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TME: to divert or not?

TME: to divert or not?. Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital. Isolated tumour deposits can be found within the mesorectum up to 3-4 cm distal to the main tumour. Line of transection in conventional rectal surgery.

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TME: to divert or not?

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  1. TME: to divert or not? Dr. Jimmy Li Chak Man Department of Surgery Prince of Wales Hospital

  2. Isolated tumour deposits can be found within the mesorectum up to 3-4 cm distal to the main tumour Line of transection in conventional rectal surgery The mesorectum in rectal cancer: the clue to pelvic recurrenceHeald et al. Br J Surg 1982; 69: 613-616.

  3. The Basingstoke experience of TME, 1978-1997Heald et al. Arch Surg 1998; 133: 894-898. • TME: the new ‘gold standard’ in rectal cancer surgery • 519 patients with rectal cancer with operation • 405 ‘curative’ resections, the local recurrence rate was 3% at 5 years and 4% at 10 years • Disease-free survival in this group was 80% at 5 years and 78% at 10 years • Anastomotic leak rate: 6.5% clinical and 5.5% radiological • Temporary stomas were constructed in 73%

  4. N=219 P=0.03 Leakage rate after TME • Karanjia et al. Br J Surg 1994; 81:1224-26. • Defunctioning colostomy group has significantly lower risk of major leakage (p=0.03) • The overall leakage rate was the same between the two groups

  5. Concerns and controversies • Leakage rate? • Consequences of leakage? • Does protective stoma prevent major complication? • What are the risk factors for leakage? • Which type of stoma is better? • Does protective stoma affect survival? • What should be the timing of stoma closure? • Is stoma cost effective? • How many patients will end up with permanent stoma?

  6. Stoma or no stoma: results from RCTs • 2 RCTs identified: • Graffner at el. Dis Colon Rectum 1983; 26: 87-90. • 50 patients included, with overall leakage rate 8% • No significant difference in all parameters including leakage rate • Pakkasite at el. Eur J Surg 1997; 163: 929-33. • 38 patients included, with overall leakage rate 24% • No significant difference in major and overall leakage rate • No stoma group has significantly higher reoperatively rate for leakage Covering stoma does not reduce anastomotic leakage rate but can reduce most of the severe infective consequences of leakage

  7. Risk factors

  8. Risk factors • Makela at el. Dis Colon Rectum 2003;46: 653-60. • Case-control study • 44 patients were identified with anastomotic leakage that required surgery Risk factors of anastomotic leakage identified: Malnutrition Hypoabluminaemia Wt loss> 5 kg Medical illness Use of alcohol Bowel preparation ASA Contamination Level of anastomosis Incomplete donuts Blood transfusion OT time >120 mins

  9. Type of defunctioning system • Loop ileostomy (LI) • Loop transverse colostomy (LTC) • Caecostomy • Transanal tube/ intracolonic device

  10. Loop ileostomy vs. loop colostomy

  11. Tube caecostomy vs. loop transverse colostomy Tschmelitsch et al. Arch Surg 1999; 134: 1385-88.

  12. Transanal tube/intracolonic device Coloshield • Patrascu at el. 2004 • Ravo at el. 1984 (coloshield) • 38 patients and 10 patients respectively • No major complication reported

  13. P<0.01 Dukes’ B Long term survival: affects by diversion stoma and early closure? • Experimental carcinogenesis is enhanced at colorectal anastomosis • Inhibited by proximal faecal diversion • Promoted by the closure of a defunctioning stoma Meleagros et al. BJS 1995; 82: 21-25.

  14. Timing of closure Early closure is possible But how many patient can have early closure? Advantage and disadvantage? Any logistic problem in our hospital?

  15. Techniques and complications of ileostomy closure Phang et al. Am J Surg 1999; 177, 463-6. 339 patient with LI closure 65%: enterotomy suture 20%: resection with handsewn anastomosis 15%: stapled anastomosis IO rate significantly lower in enterotomy suture group Leakage rate no significant difference between groups

  16. Cost-effectiveness of defunctioning stomas Koperna Arch Surg 2003; 138: 1334-1338 Cost analysis study Cost drivers: Anastomotic leak and Defunctioning stomas Leakage rate of 16.5% necessary to balance the overall cost of stoma Conclusion: should keep low stoma rate and low leakage rate for LAR : 10% stoma rate and 10% leakage rate

  17. Incidence and causes of permanent stoma after anterior resection Some patient had no stoma closed • General health • Age • Complications • Anastomotic stricture • Disease factors • Local • Systemic recurrence Bailey et al. Colorectal disease 2003; 5: 331-334. • 59 with defunctioning stoma • 5/59 not closed (8%) • 2 metastatic disease, 2 anastomotic stricture, 1 patient choice

  18. Summary • Clinical leakage rate? 3-17% • Consequences of leakage? Re-operation 3-16% • Does protective stoma prevent major complication? Yes • Which type of stoma is better? Depends on surgeon preferences • Is stoma cost effective? Stoma is expensive if leakage rate is low • How many patients will end up with permanent stoma? ???

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