Laparoscopic Versus Open Pre-Treatment Loop Colostomy for Fecal Diversion in Rectal Cancer Patients: Is Laparoscopic Colostomy Better?

Abstract

Diversion colostomy plays a crucial role in the management of carcinoma rectum in low- and middle-income countries as significant number of patients present with partial intestinal obstruction. The aim of this study was to compare laparoscopic and open approaches for fecal diversion done in patients with adenocarcinoma of the rectum as a pretreatment procedure. The primary end point of our study was time to initiation of neoadjuvant chemo radiation. It was a retrospective study that included all patients diagnosed to have carcinoma rectum and underwent a pretreatment fecal diversion between 2012 and 2014. A total of 55 patients underwent pretreatment diversion colostomy of which 33 were performed via the laparoscopic approach while 22 had open diversion. The time for initiation of neoadjuvant therapy was shorter in the laparoscopic group compared to the open approach (16 days vs. 20.5 days, P = 0.31). The study concluded that pretreatment diversion colostomy using the laparoscopic approach was a safe option in low- and middle-income countries as it was associated with faster recovery and early initiation of neoadjuvant therapy in patients with partially obstructed locally advanced carcinoma rectum.

Introduction

Management of adenocarcinoma of the rectum has evolved over the past century with significant improvement in the oncological outcomes over the past 20 years [1]. A better understanding of the etiopathogenesis, widespread availability of magnetic resonance imaging for accurate local staging, combined modality of management as decided by a dedicated multidisciplinary team, refined surgical technique, and detailed accurate pathological reporting have all contributed to better survival and enhanced quality of life [2]. Radical rectal resection remains the cornerstone in the management of rectal cancer in addition to other modalities like chemotherapy or radiation therapy used either in the neoadjuvant setting or adjuvant setting [3, 4].

Patients with adenocarcinoma of the rectum can present with features suggestive of luminal obstruction [5]. These patients often have locally advanced disease and require neoadjuvant chemoradiation prior to curative surgery [1, 3, 4, 6, 7]. It is also a well-known fact that neoadjuvant chemoradiation causes tumor edema during the initial few days precipitating luminal compromise resulting in acute rectal obstruction [8]. To prevent this dreaded complication, partially obstructed patients require fecal diversion prior to the initiation of cancer-directed therapy [9]. Stenting is also an alternative to tide over the acute obstruction; however, it has limitations with respect to cost, failure rates, ease of application, and the longer learning curve [10].

Pre-emptive and prompt pretreatment fecal diversion in these selected patients aims to alleviate the obstruction and facilitates uninterrupted chemoradiation [11]. Fecal diversion is most frequently done as sigmoid or a transverse loop colostomy at our institution. Stoma creation and its reversal required laparotomy until recently in low- and middle-income countries such as ours in India when laparoscopy gained popularity [12]. Our study aimed to compare the short-term outcomes of pretreatment diversion loop colostomy between open and laparoscopic approaches. The objectives were to compare time to initiation of neoadjuvant therapy, post-operative recovery, and morbidity.

Materials and Methods

After approval from the institutional review board (CMC Vellore IRB Min No: 10153 [Retro] dated 22.06.2016), a retrospective cohort study was conducted on patients admitted and treated at Christian Medical College Vellore from January 2012 to December 2014. The study included all patients diagnosed to have adenocarcinoma of rectum requiring pretreatment diversion loop colostomy. Their electronic in-patient and out-patient hospital records were used for data extraction and analyzed using standard statistical tools. The diagnosis of rectal adenocarcinoma was made based on trans-anal punch biopsy. The locoregional staging and metastatic workup was done based on high-resolution MRI of the pelvis and contrast-enhanced computed tomography of the abdomen and thorax respectively. The treating surgeon made the clinical diagnosis of rectal obstruction and the multidisciplinary team (MDT) eventually ratified the decision for pretreatment diversion colostomy based on the clinical features and imaging findings. Option of colonoscopic stenting was not considered in any of the study patients. Laparoscopic fecal diversion was offered to patients who could afford to bear the additional cost of laparoscopy. All other patients had undergone open fecal diversion procedure.

The laparoscopic approach to performing diversion loop colostomy used a standard three-port technique after placing the patient in Lloyd-Davies position. Pneumoperitoneum was achieved using Hasson’s technique or via optiport entry after achieving pneumoperitoneum with Veress needle technique at Palmer’s point. After ruling out disseminated disease like liver surface lesions and peritoneal metastasis, redundant loop of sigmoid was identified and brought to the abdominal surface of the pre-marked stoma site. If a short mesocolon was encountered, mobilization of the peritoneum from the lateral abdominal wall was performed laparoscopically. Trephine opening was made over the anterior abdominal wall, following which the desired loop of the colon was exteriorized, and loop colostomy was matured using No.3-0 polyglactin sutures. Port sites were closed using either nylon sutures or skin staplers. Patients were encouraged to take a normal diet soon after they reached the surgical ward. They were discharged once comfortable, tolerating oral diet and with a healthy, functioning stoma. The open approach was via a lower midline laparotomy and the rest of the stoma creation was done similar to that described in the laparoscopic approach. Rectus was closed using No.1 Polydioxanone loop suture in a continuous fashion and skin was closed using skin staplers. All the operations were performed under general anesthesia. Skin staplers would be removed on postoperative day 10 and earlier lay opening of skin clips would be performed if the need arises based on the surgical team involved if surgical site infection was suspected.

