Outcome of selective non-diverting low anterior resection after neoadjuvant chemoradiotherapy and curative surgery for proximal rectal cancer: A prospective case series.

Background: Low anterior resection (LAR) is the gold standard for curative cancer treatment in the middle and upper rectum. In radically operated patients, the local recurrence rates with total mesorectal excision (TME) after 5 and 10 years was<10%, with 80% in 5 years survival. Anastomotic leakage (AL) affects 4%-20% of patients who underwent LAR. Based on some studies, there is a risk reduction of symptomatic AL after LAR and the need for reoperation in patients with a defunctioning stoma (DS), also known as diverting stoma. Ileostomy has many complications, such as skin irritation and leakage, dehydration, obstruction, and parastomal hernia. Considering the complications of defunctioning loop-ileostomy (DLI) we designed this study to evaluate noninserting stoma in a particular group of patients.

Methods: This retrospective cohort case series study utilized data of 20 patients with rectal adenocarcinoma with lesion>7 cm from anal verge in rectoscopy who underwent LAR after 28 sessions of chemoradiotherapy (CRT) and 6 weeks of rehabilitation. All of the patients matched our criteria, so DLI was not performed on any of them.

Results: Among our 20 patients, four AL were happened (20%). C-reactive protein (CRP) on post-operation day (POD) six was valuable. Computed tomography (CT) scan was not used as a reliable modality in our study. In all patients with positive AL, magnetic resonance imaging (MRI) was useful and reported correctly, and direct vision of the anastomosis site by rigid rectoscopy was not safe enough to make decisions about it.

Conclusion: The leakage rate was not far from the average leakage rate in other studies. Then it seems it is possible to forget about defunctioning loop stoma (DLS) in safe cases to reduce the stoma complications. Due to our restricted case selection and our close observation protocol, we had no significant complications compared to other studies. According to this study, not inserting stoma in suitable cases with restricted protocol selection is possible, and the leakage rate is not higher in comparison with patients with stoma.