in TME-procedure. Therefore, new studies should explore the protective role of DLI specifically in the current surgical practice of laparoscopic and trans-anal TME procedures.

Data Availability

The data that support the findings of this study are available from SCRCR, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of SCRCR.

References

  1. Hain E, Maggiori L, Manceau G, Zappa M, Prost a la Denise J, Panis Y. Persistent asymptomatic anastomotic leakage after laparoscopic sphincter-saving surgery for rectal Cancer: can Diverting Stoma be reversed safely at 6 months? Dis Colon Rectum. 2016;59(5):369–76. https://doi.org/10.1097/DCR.0000000000000568.

    Article  PubMed  Google Scholar 

  2. Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ, Dutch Snapshot Research G. Anastomotic leakage and chronic presacral sinus formation after low anterior resection: results from a large cross-sectional study. Ann Surg. 2017;266(5):870–7. https://doi.org/10.1097/SLA.0000000000002429.

    Article  PubMed  Google Scholar 

  3. Qu H, Liu Y, Bi DS. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc. 2015;29(12):3608–17. https://doi.org/10.1007/s00464-015-4117-x.

    Article  PubMed  Google Scholar 

  4. McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg. 2015;102(5):462–79. https://doi.org/10.1002/bjs.9697.

    Article  CAS  PubMed  Google Scholar 

  5. Kong M, Chen H, Jiang Y, Xin Y, Han Y, Sheng H. Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: a retrospective case-control study. Surgery. 2021;169(4):767–73. https://doi.org/10.1016/j.surg.2020.09.038.

    Article  PubMed  Google Scholar 

  6. Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14. https://doi.org/10.1097/SLA.0b013e3180603024.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Tan WS, Tang CL, Shi L, Eu KW. Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg. 2009;96(5):462–72. https://doi.org/10.1002/bjs.6594.

    Article  CAS  PubMed  Google Scholar 

  8. Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, et al. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg. 2015;220(2):186–94. https://doi.org/10.1016/j.jamcollsurg.2014.10.017.

    Article  PubMed  Google Scholar 

  9. Snijders HS, van den Broek CB, Wouters MW, Meershoek-Klein Kranenbarg E, Wiggers T, Rutten H, et al. An increasing use of defunctioning stomas after low anterior resection for rectal cancer. Is this the way to go? Eur J Surg Oncol. 2013;39(7):715–20. https://doi.org/10.1016/j.ejso.2013.03.025.

    Article  CAS  PubMed  Google Scholar 

  10. (HQIP) HQIPL. National Bowel Cancer Audit: Annual Report. Healthcare Quality Improvement Partnership Ltd. (HQIP). ; 2017 14 December 2017.02/05/2018.

  11. Regionala Cancercentrum I, Samverkan. Regionala Cancercentrum; 2021. Contract No.: November 6 2021

  12. Holmgren K, Kverneng Hultberg D, Haapamaki MM, Matthiessen P, Rutegard J, Rutegard M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis. 2017;19(12):1067–75. https://doi.org/10.1111/codi.13771.

    Article  CAS  PubMed  Google Scholar 

  13. Floodeen H, Lindgren R, Matthiessen P. When are defunctioning stomas in rectal cancer surgery really reversed? Results from a population-based single center experience. Scand J Surg. 2013;102(4):246–50. https://doi.org/10.1177/1457496913489086.

    Article  CAS  PubMed  Google Scholar 

  14. Akesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis. 2012;27(12):1619–23. https://doi.org/10.1007/s00384-012-1490-y.

    Article  PubMed  Google Scholar 

  15. Munshi E, Bengtsson E, Blomberg K, Syk I, Buchwald P. Interventions to reduce dehydration related to defunctioning loop ileostomy after low anterior resection in rectal cancer: a prospective cohort study. ANZ J Surg. 2020;90(9):1627–31. https://doi.org/10.1111/ans.16258.

    Article  PubMed  Google Scholar 

  16. Rud CL, Baunwall SMD, Bager P, Dahlerup JF, Wilkens TL, Tottrup A, et al. Patient-reported outcomes and health-related quality of life in people living with Ileostomies: a Population-Based, cross-sectional study. Dis Colon Rectum. 2021. https://doi.org/10.1097/DCR.0000000000002100.

    Article  Google Scholar 

  17. Vogel I, Reeves N, Tanis PJ, Bemelman WA, Torkington J, Hompes R, et al. Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol. 2021;25(7):751–60. https://doi.org/10.1007/s10151-021-02436-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Gadan S, Floodeen H, Lindgren R, Matthiessen P. Does a Defunctioning Stoma impair anorectal function after low anterior resection of the rectum for Cancer? A 12-Year follow-up of a Randomized Multicenter Trial. Dis Colon Rectum. 2017;60(8):800–6. https://doi.org/10.1097/DCR.0000000000000818.

    Article  PubMed  Google Scholar 

  19. Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S. The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis. 2009;24(6):711–23. https://doi.org/10.1007/s00384-009-0660-z.

