Switzerland: A recent study in the journal Diseases of the Colon & Rectum showed that early closure of ileostomy (at 2 weeks) does not provide a better quality of life (QoL) up to 4 months after low rectal resection for cancer. However, it is afflicted with significantly higher morbidity and adverse feasibility versus late closure.
The creation of a diverting stoma is an accepted method for protecting low colorectal or coloanal anastomosis (LA) following rectal cancer surgery. Previous studies have shown a decrease of clinically relevant anastomotic leaks and the need for interventional or surgical revisions when a protective stoma was created. However, the presence of stoma may be a big burden for the patient, regardless of the positive effect on LA healing. Several studies have shown a negative effect on the patients' QoL. Therefore, the concept of early stoma closure (EC), that is, ≈2 weeks after rectal resection, has been proposed as an alternative to late stoma closure (LC) after 12 weeks.
Several RCTs have reported promising results for the concept of EC after low anterior resection (LAR) in selected patients. Another study had to be terminated prematurely because of safety after EC. In the present prospective randomized controlled multicenter trial, Andreas T. Elsner, Department of Surgery, Hospital of Baselland–Liestal, Liestal, Switzerland, and colleagues aimed to evaluate this early time point of protective stoma closure after LAR with regard to patient QoL, general and intraoperative feasibility, and safety (morbidity and mortality) in comparison with LC.
The study, conducted at 3 Swiss hospitals, included 2 parallel groups. It included patients undergoing low anterior resection and temporary ileostomy for cancer. Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity.
The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection.
Owing to safety concerns, the trial was stopped after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients).
Following were the study's key findings:
There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0) and 4 months (108.6 vs 107.1) after index surgery.
Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3), adhesions (visual analog scale: 61.3 vs 46.2), leak of colonic anastomosis (19% vs 0%), leak of colonic or ileal anastomosis (24% vs 0%), and reintervention (16% vs 0%) were significantly higher after early closure.
The concept of early closure failed in 10 patients (27% vs 0% in the late closure group).
"Our findings showed that early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure," the authors concluded.
Reference:
Elsner, Andreas T. M.D.1,2; Brosi, Philippe M.D.1,3; Walensi, Mikolaj M.D.1,4; Uhlmann, Michael M.D.1,5; Egger, Bernhard M.D.6; Glaser, Christine M.D.1,7; Maurer, Christoph A. M.D.1,3 Closure of Temporary Ileostomy 2 Versus 12 Weeks After Rectal Resection for Cancer, Diseases of the Colon & Rectum: November 2021 - Volume 64 - Issue 11 - p 1398-1406 doi: 10.1097/DCR.0000000000002182