Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial

Prediction of symptomatic anastomotic leak after rectal cancer surgery: A machine learning approach

INTRODUCTION

Anastomotic leakage (AL) remains the most dreaded and unpredictable major complication after low anterior resection for mid-low rectal cancer. The aim of this study is to identify patients with high risk for AL based on the machine learning method.

METHODS

Patients with mid-low rectal cancer undergoing low anterior resection were enrolled from West China Hospital between January 2008 and October 2019 and were split by time into training cohort and validation cohort. The least absolute shrinkage and selection operator (LASSO) method and stepwise method were applied for variable selection and predictive model building in the training cohort. The area under the receiver operating characteristic curve (AUC) and calibration curves were used to evaluate the performance of the models.

RESULTS

The rate of AL was 5.8% (38/652) and 7.2% (15/208) in the training cohort and validation cohort, respectively. The LASSO-logistic model selected almost the same variables (hypertension, operating time, cT4, tumor location, intraoperative blood loss) compared to the stepwise logistic model except for tumor size (the LASSO-logistic model) and American Society of Anesthesiologists score (the stepwise logistic model). The predictive performance of the LASSO-logistics model was better than the stepwise-logistics model (AUC: 0.790 vs. 0.759). Calibration curves showed mean absolute error of 0.006 and 0.013 for the LASSO-logistics model and stepwise-logistics model, respectively.

CONCLUSION

Our study developed a feasible predictive model with a machine-learning algorithm to classify patients with a high risk of AL, which would assist surgical decision-making and reduce unnecessary stoma diversion. The involved machine learning algorithms provide clinicians with an innovative alternative to enhance clinical management.

High-output stoma is a risk factor for stoma outlet obstruction in defunctioning loop ileostomies after rectal cancer surgery

PURPOSE

Defunctioning loop ileostomy has been reported to reduce symptomatic anastomotic leakage after rectal cancer surgery; however, stoma outlet obstruction (SOO) is a serious postileostomy complication. We, therefore, explored novel risk factors for SOO in defunctioning loop ileostomy after rectal cancer surgery.

METHODS

This is a retrospective study that included 92 patients who underwent defunctioning loop ileostomy with rectal cancer surgery at our institution. Among them, 77 and 15 ileostomies were created at the right lower abdominal and umbilical sites, respectively. We defined the output volumeMAX as the maximum output volume the day before the onset of SOO or-for those without SOO-that was observed during hospitalization. Univariate and multivariate analyses were performed to evaluate risk factors for SOO.

RESULTS

SOO was observed in 24 cases, and the median onset was 6 days postoperatively. The stoma output volume in the SOO group was consistently higher than that in the non-SOO group. In the multivariate analysis, the rectus abdominis thickness (p < 0.01) and output volumeMAX (p < 0.01) were independent risk factors for SOO.

CONCLUSION

A high-output stoma may predict SOO in patients with defunctioning loop ileostomy for rectal cancer. Considering that SOO occurs even at umbilical sites with no rectus abdominis, a high-output stoma may trigger SOO primarily.

Factors affecting timing of loop ileostomy closure: a regional centre's experience with 106 patients

INTRODUCTION

The burden of defunctioning ileostomy is significant with up to two thirds of patients reporting stoma-related morbidity. While timely reversal is safe and cost-effective, the time to reversal in regional Australian hospitals is not well described in professional publications. We aim to assess the current timeliness of ileostomy closure and identify possible reasons for delaying closure.

METHODS

A retrospective analysis of loop ileostomies created and reversed in Launceston General Hospital for both rectal cancer surgery and other benign indications was undertaken. Patients with loop ileostomy created between 2010 and 2020 were included. Clinical data of timing of events, complications, readmission and stoma follow-up were recorded; and analysed using multivariate regression analyses to identify clinically relevant risk factors for delayed closure.

RESULTS

A total of 123 patients underwent loop-ileostomy formation during the study period, of which 106 patients (86.2%) were reversed. Median time to closure was 8.5 months (IQR 5.2-12.4) for patients with rectal cancers, compared to 5.2 months (IQR 3.6-9.3) for patients who did not have rectal cancer, with a difference of 3.4 months (95% CI 0.9, 5.9; P = 0.008). Adjuvant chemotherapy and unexpected readmission to hospital were associated with delayed reversal (P = 0.0081 and P = 0.0005, respectively).

