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Systematic Review and Meta-Analysis of the Role of Defunctioning Stoma in Low Rectal Cancer Surgery

Hüser, Norbert MD*; Michalski, Christoph W. MD*; Erkan, Mert MD*; Schuster, Tibor MSc; Rosenberg, Robert MD*; Kleeff, Jörg MD*; Friess, Helmut MD*

doi: 10.1097/SLA.0b013e318176bf65

Summary Background Data: The role of a defunctioning stoma in patients undergoing low anterior resection for rectal cancer is still the subject of controversy. Recent studies suggest reduced morbidity after low anterior rectal resection with a defunctioning stoma.

Methods: Retrospective and prospective studies published between 1966 and 2007 were systematically reviewed. Randomized controlled trials (RCTs) comparing anterior resections with or without defunctioning stoma were included in a meta-analysis. The pooled estimates of clinically relevant anastomotic leakages and of reoperations were analyzed using a random effects model (odds ratio and 95% confidence interval, CI).

Results: Relevant retrospective single (n = 18) and multicenter (n = 9) studies were identified and included in the systematic review. Analysis of incoherent data of the leakage rates in these nonrandomized studies demonstrated that a defunctioning stoma did not influence the occurrence of anastomotic failure but seemed to ameliorate the consequences of the leak. Four RCTs were included in the meta-analysis. The odds ratio for clinically relevant anastomotic leakage was 0.32 (95% CI 0.17–0.59), revealing a statistically significant benefit conferred through a defunctioning stoma (Z = 3.65, P = 0.0003). The odds ratio for reoperation because of leakage-caused complications was 0.27 (95% CI 0.14–0.51), with significantly fewer reoperations in patients with a defunctioning stoma (Z = 3.95, P < 0.0001). Overall mortality rates were comparable regardless of the presence of a defunctioning stoma.

Conclusion: A defunctioning stoma reduces the rate of clinically relevant anastomotic leakages and is thus recommended in surgery for low rectal cancers.

In this study, a systematic review and a meta-analysis of the role of defunctioning stoma in low rectal cancer surgery were performed, revealing that a stoma reduces the rate of clinically relevant anastomotic leakages. Furthermore, overall mortality rates were comparable. Thus, creation of a defunctioning stoma is recommended in surgery for low rectal cancers.

From the *Department of Surgery, and †Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany.

N.H., C.W.M. and M.E. contributed equally to this study.

Reprints: Helmut Friess, MD, Department of Surgery, Technische Universität München, Ismaningerstrasse 22, 81675 Munich, Germany. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.