With increased life expectancy, the incidence and mortality of colorectal cancer is also increasing worldwide and especially in China (1, 9, 10). Unlike in western countries, rectal cancer is more common in China, and the majority of patients have lower rectal cancer (2). Because surgical resection is the main form of treatment for rectal cancer, the choice of surgical method is particularly important. Anastomotic leakage is the most serious complication after rectal resection and is associated with increased morbidity, mortality, and prolonged hospitalization (11–13). Mirnezami and McArdle reported that anastomotic leakage can lead to an increase in local recurrence of rectal cancer, reducing the overall survival (14, 15). Rullier(8) conducted a multivariate analysis and showed that the level of anastomosis was an independent factor for development of anastomotic leakage. It is worth noting that surgeons are more inclined to perform temporary ostomy in male patients to avoid anastomotic leakage; this is consistent with Rullier's (8) and Lipska’s (16) conclusions that male sex is a risk factor of anastomotic leakage. This may be due to the combination of anatomical differences in the narrower male pelvis (16, 17) and the recently shown hormonal differences that influence the intestinal microcirculation (18). Low anterior resection with intraoperative temporary ostomy is a type of anus-preserving surgery that is used by surgeons to minimize the consequences of postoperative anastomotic dehiscence(4). Several studies(4–7) have confirmed that temporary ostomy is effective and beneficial for patients at high-risk of anastomotic leakage, such as those with previous irradiation of the pelvis, those who are hemodynamically unstable (e.g., trauma or sepsis), those undergoing chemotherapy or treatment with other biological agents that can impair wound healing, or those who have an intestinal anastomosis < 5–7 cm from the anal verge. A meta-analysis and systematic review showed that a temporary ostomy reduces the rate of clinically relevant anastomotic leakages and is thus recommended in surgery for low rectal cancers (19).
Normally, patients with a temporary ostomy reported difficulty in exercise, sleep, social activities, sexual activities, and wearing certain types of clothing. Additionally, some may suffer peristomal inflammation and dehydration resulting from high output. A systematic review (20) concluded that living with an ostomy negatively influences the overall quality of life. However, studies have identified ostomates’ two major phases: stoma-related difficulties and perceived response shift. Patients’ perception of quality of life with a temporary ostomy appears to have undergone a response shift through recalibration of their standards for measuring the quality of life and reconceptualization of what “good quality of life” is (21). In other words, patients' perceptions of the inconvenience of disease can be reshaped, in a positive direction. Florian investigated the impact of a diverting stoma on the quality of life in patients undergoing rectal cancer resection before and after stoma closure and found out that the negative impact on social functioning and GI symptoms had no clinically relevant influence on the global quality of life (22).
However, Taylor reported that some patients will experience altered bowel function after temporary ostomy reversal (23). A randomized multicenter trial showed that the severity of LAR syndrome was comparable in the ostomy and the non-ostomy groups, but incontinence for flatus and liquid stools were more commonly reported in the ostomy group(24). For the elderly(25), especially patients aged ≥ 70 years, they undergo proportionately more permanent fecal ostomy procedures than younger patients, with longer hospital stays, more postoperative complications, and higher mortality rates after undergoing the reversal operation.
In our study, we found that even with a higher proportion of neoadjuvant chemoradiotherapy and lower anastomosis, the ostomy group had a lower rate of grade C anastomotic leakage than the non-ostomy group. Cases of grade C anastomotic leakage are often fatal if operative reintervention with control of the septic source is delayed or not performed (26). Although the operation was more time-consuming, the first hospitalization expenses and postoperative recovery were similar between the two groups, which means that ostomy does not place too much extra burden on the patient or the health care system.
Orit Kaidar-Person summarized a series of complications of construction and closure of temporary loop ileostomy and reported a complication rate between 5% and 100% and incidence of non-closure rates between 0% and 19% (27). In our study, the complications associated with the stoma were mild, did not cause the patient great pain, and were completely curable with the reversal operation. Den Dulk's(28) study showed that 97% of patients chose to have a reversal operation within 1 year after prophylactic ostomy, while most of the remaining ostomy tend to be permanent. Studies have shown that postoperative metastasis(29) and local recurrence(30) of rectal cancer are risk factors for stoma to turn permanent, which was also consistent with the conclusion that advanced AJCC stage affected the rate of reversal in this study. It should be noted that anastomotic stenosis has often been neglected in the past, and its incidence has been reported as high as 30% in the previous research(31). Although endoscopic dilatation(32) is effective in the treatment of anastomotic stenosis, there are still many patients who cannot close their ostomies for this reason. Considering the high percentage of patients who can not reverse their ostomies in our study, preoperative consent for surgical patients is extremely important, especially given the possibility of the ostomy becoming permanent.
Even so, temporary stomas have a good preventive effect on grade C anastomotic leakage and they should be considered as an important means to avoid serious postoperative complications, especially in patients who cannot tolerate severe infection and have other risk factors and complications such as older age, primary underlying diseases, and immunocompromised status. To improve the quality of life of patients, reduce medical costs, and avoid permanent ostomy some studies have suggested temporary percutaneous ileostomy as a safe, efficient, and cost-effective option (11, 33). However, because this method of fecal diversion may not be sufficient, it has not yet been used on a large scale.
Our study has some limitations. First, the study is retrospective in nature and hence, biases may exist. Second, because the patients were not randomized, the surgeons decided which surgical approach was used, leading to a likely selection bias. Third, the end point of our study was the one-year follow-up after first discharge from hospital, which means that long-term survival data and complications could not be completely observed and assessed. The lack of above-mentioned data may affect the objectivity and comprehensiveness of the conclusion. Last, we did not evaluate other techniques involved in reducing anastomotic leakage and the corresponding reoperation rates. Despite these limitations, a large number of patients were included from multiple aspects in our study and relevant clinical data were complete, detailed, and reliable. Prospective randomized controlled trials and more observation time are needed to further validate our findings.