Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis

BACKGROUND: Some patients receiving defunctioning stomas will never undergo stoma reversal, but it is difficult to preoperatively predict which patients will be affected. OBJECTIVE: The aim of this meta-analysis was to identify the risk factors associated with nonclosure of temporary stomas after sphincter-preserving low anterior resection for rectal cancer. DATA SOURCES: We performed a comprehensive search of the PubMed, Embase, and Cochrane Central Library databases for all of the studies analyzing risk factors for nonclosure of defunctioning stomas. STUDY SELECTION: We only included articles published in English in this meta-analysis. The inclusion criteria were as follows: 1) original article with extractable data, 2) studies including only defunctioning stomas created after low anterior resection for rectal cancer, 3) studies with nonclosure rather than delayed closure as the main end point, and 4) studies analyzing risk factors for nonclosure. INTERVENTION: Defunctioning stomas were created after low anterior resection for rectal cancer. MAIN OUTCOME MEASURES: Stoma nonclosure was the only end point, and it included nonclosure and permanent stoma creation after primary stoma closure. The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies, and risk ratios and 95% CIs were used to assess risk factors. RESULTS: Ten studies with 8568 patients were included. The nonclosure rate was 19% (95% CI, 13%-24%; p < 0.001; I-2=96.2%). Three demographic factors were significantly associated with nonclosure: older age (risk ratio= 1.50 (95% CI, 1.12-2.02); p = 0.007; I-2= 39.3%), ASA score >2 (risk ratio = 1.66 (95% CI, 1.51-1.83); p < 0.001; I-2= 0%), and comorbidities (risk ratio = 1.58 (95% CI, 1.29-1.95); p < 0.001; I-2= 52.6%). Surgical complications (risk ratio = 1.89 (95% CI, 1.48-2.41); p < 0.001; I-2= 29.7%), postoperative anastomotic leakage (risk ratio = 3.39 (95% CI, 2.41-4.75); p < 0.001; I-2= 53.0%), stage IV tumor (risk ratio = 2.96 (95% CI, 1.73-5.09); p < 0.001; I-2= 88.1%), and local recurrence (risk ratio = 2.84 (95% CI, 2.11-3.83); p < 0.001; I-2= 6.8%) were strong clinical risk factors for nonclosure. Open surgery (risk ratio = 1.47 (95% CI, 1.01-2.15); p = 0.044; I-2= 63.6%) showed a borderline significant association with nonclosure. LIMITATIONS: Data on some risk factors could not be pooled because of the low number of studies. There was conspicuous heterogeneity between the included studies, so the pooled data were not absolutely free of exaggeration or influence. CONCLUSIONS: Older age, ASA score >2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence are risk factors for nonclosure of defunctioning stomas after low anterior resection in patients with rectal cancer, whereas tumor height, radiotherapy, and chemotherapy are not. Patients with these risk factors should be informed preoperatively of the possibility of nonreversal, and joint decision-making is preferred.