Table 1 shows the patient background. The median patient age was 64 years (range, 25–86 years). The participants consisted of 267 men and 133 women. The median BMI of the patients was 23.0 kg/m2 (14.3 to 34.4 kg/m2). The tumors were located in the RS, Ra, and Rb in 115, 172, and 112 patients, respectively. The laparoscopic approach was adopted in 272 patients (68%). Concerning the surgical procedure, low anterior resection, high anterior resection, and intersphincteric resection were performed in 308 (77.0%), 55 (13.8%), and 37 (9.3%) patients, respectively. Furthermore, DS was constructed in 153 (38.3%) patients. Overall, POCs were identified in 120 (30%) patients, leading to reoperation in 19 (4.8%) patients. One case of patient death was recorded due to cerebral hemorrhage.
The characteristics of patients in the DS (-) and DS (+) groups are shown in Table 2. There were no significant intergroup differences in age, gender, or BMI. Regarding the distribution of tumor location, the proportion of patients with Rb tumors was significantly higher in the DS (+) group (p<0.01). The choice of preoperative treatment, including CRT and NAC, was significantly different in the two groups (p<0.01). The p Stage was I, II, III, and IV in 67, 65, 85, and 18 patients in the DS (-) group, and 62, 39, 45, and 7 patients in the DS (+) group, respectively (p=0.03).
The surgical outcomes of patients in the DS (-) and DS (+) groups are shown in Table 3. There were intergroup differences in the distribution of surgical procedure type, performance rate of lateral lymph node dissection, and laparoscopic approach rate. The operative time was significantly longer in patients in the DS (+) group (268 min vs. 405 min, p<0.01); nonetheless, the volume of blood loss was not significantly different (30 mL vs. 50 mL, p=0.84). Furthermore, the ano-anastomotic distance was significantly smaller in patients in the DS (+) group (8 cm vs. 4 cm, p<0.01).
Short-term outcomes of DS construction are shown in Table 4. Oral ingestion was started on postoperative day 6 (4 to 41) in the DS (-) group and on postoperative day 4 (2 to 18) in the DS (+) group. This demonstrated that the time to oral ingestion was significantly shorter in the DS (+) group (p=0.01).
POCs with grade >4 was detected in 1 patient in the DS (+) group. Moreover, the number of patients with grade 1-3 POCs was significantly higher in the DS (+) group. However, there was no significant intergroup difference in the number of patients with POCs grade 3b (12 vs. 7, p=0.90). There was no significant intergroup difference in the proportion of patients with AL of all grades (10.9% vs. 15.0%, p=0.31); the proportion of patients with AL grade 3b was significantly higher in the DS (-) group (4.5% vs. 0%, p=0.01). On the other hand, to patients occurring bowel obstruction, not only the incidence of all grade but also the incidence of grade3, were significantly higher in the DS (+) group (4.0% vs. 25.5%, p<0.01, 2.4% vs. 17.0%, p<0.01, respectively).
However, there were no significant intergroup differences in the incidences of SSI and micturition disorders. The postoperative hospitalization period was significantly shorter in the DS (-) group (12 days vs. 15 days, p=0.02).
Reoperation was required in 12 (4.9%) and 7 (4.6%) patients in the DS (-) and DS (+) groups, respectively, which was not significantly different between the groups (p=0.90). Reoperation factors in the DS (-) group included AL (11 cases) and adhesive bowel obstruction (1 case). In the DS (+) group, reoperation factors included stoma outlet syndrome (4 cases), electrolyte imbalance (1 case), mucocutaneous stoma separation (1 case), and intraperitoneal hematoma (1 case); moreover, reoperation was required for SRCs in 6 of the 7 patients (Table 5).
Early complications were observed in 33 patients (21.6%): stoma outlet syndrome (19 cases, 12.4%), electrolyte imbalance (7 cases, 4.6%), peristomal dermatitis (6 cases, 3.9%), and infection-related stoma separation (1 case, 0.7%). Neither hemorrhage nor necrosis was reported in these patients (Table 5). As a late complication, parastomal hernia was noted in 3 patients (2.0%). Neither prolapse nor fistula formation was noted.
The median follow-up time after DS construction was 229 (range, 10–2,331) days. In 145 (94.8%) of the 153 patients, DS reversal was achieved. In 8 patients (5.2%), a DS was left due to death cause by other disease (3 cases), refractory fistulae (2 cases), stage IV cancer (2 cases), and the patient’s request (1 case).