Following the diversion colostomy, the treatment algorithm would be made in the same multidisciplinary tumor board meeting and a plan for neoadjuvant chemotherapy followed by long course chemoradiation (LCCRT) or only LCCRT would be decided. After a reassessment MRI and further discussion in the MDT, all operable patients would then undergo radical rectal resection and would subsequently be planned for adjuvant chemotherapy if needed.

Results

A total of 55 patients with a diagnosis of adenocarcinoma rectum underwent pretreatment diversion colostomy between 2012 January and 2014 December. Thirty-three of them were performed via laparoscopic approach while 22 had open diversions. The demographic and comparative details are described in Table 1. The primary endpoint of the study was time to initiation of neoadjuvant chemotherapy or chemoradiation (LCCRT) as decided by the multidisciplinary team.

Table 1.

Demographic and comparative details of the patients

Variable		Laparoscopy (n = 33)	Open (n = 22)
Age, years		48.5 (23–73)	53 (32–77)
Gender	Male, n	24	13
	Female, n	9	9
Neoadjuvant chemoradiation therapy, n		12	8
Long course chemo radiation therapy, n		21	14
Duration between diversion and neoadjuvant therapy, n		16 (13.5–21.5)	20.5 (15.75–27)

Neoadjuvant chemo includes patients who received therapeutic dose of chemotherapy along with radiation. Long course chemoradiation therapy includes patients who received only a sensitizing dose of chemotherapy

The median time for treatment initiation in the laparoscopic diversion group was 16 days (interquartile range of 13.5 to 21.5) in comparison to the open diversion group, which was 20.5 days (interquartile range of 15.75 to 27) using Mann-Whitney test. Fig. 1 shows the individual time to initiation of chemoradiation. One patient in the open group and four patients in the laparoscopic group took more than 50 days for the initiation of chemoradiation. The hospital records did not reveal any adverse complications secondary to the operative procedure in these patients. Socioeconomic factors were presumed to be the reason for the delay in neoadjuvant chemoradiation in these patients. There were no documented problems relating to laparoscopic procedures and there were no conversions to open procedure.

Fig. 1.

Comparison between Open and Laparoscopic diversion groups with respect to 'time to initiation of Neo-adjuvant therapy

Discussion

Laparoscopy is gaining widespread acceptance as the standard approach to basic surgical procedures in low- and middle-income countries such as India [13, 14]. In our experience, diversion colostomy plays a crucial role in the management of carcinoma rectum as significant number of patients present with partial intestinal (rectal) obstruction. Delay in initiation of neoadjuvant therapy probably due to late diagnosis, lack of colorectal screening programs directly influences survival rate in patients which mandates early recovery after diversion colostomy in partially obstructed rectal cancer patients [11].

A midline laparotomy is a technique conventionally used for diversion stoma which has disadvantages like increased postoperative pain, slower recovery, longer hospital stay, surgical site infection, acute wound failure, and poor cosmesis in addition to access difficulties during definitive operation [12, 15]. Most of these factors will play a significant role in delaying the initiation of neoadjuvant therapy. In order to overcome the drawbacks of laparotomy, more emphasis has been laid on minimally invasive stoma creation. The techniques employed are trephine and laparoscopic diversion colostomies. Trephine stoma has certain advantages like limited abdominal incision and being able to perform under local or regional anesthesia [16, 17]. However, limited exposure makes the exploration of the abdomen impossible. The other complications include retraction of the stoma due to inadequate mobilization, misalignment of the colonic loop, prolapse due to inadvertent transverse colostomy, and stricture due to difficult exteriorization especially in obese individuals and subsequent parastomal septic complications [17–20].

The feasibility and simplicity of laparoscopic diversion colostomy has been demonstrated over many years through various studies [21–24]. Laparoscopic diversion colostomy has distinct advantages in terms of better anatomical view for stoma and abdominal exploration to look for peritoneal disease [17]. Loop stomas can be challenging in patients with obesity, disseminated malignancy, and the ones with short mesocolon [25]. The technical difficulties associated with exteriorizing loops stomas can be minimized when laparoscopy is employed as there is more room for mobilization of splenic flexure and lateral peritoneal attachments [12, 17]. The reduction in blood loss and the requirement of decreased use of analgesics postoperatively in laparoscopic diversion colostomy compared to open approach has been affirmed by multiple studies [12, 26, 27]. Similarly, the operating time between the two approaches is comparable and there is an early return of bowel function in laparoscopic diversion probably due to less bowel handling [26–29].

The primary endpoint of our study was time to initiation of neoadjuvant therapy either by radiation (LCCRT) or chemotherapy after diversion colostomy. This time reflected the speed of recovery from the diversion surgery. The study showed that the time to initiation of neoadjuvant therapy was shorter with laparoscopic approach compared to open diversion (16 vs. 20.5 days, P = 0.31). In addition to patient benefit, laparoscopic diversion colostomies facilitate post-graduate training in basic laparoscopy.

The limitations of this study include its retrospective observational nature, small sample size, and it being a single-institution study. There is also a need to analyze in a subgroup, emergency versus elective pretreatment diversions. There is insufficient information regarding the decision to choose a particular approach. It is presumed that it is dependent on the preference of the operating surgeon and cost factor. Other factors that influence an approach need to be studied. An in-depth cost-benefit analysis would also help substantiate the superiority of the laparoscopic approach over the open approach as we noticed shorter operating times and shorter postoperative hospital stay and analgesic use in the laparoscopic approach.

Conclusion

This study has shown that pretreatment diversion colostomy using the laparoscopic approach is a safe option which is associated with faster recovery and early initiation of the desired neoadjuvant treatment in patients with locally advanced carcinoma rectum.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all participants in the study.