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Dr Arjun Rajagopalan

Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer

We know … • Anastomotic leakage (AL) after low anterior resection

(LAR) for rectal cancer is a complication that is associated with high mortality (6 - 22%), and possibly increased rates of local recurrence.

• Diverting stoma (DS) have been recommended as a strategy to lower the incidence of AL.

We don’t know … • The impact of DS on AL in terms of the above

mentioned problems has not be scientifically examined.

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Background

Dr Arjun Rajagopalan

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1: Population

Patient selection for study

606 330

Study groupOmitted from study

From this population, a subgroup was picked

out using a “Propensity Score Matching” to

distribute confounding factors evenly.

2: Indicator variable

4: Comparison

Patients with rectal adenocarcinoma located within 10 cm of the anal verge • > 20 years of age. • Treated with low anterior resection

(LAR) using a circular stapler. • Seen at 40 specialised institutions in

Japan.

Dr Arjun Rajagopalan

After Propensity Score Matching

165 165 With StomaWithout stoma

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3: OutcomesAll grades

Grades B & C

Grade C0.6%

10.9%

14.5%

9.1%

15.8%

15.8%

Without stomaWith stoma

Dr Arjun Rajagopalan

“Symptomatic” anastamotic leakage • Emission of gas, pus or feces from the drain, wound or vagina. • AL confirmed by contrast radiography or CT.

Grading of severity of anastamotic leakage • Grade A: requiring no change in patient management. • Grade B: requiring therapeutic intervention but not re-laparotomy. • Grade C: requiring re-laparotomy.

p = 0.001

NS

NS

Sampling

Centre 40 specialised institutions in Japan.

TImeframe August 2010 - December 2012

Analysis Case-control using a propensity scoring matching system.

Sample sizing Not done.

Exclusions Previous colorectal surgery, emergency operations.

Numbers From the cohort of 936 patients; 330 were extracted.

ComparisonControls Randomisation Protocols Comparability

✅ - matched ⛔️ - ✅ *

MeasurementTraining Blinding Multi-

observers Duplication

- - - -

* Achieved by the propensity scoring matching method of patient recruitment.

CHECKLIST

Dr Arjun RajagopalanDr Arjun Rajagopalan

The author(s) conclude:

Diverting stoma did not have a significant relationship with symptomatic anastomotic leakage after propensity score m a t c h i n g . H o w e v e r , a diverting stoma does seem to mitigate the consequences of leakage, reducing the need for urgent abdominal reoperation.