CONCLUSION

Stoma reversal is often scheduled 3-6 months after creation. More than two-thirds of patients experienced delays due to changing clinical concerns and non-clinical factors, such as unexpected delays at each stage of surgical planning. Early placement on the waiting list and better-coordinated follow-ups may expedite reversal surgery and reduce associated morbidities.

What affects the selection of diverting ileostomy in rectal cancer surgery: a single-center retrospective study

BACKGROUND

The selection of diverting ileostomy (DI) is controversial. This study aimed to explore the factors affecting the selection of diverting ileostomy (DI) following laparoscopic low anterior resection for rectal cancer.

METHODS

This retrospective, case-control study included patients who underwent laparoscopic-assisted sphincter-saving surgery for mid-low rectal cancer from January 2019 to June 2021. Univariate and multivariate analyses were performed on the patient's clinicopathological characteristics and pelvic dimensions measured by abdominopelvic electron beam computed tomography.

RESULTS

A total of 382 patients were included in the analysis, of which 182 patients (47.6%) did not undergo DI, and 200 patients (52.4%) underwent DI. The univariate analysis suggested that male sex (p = 0.003), preoperative radiotherapy (p < 0.001), patients with an anastomosis below the levator ani plane (p < 0.001), the intertuberous distance (p < 0.001), the sacrococcygeal distance (p = 0.025), the mid pelvis anteroposterior diameter (p = 0.009), and the interspinous distance (p < 0.001) were associated with performing DI. Multivariate analysis confirmed that preoperative radiotherapy (p = 0.037, odds ratio [OR] = 2.98, 95% confidence interval [CI] = 1.07-8.30), anastomosis below the levator ani plane (p < 0.001, OR = 7.09, 95% CI = 4.13-12.18), and the interspinous distance (p = 0.047, OR = 0.97, 95% CI = 0.93-1.00) were independently associated with performing DI.

CONCLUSION

Pelvic parameters also influence the choice of DI. According to this single-center experience, patients with a shorter interspinous distance, particularly narrow pelvic with an interspinous distance of < 94.8 mm, preoperative radiotherapy, and anastomosis below the levator ani plane, prefer to have a DI and should be adequately prepared by the physician.

Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer

BACKGROUND

Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up.

AIMS

To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment.

METHODS

One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires.

RESULTS

80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF.

CONCLUSIONS

A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.

Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study

BACKGROUND

The surgical resection of rectal carcinoma is associated with a high risk of permanent stoma rate. Primary anastomosis rate is suggested to be higher in robot-assisted and transanal total mesorectal excision, but permanent stoma rate is unknown.

METHODS

Patients undergoing total mesorectal excision for MRI-defined rectal cancer between 2015 and 2017 in 11 centers highly experienced in laparoscopic, robot-assisted or transanal total mesorectal excision were included in this retrospective study. Permanent stoma rate, stoma-related complications, readmissions, and reoperations were registered. A multivariable regression analysis was performed for permanent stoma rate, stoma-related complications, and stoma-related reoperations.

RESULTS

In total, 1198 patients were included. Permanent stoma rate after low anterior resection (with anastomosis or with an end colostomy) was 40.1% in patients undergoing laparoscopic surgery, 21.3% in patients undergoing robot-assisted surgery, and 25.6% in patients undergoing transanal surgery (P < 0.001). Permanent stoma rate after low anterior resection with an anastomosis was 17.3%, 11.8%, and 15.1%, respectively. The robot-assisted and transanal techniques were independently associated with a reduction in permanent stoma rate in patients who underwent a low anterior resection (with anastomosis or with an end colostomy) (OR 0.39 [95% CI 0.25, 0.59] and OR 0.35 [95% CI 0.22, 0.55]), while this was not seen in patients who underwent a restorative low anterior resection. 45.4% of the patients who had a stoma experienced stoma-related complications, 4.0% were at least once readmitted, and 8.9% underwent at least one reoperation.

CONCLUSIONS

The robot-assisted and transanal techniques are associated with a lower permanent stoma rate in patients who underwent a low anterior resection.

