Fatores associados à permanência de estomia definitiva em pacientes submetidos à ressecção anterior do reto por câncer retal

Abstract

Anastomosis-related complications are among the main risk factors that are associated with permanent stomas. Therefore, several authors recommend a temporary ileostomy after a low anterior resection with low colorectal anastomoses . Despite the initial intent regarding its reversibility, some patients never undergo closure of their temporary diverting stomas. Furthermore, the closure of diverting ileostomies should not be considered a complication-free minor surgical procedure. The objective of this study was to determine the risk factors, rate of non-closure of diverting ileostomy after low anterior resection, morbidity associated with the closure of a loop ileostomy, as well as the rate of permanent stoma during a long-term follow-up of a cohort of rectal adenocarcinoma patients. Among a population of 174 consecutive patients diagnosed with rectal tumors, that received surgical treatment at the Alfa Institute of Gastroenterology/University Hospital of the Universidade Federal de Minas Gerais - Medical School, ninety-two with diagnosis of rectal adenocarcinomas were included in this study. The majority of the patients were male (53.3%), and the mean age was 55.55 years (SD [standard deviation]: ±13.57 years); however, 71 patients (77.2%) were younger than 65 years of age. Of these patients, 62 (67.4%) underwent ileostomy reversal in a median time of 8.0 months (IQR [interquartile range]: 5.0-10.0 months). Of the 30 patients who did not undergo closure of their ileostomy, 17 (56.6%) demonstrated disease progression, nine (30.0%) had received chemotherapy for more than 12 months, two (6.7%) had comorbidities that precluded the closure procedure, and two (6.7%) experienced complications from the first operation. Risk factors associated with ileostomy reversal failure, according to the multivariate analysis, included the occurrence of anastomotic leaks (PR [prevalence ratio] 2.93; 95% CI: 1.33-6.97, p=0.015) and the presence of metastasis (PR 3.64; CI 95%: 1.75-7,60 , p=0.008). Among the 62 patients who underwent ileostomy closure, 11 (17.7%) experienced some type of postoperative complication: three, five, two and one patient experienced anastomotic dehiscence, intestinal obstruction, wound infection and pneumonia, respectively. All patients with complications, except those who presented with a wound infection and pneumonia, underwent another operation to redo the stoma. In the total follow-up period of this study (84 months), 54 (58.7%) of the 92 patients had their intestinal transit restored, while 38 (41.3%) had a permanent stoma. After the multivariate analysis, reversal of the ileostomy during adjuvant chemotherapy was associated with non-restoration of intestinal transit (PR 4.21, 95% CI: 1.003- 17.657, p=0.049). It was observed that the occurrence of anastomotic leaks, the presence of metastasis and closure of the ileostomy during chemotherapy were factors associated with non-restoration of intestinal transit in rectal adenocarcinoma patients who received multimodal treatment for their disease. The implications of an ileostomy after low anterior resection should not be underestimated, as it may not be closed in many patients. It is therefore essential to characterize the factors that are related to non-closure of an ileostomy and to consider the possible complications due to its closure. This way, patients can receive realistic preoperative orientations that might prevent false expectations.