    Article  PubMed  Google Scholar 

  20. Moberger P, Skoldberg F, Birgisson H. Evaluation of the Swedish Colorectal Cancer Registry: an overview of completeness, timeliness, comparability and validity. Acta Oncol. 2018;57(12):1611–21. https://doi.org/10.1080/0284186X.2018.1529425.

    Article  PubMed  Google Scholar 

  21. Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of rectal Cancer. Surgery. 2010;147(3):339–51. https://doi.org/10.1016/j.surg.2009.10.012.

    Article  PubMed  Google Scholar 

  22. Garg PK, Goel A, Sharma S, Chishi N, Gaur MK. Protective diversion stoma in low anterior resection for rectal Cancer: a Meta-analysis of Randomized controlled trials. Visc Med. 2019;35(3):156–60. https://doi.org/10.1159/000497168.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Phan K, Oh L, Ctercteko G, Pathma-Nathan N, El Khoury T, Azam H, et al. Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials. J Gastrointest Oncol. 2019;10(2):179–87. https://doi.org/10.21037/jgo.2018.11.07.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Anderin K, Gustafsson UO, Thorell A, Nygren J. The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer. Eur J Surg Oncol. 2016;42(6):788–93. https://doi.org/10.1016/j.ejso.2016.04.001.

    Article  CAS  PubMed  Google Scholar 

  25. Rutegard M, Bostrom P, Haapamaki M, Matthiessen P, Rutegard J. Current use of diverting stoma in anterior resection for cancer: population-based cohort study of total and partial mesorectal excision. Int J Colorectal Dis. 2016;31(3):579–85. https://doi.org/10.1007/s00384-015-2465-6.

    Article  PubMed  Google Scholar 

  26. Blok RD, Westerduin RSE, Borstlap WAA, Hompes R, Bemelman WA, Tanis PJ. Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer. European Journal of Surgical Oncology. 2018;44(8):1220-5. https://doi.org/

  27. Denost QA, Phase III. Randomized Trial Evaluating the Tailored Versus the Systematic Use of Defunctioning Stoma After Total Mesorectal Excision for Rectal Cancer. [Randomized interventional clinical trial]. In press June 2022.

  28. Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, et al. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55(2):175–80. https://doi.org/10.1097/DCR.0b013e31823d0ec5.

    Article  PubMed  Google Scholar 

  29. Li L, Lau KS, Ramanathan V, Orcutt ST, Sansgiry S, Albo D, et al. Ileostomy creation in colorectal cancer surgery: risk of acute kidney injury and chronic kidney disease. J Surg Res. 2017;210:204–12. https://doi.org/10.1016/j.jss.2016.11.039.

    Article  PubMed  Google Scholar 

  30. Paik B, Kim CW, Park SJ, Lee KY, Lee SH. Postoperative outcomes of Stoma Takedown: results of long-term follow-up. Ann Coloproctol. 2018;34(5):266–70. https://doi.org/10.3393/ac.2017.12.13.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Yin TC, Tsai HL, Yang PF, Su WC, Ma CJ, Huang CW, et al. Early closure of defunctioning stoma increases complications related to stoma closure after concurrent chemoradiotherapy and low anterior resection in patients with rectal cancer. World J Surg Oncol. 2017;15(1):80. https://doi.org/10.1186/s12957-017-1149-9.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Holmgren K, Haggstrom J, Haapamaki MM, Matthiessen P, Rutegard J, Rutegard M. Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer. Colorectal Dis. 2021;23(11):2859–69. https://doi.org/10.1111/codi.15836.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Anna Åkesson statistician at Forum Söder.

Funding

This research received no specific grant from any funding agency in the public or commercial sectors.

Open access funding provided by Lund University.

Author information

Authors and Affiliations

  1. Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden

    Eihab Munshi, Marie-Louise Lydrup & Pamela Buchwald

  2. Department of Surgery, University of Jeddah, Jeddah, Saudi Arabia

    Eihab Munshi

  3. Department of Surgery, Skåne University Hospital, Malmö, Sweden

    Marie-Louise Lydrup & Pamela Buchwald

  4. Department of Surgery, Samsung Medical Center, Seoul, South Korea

    Eihab Munshi

Authors
  1. Eihab Munshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marie-Louise Lydrup
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pamela Buchwald
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

This original research is a part of doctoral studies for EM, who wrote the main manuscript with the figure and tables. The project is supervised and guided by PB (supervisor) and M-LL (Co-supervisor), who contributed to designing the project, then reviewing and editing the manuscript.

Corresponding authors

Correspondence to Eihab Munshi or Marie-Louise Lydrup.

Ethics declarations

Ethical approval and consent

The Swedish ethical review authority (Etikprövningsmyndigheten) provided the ethical approval for the study (Diary number 2020 − 01082), and it waived the informed consent owing to retrieving the data from the national registry. Additionally, the study was conducted following the relevant ethical considerations according to the Helsinki declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Munshi, E., Lydrup, ML. & Buchwald, P. Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study. BMC Surg 23, 167 (2023). https://doi.org/10.1186/s12893-023-01998-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12893-023-01998-5

Keywords

BMC Surgery

ISSN: 1471-2482

Contact us