DOI 10.1007/s00384-009-0662-x
REVIEW
Abstract
Background Sphincter-saving surgery for the treatment of
middle and low rectal cancer has spread considerably when
total mesorectal excision became standard treatment. In
order to reduce leakage-related complications, surgeons
often perform a derivative stoma, a loop ileostomy (LI), or
a loop colostomy (LC), but to date, there is no evidence on
which is the better technique to adopt.
Methods We performed a systematic review and metaanalysis of all randomized controlled trials until 2007 and
observational studies comparing temporary LI and LC for
temporary decompression of colorectal and/or coloanal
anastomoses.
Clinically relevant events were grouped into four study
outcomes:
480
Introduction
Search strategies
A systematic review of the literature was performed using
the following databases: MEDLINE, the Cochrane database
of systematic reviews, and the Cochrane controlled trials
register. Also, a manual search was done on important
relevant literature. The following terms were used for the
search: loop ileostomy, loop colostomy, colorectal anastomosis, coloanal anastomosis. The following restrictions
were used: age >19 and study in humans.
Reference lists of available reviews and selected studies
were cross-searched for additional literature. The authors
also searched independently on the internet and in libraries
for published and unpublished abstracts. Moreover, experts
in the field of colorectal surgery were consulted.
Inclusion and exclusion criteria
All published and unpublished studies comparing LI and
LC were considered for analysis as well as cohort studies
including only patients undergoing a specific derivative
procedure; either LI or LC was excluded from the
analysis.
Study outcomes
The following outcomes were considered for the analysis:
wound infection (during open stoma), dehydratation,
necrosis, prolapse, retraction, parastomal hernia, stenosis,
sepsis, hemorrhage, occlusion, wound infection (post-stoma
closure), anastomotic leak or fistula, hernia (post-stoma
closure), skin irritation, and bowel occlusion.
To obtain results which could be compared from present
literature and to assess a higher number of events, the study
outcomes were grouped into four categories, as was done in
the Guenaga study [9].
AGENERAL OUTCOME MEASURES: wound infection and dehydratation.
BCONSTRUCTION OF THE STOMA OUTCOME
MEASURES: necrosis, prolapse, retraction, parastomal
hernia, stenosis, sepsis, and hemorrhage.
CCLOSURE OF THE STOMA OUTCOME MEASURES: occlusion, wound infection, anastomotic leak or
fistula, and hernia.
DFUNCTIONING OF THE STOMA OUTCOME
MEASURES: skin irritation and occlusion.
The rates of tardive bowel occlusion and late reintervention were not examined, since data pertaining to these
were not present in the studied literature.
481
Data collection
Two reviewers independently extracted the following from
each study: first author, year of publication, study population characteristics (urgent or elective surgery), study
design, inclusion and exclusion criteria, matching criteria,
number of patients operated on with each technique,
duration of follow-up, mean age, male-to-female ratio, and
stoma closure rates.
Only published data were considered for analysis.
Statistical analysis
The meta-analysis was performed according to the recommendations of the Cochrane Collaboration and the Quality
of Reporting of Meta-analyses guidelines [11, 12]. Statistical analysis of dichotomous outcomes was performed
using odds ratios (OR) as the summary statistic and was
reported with 95% confidence intervals (CI). Odds ratios
for the outcomes of interest were combined using Der
Simoman and Laird. Haldane correction was applied when
studies contained a zero in one cell for the number of events
of interest in either of the two groups.
Study quality was assessed using the Star Rating Scale
[13], modified according to Tilney criteria. Pre-planned
subgroup analyses included study design (RCT vs. nonRCT) and clinical setting (elective vs. urgent).
Heterogeneity was assessed by two methods: graphical
exploration with funnel plots to evaluate publication bias
[14, 15] and Cochrans chi-square test with I-squared test
for heterogeneity to assess between-studies heterogeneity.
Statistically significant heterogeneity was considered to be
present when p<0.10 and I squared>50% [16].
Analysis was conducted using the statistical Review
Manager Version 4.2 (The Cochrane Collaboration, Software Update, Oxford) and stat aver 9.2 (Statacorp LP).
Results
Our search retrieved 93 papers (Fig. 1). Seventy-two papers
were excluded after reviewing the title as they reported on:
the complications of colorectal anastomosis, the clinical
outcome of patients treated with or without derivative
enterostomy after colorectal surgery, and different surgical
technique or outcomes. While the remaining 21 papers
were evaluated in their full text, of these, 16 were
excluded as they did not report on this meta-analysis
prespecified outcomes. From an analysis of the selected
papers reference lists, an additional ten studies were
found to compare the clinical course of LI and LC after
482
Age at surgery
(mean unless
stated)
Females
N (%)
Edwards
et al.
