Role of diversion ileostomy in low rectal cancer

review of article

1. Role Of Diversion Ileostomy In Low Rectal Cancer: A Randomized Controlled Trial. Mukhtar Thoker a , Imtiaz Wani a , , Fazl Q. Parray a , Nawab Khan a , Shabeer A. Mir a , Parvaiz Thoker b * a . Department Of General Surgery, Sheri- kashmir Institute Of Medical Sciences, Srinagar b.Department Of Surgical Oncology, Sheri- kashmir Institute Of Medical Sciences, Srinagar M. Thoker et al. / International Journal of Surgery 12 (2015) 945e95 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. Presenter : Dr. Mohd . Shahnawaz Alam

2. Introduction: Rectal Cancer Continues To Be Devastating Malignancy Worldwide. LAR Is Generally Performed For Lesions In The Upper And Middle Third Of Rectum. Sphincter Preservation Is The Need Of The Hour. Anastomotic Leak Ranges From 3 To 11% For Middle-third And Upper-third Anastomosis And To 20% For Lower-third Anastomosis. Proximal Diversion In The Form Of Loop Ileostomy Is Adopted Because Of The High Rates Of Anastomotic Complications Associated With Low Colorectal And Coloanal Anastomosis.

3. Aim: To Compare Two Groups Of Low Anterior Resection With And Without Diversion Ileostomy In Rectal Cancer Patients.

4. Material And Methods: Type Of Study : A Prospective Study. Time Of Study : June 2009 To Decm 2011 For A Period Of 30 Months. Inclusion Criteria: Operable Rectal Cancer 4 -12 cm From Anal Verge. Exclusion Criteria: All Those Pt Who Were Otherwise Planned For Any Such Procedure(sphincter Saving) But Ended Up With Abdomino -perineal Resection. Total No. Of Cases: 78 [ 34 Grp-A, 44 Grp-B]

5. Material And Methods contn : Pt. Planned For LAR : Detailed History Thorough Physical Examination Local Examination Routine Investigations Specialized Investigation Like Serum CEA Level A Diagnostic Pre-op Biopsy Pre-op Staging By Duke’s, Multi-slice CT,TRUS Or MRI Oncologist Advice For Neoadjuvant Or Adjuvant Therapy Pre-op Bowel Preparation & Antibiotics Part Preparation & Pre-op Counselling By Stoma Therapist Informed & Written Consent

6. Material And Methods contn : All Cases Were Done Under GA. Intra-op Every Attempt To Stick On Oncological Principle With Stress On The Complete Resection Of Tumor. Anastomosis Either By Circular Stapler Or By Hand Sewn Closure. Details Of Intra-op Findings Confirmed. Decision Of Diversion Ileostomy Was Taken On The Basis Of Inclusion Criteria. Demonstration Of Leak Or Sepsis Was Confirmed By Septic Profile, USG- Abdomen/Pelvic And All Post-op Complications Were Recorded. Opd Follow-up At 1m,3m & 6m Interval. Stoma Closure Done After 3 Months After Doing A Cologram . Ethical Clearance.

7. Material And Methods contn : Quality Of Life Was Assessed By Scoring Done By Self Designed Method. A Total Score Of 0-20 Given For following Parameters : Patient Satisfaction: a) Bowel/Stoma evacuation – Complete/Incomplete b) Frequency - >10 Motions />7 Motions/3-5 Motions/2 or less c) Feeling of well being- Quite Happy/ so-so /Not Happy /Sad/Miserable d) Surgical Procedures- Fully satisfied/So-so / Not satisfied /Sad/Miserable

8. Material And Methods contn : 2.Functional outcome: Sexual dysfunction-Y/N Return to Work –Y/N c) Independent Living-Y/N d) Socializing-Y/N e) Recommendation to others-Y/N 3.Symptomatology of anterior resection syndrome: Feeling of loss of reservoir function-Y/N b) Feeling of incomplete bowel evacuation-Y/N c) Not soiling-Y/N d) Incontinence to flatus-Y/N e) Incontinence to stools-Y/N Any score >15 excellent result 10-15 good result 8-10 average result <8 poor result **Descriptive statistical method used were chi-square, odds ratio and Manne Whitney U Test. P-value <0.05 was considered statistically significant.

9. Result : Majority of cases(36%) – age group 51-60 yrs with M:F = 1.2:1 Bleeding P/R was c/o in 97 % followed by wt. loss in 40% Constipation was commonest bowel habit ( 60% ) Family h/o rectal malignancy present in 10% O/E pallor was most frequent findings (81%) Growth was felt on DRE in 72% & blood smearing of finger present in 67%

10. Result contn : 50 % lesions were 5-8 cm from anal verge. CEA level was in range of 6-10 ng/ml in 44% cases in pre-op period. Blood group “O” was commonest. Neo-adjuvant therapy was given in 29% Well differentiated adenocarcinoma commonest. Mostly pt. presented in Duke’s B stage.

11. Result contn : Spectrum of complications in two groups : Group-A Group-B Anastomotic leak 6% 11% peritonitis 0 % 4.5% Pelvic collection 11.8% 22.7% Small bowel obstruction 0% 4.5% Post-op ileus 11.76% 11.36% Wound sepsis 32% 18% hypokalemia 8.8% 2.27% Sexual dysfunction 32% 11.3% Frequency of stomal complications in Group-A: Stomal complication percentage Skin excoriation 14.7 Stomal leakage 5.9 Stomal obstruction 2.9 Stomal retraction 2.9

12. Result contn : Group-A Group-B Bowel movements 4.1 ± 1.3 days 5.6 ± 1.7 days Resumption of diet 4.1 ± 1.3 days 5.6 ± 1.7 days Mean hospital stay 9.8 ± 3.3 days 14 ± 2.9 days Recurrence rate 3% 7% QOL score 14.1 ± 3.1 13.2 ± 1.9 Other outcomes :

13. Conclusion: LAR With Ileostomy Has Certain Advantages Over LAR Without Ileostomy : Anastomotic Leak Postoperative Ileus Resumption Of Diet Wound Infection, Small Bowel Obstruction And In Terms Of Mortality And Recurrence. However Stoma Related Complications Were Main Disadvantage In LAR With Ileostomy.