The effect of a diverting stoma on morbidity and risk of permanent stoma following anastomotic leakage after low anterior resection for rectal cancer: a nationwide cohort study

BACKGROUND: Diverting stomata (DS) have been shown to mitigate the clinical impact of anastomotic leakage (AL) but not without complications, and their routine use remains a matter of international debate. The objective of this study was to examine the association between stomata and the clinical consequences of AL.

METHODS: This was a nationwide retrospective cohort study including all patients suffering from AL after low anterior resection from 2001 to 2010.

RESULTS: Four thousand sixty-three patients were treated in the period of whom 581 (11.9%) developed AL. In case of AL, patients without a diverting stoma had a slightly higher 90-day mortality rate (13.5% versus 8.7%, p = 0.089). Patients suffered more complications due to AL, both surgical (52% versus 28%, p < 0.001) and non-surgical (48% versus 35%, p = 0.004) with a higher Clavien-Dindo score. Twenty percent of patients developed stoma-related complications prior to stoma reversal. Mortality related to stoma reversal was 2.4%. Factors associated with a risk of a permanent stoma were age (HR 1.04, 95% CI 1.01-1.08), blood transfusion during primary surgery (HR 2.35, 95% CI 1.16-4-78), conserved anastomosis after AL (HR 0.019, 95% CI 0.009-0.04), and a diverting stoma fashioned at the index operation (HR 0.50, 95% CI 0.26-0.97).

CONCLUSION: The use of diverting stomata during low anterior resection mitigates the clinical impact of AL. However, this benefit needs to be balanced against the risk of stoma-related complications, seen in 20%, and mortality with stoma reversal (2.4%). Where practical, the decision to divert should be made pre-operatively in a multidisciplinary setting.