Predictive model for early postoperative stomal complications in colorectal cancer: A systematic review

Table 1 Studies on patient- and disease- related factors and stomal complications

Factors	Findings	Ref.
Age and gender	Elderly (> 65 years) women are at a higher risk of stomal complications	Yuan et al[6], Dai et al[7], Saghir et al[8], Nastro et al[9], Fish et al[10], Bai et al[11]
Nutritional status	Malnutrition is an independent, modifiable risk factor for stomal complications	Yuan et al[6], Ba et al[29]
Comorbid status and smoking	Unoptimized comorbidities lead to poor healing and increase stomal compilations	Dai et al[7], Nastro et al[9], Fish et al[10], Bai et al[11], Ba et al[29], Souwer et al[30]
Long-term immunosuppression	Increases risk of postoperative infections, impair tissue healing and prolonged hospitalization	Yuan et al[6], Dai et al[7]
ASA status prior to surgery	Grade III or worse has a significant correlation with stomal complications	Dai et al[7], Saghir et al[8], Nastro et al[9]
Obesity	BMI > 25 kg/m2 increases the risk of stomal complications as well as adds to the intraoperative difficulty	Dai et al[7], Nastro et al[9], Parmar et al[14]
Stage of carcinoma	Higher the TNM stage, more is the risk of stomal complications	Dai et al[7], Fish et al[10], Bai et al[11]
Preoperative chemotherapy and/or radiotherapy	It adversely affects the healing process	Fish et al[10], Bai et al[11], Ba et al[29]

ASA: American Society of Anesthesiologists; BMI: Body mass index; TNM: Tumor-node-metastasis.

Table 2 Studies on technical and surgeon related factors

Factors	Findings	Ref.
Stoma site selection	Preoperative stoma marking reduces complications	Dai et al[7], Qureshi et al[12], Park et al[13], Parmar et al[14]
Diameter of stoma	Diameter of stoma is critical for proper appliance fitting in preventing complications	Dai et al[7], Park et al[13], Ota et al[15], Wang et al[16]
Inadequate length and reduced vascularity of exteriorized bowel	Tension and ischemia at stoma site leads to disruption	Ota et al[15]
Suturing technique	Fine absorbable sutures are essential to prevent mucocutaneous separation and stoma necrosis	Dai et al[7]
Emergency surgery	Lack of preoperative planning increases the risk of complications	Qureshi et al[12], Park et al[13], Parmar et al[14]

Table 3 Studies on role of biomarkers which may be useful in early detection of stomal complications

Factors	Findings	Ref.
CRP, PCT	Both CRP and PCT have a NPV in ruling out septic complications. Threshold value for CRP is 170 to 190 on day 3 and 120 mg/dL to 140 mg/dL on day 4	Dai et al[7], Ramanathan et al[18], Giaccaglia et al[21], Kumar et al[22]
NLR	NLR predicts ischemic complications, threshold value being ≥ 3.54 preoperatively and ≥ 5.5 on postoperative day 7	Forget et al[20], Kumar et al[22]
NAR, GLR, GLB	NAR > 0.086, GLR > 3.662, and GLB ≤ 28 g/L are independent predictors of stomal complications	Yuan et al[6]

CRP: C-reactive protein; PCT: Procalcitonin; NPV: Negative predictive value; NLR: Neutrophil-to-lymphocyte ratio; NAR: Neutrophil-to-albumin ratio; GLR: Glucose-to-lymphocyte ratio; GLB: Globulin level.

Table 4 Publications on application of artificial intelligence and its role in stomal management

Factors	Findings	Ref.
Surgical skill and decision-making	AI can predict the need and type of stoma whether end or loop. Deep learning model can predict the outcome better than logistic regression for complex combination of patient- and procedure-related variables. AI may help in assessment of surgical resection margins which can be applied to surgical decision making	Ghosh and Kumar[23], Kuo et al[24], Bektaş et al[25], Hassan et al[28]
Perfusion and oxygenation of exteriorized bowel	Techniques like ICG and HSI can provide precise information regarding perfusion and oxygenation, preventing potential ischemic complications	Spinelli et al[27]

AI: Artificial intelligence; ICG: Indocyanine green; HIS: Hyperspectral imaging.

Table 5 Proposed nomogram model for prediction of stomal complications

Factors	Criteria	Score1
Age, years	≤ 65	0
	> 65	1
Gender	Male	0
	Female	1
BMI, kg/m2	18.5-25	0
	> 25	1
Diabetes or cardiac comorbidities	No	0
	Yes	1
Tobacco abuse	No	0
	Yes	1
Long-term immunosuppression, > 3 months	No	0
	Yes	1
ASA status	< Grade III	0
	≥ Grade III	1
AJCC stage of carcinoma	Stage 1 or 2	0
	Stage 3 or 4	1
Preoperative chemotherapy and/or radiotherapy	No	0
	Yes	1
Type of surgery	Elective	0
	Emergency	1
Experience of surgeon	Specialist colorectal surgeon	0
	Trainee
	Senior registrar	1
Preoperative stoma markings	No	0
	Yes	1
Intraoperative difficulty related to length of exteriorized bowel or vascularity	No	0
	Yes	1
CRP level > 170 mg/dL on postoperative day 3	No	0
	Yes	1
NLR ≥ 3.54 preoperatively	No	0
	Yes	1
NLR ≥ 5.5 on postoperative day 7	No	0
	Yes	1
NAR > 0.086 on postoperative day 3	No	0
	Yes	1
GLR > 3.662 on postoperative day 3	No	0
	Yes	1
GLB ≤ 28 g/L on postoperative day 3	No	0
	Yes	1
Use of artificial intelligences	Yes	0
	No	1

¹Higher the total score, more is the risk of stomal complications.

BMI: Body mass index; ASA: American Society of Anesthesiologists; AJCC: American Joint Committee on Cancer; CRP: C-reactive protein; NLR: Neutrophil-to-lymphocyte ratio; NAR: Neutrophil-to-albumin ratio; GLR: Glucose-to-lymphocyte ratio; GLB: Globulin level.