Protective defunctioning stoma in low anterior resection for rectal carcinoma (Br J Surg 2005; 92: 1137-1142)

Sir We agree with the authors' conclusions on the merits of a protective defunctioning stoma after low anterior resection for rectal carcinoma and would like to raise a few points in the context of our own experience in the Gastrointestinal Oncology Unit at India's largest cancer centre at the Tata Memorial Hospital, Mumbai. In the authors' study, the decision to fashion a defunctioning stoma was left to the individual surgeon. We have a protocol for constructing a protective stoma that includes: age over 65 years, ultralow anterior resection (within 5 cm of the anal verge) or intersphincteric resection, preoperative irradiation and following technical problems like incomplete doughnuts. On analysing the data from 168 patients who underwent sphincter-saving surgery for rectal cancer between April 2002 and April 2005, a covering stoma was performed in 63 patients (37·5 per cent). Fifteen patients (9 per cent) developed an anastomotic leak, nine in the group without, and six in the group with a covering stoma. Three patients were managed conservatively, all of whom had a covering stoma in place. Surgical intervention was needed in 12 patients. Two required only peritoneal lavage, both of them had a covering stoma. In five patients a covering colostomy was fashioned and the remaining five required an anastomotic disconnection and conversion to Hartmann's procedure. One patient died from ongoing septicaemia; this patient did not have a covering stoma at the primary surgery. Similar to the authors' observations, we have shown that though a covering stoma does not prevent an anastomotic leak, it mitigates the clinical consequences and reduces the rate of re-exploration. If surgical re-exploration is required, a procedure of lesser magnitude is likely for a patient who already has a covering stoma.