[20]
Gastinger
et al. [5]
Khoury et
al. [21]
Law et al.
[22]
Rullier et
al. [23]
Rutegard
and
Dahlgren
[24]
Tocchi et
al. [25]
Fasth et
al. [29]
Gooszen
et al.
[28]
Williams
et al.
[27]
Gohring
et al.
[26]
Sakai et
al. [30]
RCT
34
36
1, 2, 5, 7
n/c
I=2 (5.9)
C=5 (13.9)
I=63 (median)
C=68 (median)
21 (30.0) ********
PNR
407
229
1, 2, 4, 5
n/c
n/c
n/c
RCT
32
29
A, B
1, 2, 4, 5
42
38
Retro
107
60
PNR
32
29
A, B, C
1,
6,
1,
5,
1,
5,
I=65
C=65
I=65.2
C=67.8
I=63 (median)
C=64 (median)
I=67
C=72
25 (41.0) ********
RCT
a, b, c,
d, e
f
I=48 (10.5)
C=40 (14.9)
n/c
Retro
17
24
PNR
21
21
n/c
RCT
37
39
RCT
23
Retro
Retro
2,
7,
2,
7
2,
9
4, 5,
8
3, 4,
3, 4,
a, e
n/c
I=7 (16.7)
C=0 (0)
I=11 (10.3)
C=10 (16.7)
I=24 (75.0)
C=14 (48.3)
Study quality
(star rating)
(max 11)
****
31 (38.8) ********
46 (27.5) ******
27 (44.3) *****
1, 2, 3, 4,
5
1, 2, 8, 9
n/c
n/c
A, B, C
1, 2, 3, 4,
6
a, e, g
I=0 (0)
C=0 (0)
I=8 (21.6)
C=7 (17.9)
I=63.3
14 (34.1) *****
C=63.2
I=73 (median)
24 (57.1) ****
C=69 (median)
I=63.2 (median) 49 (64.5) ********
C=64.7 (median)
24
A, B, C
1, 2, 4, 6,
8
n/c
I=3 (13.0)
C=4 (16.7)
I=71 (median)
23 (48.9) ********
C=66.5 (median)
79
43
A, B, C
1, 2, 4, 6,
8
n/c
I=8 (10.2)
C=7 (16.3)
I=59 (median)
C=63 (median)
n/c
63
63
A, B, C
1, 2, 3, 4
a, b, e
I=15 (23.9)
C=23 (36.6)
I=64 (median)
C=64 (median)
64 (50.8) *****
*****
I ileostomy, C colostomy, Retro retrospective, PNR prospective non-randomized, RCT randomized controlled trial, n/c no comment; A colorectal
cancer, B diverticular disease, C other; 1 age, 2 gender, 3 body mass index, 4 diagnosis, 5 tumor level, 6 anastomosis level, 7 tumor stage,
8 anastomosis method, 9 mode of surgery; a poor bowel preparation, b colonic obstruction, c severe cardiovascular disease, d extensive local
malignancy, e technical anastomotic problem, f anastomosis below 5 cm, g anastomosis at risk
483
General
outcome measures
Construction
outcome measures
Closure
outcome measures
a2
b2, b4, b6
c1, c2
c1, c3
a1
a2
a2
a1
a2
a1
b4,
b2,
b1,
b2,
b3,
b6,
b3,
b2,
b4,
b4,
b7
b4
b3, b4, b5, b6, b7
b6
c1, c2, c3
c1, c2, c3, c4
c1
c2,
c1,
c1,
c1,
c1,
c3
c2, c3
c2
c2, c3
c2
Functioning
outcome measures
d2
d1
d1, d2
d2
d1
d1, d2
d1
d1, d2
d1
AGENERAL OUTCOME MEASURES: wound infection (a1) and dehydratation (a2); BCONSTRUCTION OF THE STOMA OUTCOME
MEASURES: necrosis (b1), prolapse (b2), retraction (b3), parastomal hernia (b4), stenosis (b5), sepsis (b6), hemorrhage (b7); CCLOSURE OF
THE STOMA OUTCOME MEASURES: occlusion (c1), wound infection (c2), anastomotic leak or fistula (c3), hernia (c4); DFUNCTIONING
OF THE STOMA OUTCOME MEASURES: skin irritation (d1) and occlusion-ileus (d2)
484
485
Discussion
It has been demonstrated that the systematic use of a
temporary diverting stoma to decompress low and ultra-low
486
487
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