title: The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program.
abstract: BACKGROUND
  Anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) with total mesorectal excision (TME) for rectal cancer. Whether the Enhanced Recovery After Surgery (ERAS)-protocol influences the risk of short-term morbidity in relation to the use of a diverting stoma is unclear.
  
  
  METHODS
  Between 2002 and 2011, 287 consecutive patients underwent LAR with TME for rectal cancer at Ersta Hospital, Sweden. All patients were treated according to the ERAS program and thereby included. Between 2002 and 2006 15% had a diverting stoma compared to 91 %, 2007 to 2011.
  
  
  RESULTS
  One hundred and thirty-nine patients were operated with a diverting stoma at primary surgery (S+), 148 patients were not (S-). The groups were comparable regarding pre- and peroperative data and patients' characteristics. Postoperative morbidity within 30 days after surgery (S+ 53% vs. S- 43%) and hospital stay (S+ 11 days vs. S- 9 days) did not differ. AL occurred in 22% of all patients. In a multivariate analysis, no significant difference in AL was found in relation to the use of a diverting stoma (S+ vs. S-, OR 0.64, 95% CI 0.34-1.19). Eleven patients (8%) in the S+ group underwent relaparotomy versus 22 (15%) in the S- group (p = 0.065). Total overall compliance to the ERAS program was 65%. Patients in S- had faster postoperative recovery.
  
  
  CONCLUSIONS
  A diverting stoma did not affect postoperative morbidity in this large cohort of patients undergoing LAR within an ERAS program. However, the routine use of a diverting stoma could be expected to delay postoperative recovery.
authors.affiliation: Department of Surgical Gastroenterology, Karolinska University Hospital, Sweden; Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden. Electronic address: kajsa.anderin@karolinska.se.
authors.forename: K
authors.initials: K
authors.lastname: Anderin
authors.affiliation: Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Danderyds Hospital, Sweden.
authors.forename: U O
authors.initials: UO
authors.lastname: Gustafsson
authors.affiliation: Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden.
authors.forename: A
authors.initials: A
authors.lastname: Thorell
authors.affiliation: Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden.
authors.forename: J
authors.initials: J
authors.lastname: Nygren
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057868:Anastomotic Leak / Q000517:prevention & control* / Q000601:surgery; D002985:Clinical Protocols; D004434:Early Ambulation; D004766:Enterostomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D045823:Ileus / Q000601:surgery; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010359:Patient Readmission; D011183:Postoperative Complications / Q000145:classification; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000601:surgery*; D012086:Reoperation; D013529:Surgical Wound Dehiscence / Q000601:surgery
keywords: Diverting stoma; ERAS; Fast track surgery; Low anterior resection