Problems with preventive stoma for rectal cancer

For the question of whether to perform a preventive stoma after anal-preserving surgery for low rectal cancer, there have been two opinions over the years, one for and one against. Those who advocate preventive stoma are not doctors who are poor at surgery and lack experience. On the contrary, many of them are leading figures in anorectal surgery in our country. Those who firmly oppose preventive stoma are mostly young doctors. I was one of them, but now I realize that many of my initial views were one-sided.

Can preventive stoma reduce the incidence of anastomotic leakage? Many doctors think it cannot, but it can only play a role in diversion once leakage occurs. After communicating with some experts, I think otherwise. From the perspective of blood supply alone, preventive stoma cannot reduce the incidence of anastomotic leakage. If blood supply is impaired, the stoma will still leak. However, from the perspective of tension and infection, this is not the case. Most anastomotic leakage occurs after the patient resumes defecation. This is because stool continues to pass through the anastomosis, and the anastomosis cannot withstand the tension, which causes leakage. Especially after low rectal cancer surgery, the anus cannot be retracted and released freely. At this time, stool accumulates at the anastomosis. Infection factors and pressure on the anastomosis are the causes of leakage. Therefore, six or seven days after surgery, it is thought that the healed soon, which is exactly the time when leakage occurs most frequently. If a preventive stoma is done, this problem does not exist. Therefore, preventive stoma is not only a diversion problem, but also has the function of reducing anastomotic leakage.

In short, the reasons for whether to perform a stoma are complex and cannot be generalized. The surgeon should make his own decision based on the specific circumstances. Although it is impossible for every unit to require routine preventive stomas like Changhai Hospital, it is even more undesirable not to do it routinely.