The Impact Of Defunctioning Ileostomy On Postoperative Short-term Quality Of Life After Laparoscopic Low Anterior Resection For Rectal Cancer

BackgroundColorectal cancer is one of the most common gastrointestinal malignancies worldwide.With the progress of industrialization,the incidence of colorectal cancer has been increasing in our country.It is reported that the incidence and mortality of colorectal cancer,the fifth common malignance in our country,are 376/100000 and 191/100000 respectively in 2015.The tumour is more located at mid or low rectum,accounting for 70%-80%,according to china cancer statistics report in 2012.With the research of rectal cancer in depth,neoadjuvant chemoradiotherapy or neoadjuvant radiotherapy plays a pivotal role in the treatment of resectable mid or low rectum cancer,though surgery is still a major potential curative therapy untill now.The sphincter-preserving technique,so called low anterior resection,with total mesorectal excision have been the gold standard treatment which is more likely to be chosen by surgeons to decrease the number of permernent colostomy and to meet the physiological and psychological needs of patients.In fact,so many patients undergoing a low or ultra-low anastomosis will suffer postoperatively a constellation of symptoms including fecal uegency,frequent bowel movements,emptying difficulties,incontinence,constipation,and bowel fragmentation.This broad spectrum is called Low Anterior Resection Syndrome(LARS),the prevalence of which after rectal surgery varies in the literature from 40% to 90%.The symptoms of LARS are more severe at first year after restoration of continiuty,and then reach plateau one year later.The etiology of LARS is not clear,and pathophysiologic mechanisms of that may be involved with internal anal sphincter dysfunction,disappearance of the rectoanal inhibitory reflex(RAIR),abnormal decending colon motility patterns,and reduction in rectal reservoir capacity and compliance.Several studies have reported that LARS has a significant detrimental impact on patients’ postoperative quality of life.At the same time,there is no definitely effective therapy for the treatment of LARS,and a colostomy may be needed to improve the quality of life for the patient of major LARS.Hence,some predisposing risk factors of major LARS will be helpful to early identify high risk patients and to timely provide more information about the risk of postoperative bowel dysfunction and appropriate strategies.A defunctioning stoma reduces not only symptomatic anastomotic leakage but also the need for urgent reoperation through diverging stool stream when anastomotic leakage occurs for low-lying rectal cancer patients who undergone low anterior resection with low or ultra-low anastomosis,particularly those with neoadjuvant chemoradiotherapy.Several studies reported that with the creation of defunctioning stoma,the pooled rate of anastomotic leakage is significantly lower.A defunctioning stoma will prevent anastmosis from the mechanical injure and potential infection resulted from stool.It is reported that anastomotic leakage is an associated risk factor for LARS,probably due to increased fibrosis induced by local inflammation which contributes to a reduced neorectal capacity and compliance.Whether the presence of ileostomy is an increased risk factor for LARS is controversial,because diverting ileostomy is more likely conducted in patients with low-lying rectal cancer or neoadjuvant chemoradiotherapy,which have been confirmed as risk factor of major LARS in previous study.Whether a defunctioning ileostomy is needed for low-lying rectal cancer patient is not conclusive.we assumed that a defunctioning ileostomy may improve postoperative short-term quality of life and decrease the serious extent of low anterior resection syndrome for low-lying rectal cancer.Hence,we intend to investigate the impact of diverting ileostomy on postoperative short-term quality of life,low anterior resection syndrome and adjuvant chemotherapy compliance after low anterior resection for rectal cancer.Objetive1.To identify the predisposing risk factors of major low anterior resection syndrome.2.To investigate the impact of diverting ileostomy on postoperative short-term quality of life and LARS after laparoscopic low anterior resection for rectal cancer.3.To investigate the impact of defunctioning ileostomy on adjuvant chemotherapy compliance.Methods1.103 patients who have undergone low anterior resection in Tangdu hospital from May 2015 to May 2016 will be followed-up and be assigned to No/Minor LARS group or Major LARS according to the low anterior resection score.The following datas are recorded: age,gender,BMI,tumour distance from anal verge,neoadjuvant radiotherapy,details of ileostomy,duration of surgery,number of lymph node,TNM stage,anastomotic leakage,adjuvant themotherapy.Those datas will be analysed to identify the risk factor of major LARS.2.Ninety-eight patients with low-lying rectal cancer are enrolled in this retrospective case-control study.All patients are assigned to ileostomy group(IG,n=48)and non ileostomy group(NIG,n=50).All patients with clinical(age,gender,neoadjuvant themoradiothereapy,anesthetic risk,BMI),tumour related(stage,lymph nodes,diameter),surgical(duration,blood loss),short term(first time to flatus,postoperative hospital stay,adjuvant chemotherapy,anastomotic leakage)and follow up results(quality of life,LARS score,treatment satisfaction and adjuvant chemotherapy compliance)are considered.All clinicopathological results and follw up results will be analysed to evaluate the impact of diverting ileostomy on postoperative short-term quality of life and LARS after laparoscopic low anterior resection for low-lying rectal cancer.3.Hospitalisation satisfaction and adjuvant chemotherapy compliance will be evaluated at terminated follow-up.The result will be analysed to estimate the impact of defunctioning ileostomy on adjuvant chemotherapy compliance.Categorical variables are expressed as percentages,and continuous variables as mean and standard deviation(SD).The chi-square(χ2)test or the Fisher’s exact test is used for the comparison of categorical variables,and the Student’s t test or the analysis of covariance for the comparison of quantitative variables.Multivariate analysis is performed to determine the strongest predictor of major LARS.Statistical significance is set at P<0.05.Results are expressed as odds ratio(OR)with 95% confidence interval(CI).Datas are analysed using SPSS software version 19.0.Results1.In the univariate analysis,the following variables were significantly associated with major LARS: older than 70 years old(44.4% vs.22.3%,P=0.028),protective ileostomy(81.4% vs.46.0%,P=0.001),neoadjuvant radiotherapy(70.3% vs.40.7%,P=0.008),and tumour distance from anal verge(≤6cm)(77.7% vs.25%,P<0.001).In the multivariate analysis,variables independently associated with major LARS were neoadjuvant radiotherapy [OR: 5.002,95%CI:(1.408,17.765)] and tumour distance from anal verge[OR: 2.389,95%CI:(1.546,3.691)].2.No statistic difference was fund between two groups in terms of clinicopathological datas except the numbers of preoperative chemoradiotherapy(62.5% vs.24.0%,P<0.001)and clinical stage(P=0.008).For LARS score,the mean score of IG was significantly lower,no matter whether they had received preoperative chemoradiotheary(P<0.05).Patients of NIG had more functional and symptomatic problems related to quality of life during post-operative half a year,especially for global quality of life,physical functioning,emotional functioning and diarrhea(P<0.05),except fatige and costipation(P>0.05).3.Patients with defunctioning ileostomy had better adjuvant chemotherapy compliance than those without ileostomy(P=0.018).Conclusions1.The risk of having major LARS increases for rectal cancer patients with lower tumour distance from anal verge and neoadjuvant radiotherapy.2.The presence of ileostomy may improve postoperative short-term quality of life and decrease the serious extent of low anterior resection syndrome.3.Defunctioning ileostomy may contribute to a better adjuvant chemotherapy compliance.