A Novel Fluorescence-Based Leak Test Method for Rectal Anastomoses Using Aerosolized Indocyanine Green

BACKGROUND

The intraoperative air leak test is commonly performed during rectal surgery to evaluate anastomotic integrity. However, its drawbacks include occasional difficulties in visualizing the exact point of the leak while maintaining the pelvis under saline, the need for repeat testing to identify the leak point, and a lack of continuous visualization of the leak point.

OBJECTIVE

To evaluate the feasibility and clinical applicability of using aerosolized indocyanine green, a fluorescent tracer, for detecting rectal anastomotic leakage.

DESIGN

Animal preclinical study.

SETTING

Animal laboratory at Kagawa University.

PATIENTS

Six healthy adult female beagles were included.

INTERVENTIONS

An anastomotic leakage model with a single air leak point was created in each dog. Indocyanine green was aerosolized using a nebulizer kit with a stream of carbon dioxide flowing at 1.5 to 2.0 L/min. The aerosol was administered into the rectum transanally, and laparoscopic observations were performed.

MAIN OUTCOME MEASURES

Air leak points were observed using a near-infrared fluorescence laparoscope, after which the presence of corresponding indocyanine green fluorescence was verified.

RESULTS

Aerosolized indocyanine green was visualized laparoscopically at all anastomosis sites but not elsewhere. The median time from the administration of the aerosol to its visualization was 4.5 seconds. Pathological examinations were performed 4 weeks postsurgery in all dogs, and no histological abnormalities related to aerosolized indocyanine green administration were observed at the anastomosis sites.

LIMITATIONS

The leak points were surgically created and did not occur naturally.

CONCLUSIONS

Visualization of air leaks at the sites of rectal anastomosis was laparoscopically achievable by administering aerosolized indocyanine green transanally into the rectum in our canine model. This novel fluorescent leak test could be a valid alternative to established methods.

Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review

INTRODUCTION

Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time.

METHODS

Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data.

RESULTS

A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles).

CONCLUSION

Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.

Efferent limb stimulation prior to loop ileostomy closure: a systematic review and meta-analysis

BACKGROUND

Postoperative ileus (POI) remains a common phenomenon following loop ileostomy closure. Our aim was to determine whether preoperative physiological stimulation (PPS) of the efferent limb reduced POI incidence.

METHODS

A PRISMA-compliant meta-analysis searching PubMed, EMBASE and CENTRAL databases was performed. The last search was carried out on 30 January 2023. All randomized studies comparing PPS versus no stimulation were included. The primary endpoint was POI incidence. Secondary endpoints included the time to first passage of flatus/stool, time to resume oral diet, need for nasogastric tube (NGT) placement postoperatively, length of stay (LOS) and other complications. Random effects models were used to calculate pooled effect size estimates. Trial sequential analyses (TSA) were also performed.

RESULTS

Three randomized studies capturing 235 patients (116 PPS, 119 no stimulation) were included. On random effects analysis, PPS was associated with a quicker time to resume oral diet (MD - 1.47 days, 95% CI - 2.75 to - 0.19, p = 0.02), shorter LOS (MD - 1.47 days, 95% CI - 2.47 to - 0.46, p = 0.004) (MD - 1.41 days, 95% CI - 2.32 to - 0.50, p = 0.002, I2 = 56%) and fewer other complications (OR 0.42, 95% CI 0.18 to 1.01, p = 0.05). However, there was no difference in POI incidence (OR 0.35, 95% CI 0.10 to 1.21, p = 0.10), the requirement for NGT placement (OR 0.50, 95% CI 0.21 to 1.20, p = 0.12) or time to first passage of flatus/stool (MD - 0.60 days, 95% CI - 1.95 to 0.76, p = 0.39). TSA revealed imprecise estimates for all outcomes (except LOS) and further studies are warranted to meet the required information threshold.

CONCLUSIONS

PPS prior to stoma closure may reduce LOS and postoperative complications albeit without a demonstrable beneficial effect on POI. Further high-powered studies are required to confirm or refute these findings.

Is early CT in cases of elevated postoperative CRP the best option for the diagnosis of colorectal anastomotic leakage?

PURPOSE

After colorectal surgery (CRS), the early detection and treatment of anastomotic leakage (AL) is critical. We aimed to evaluate the efficacy of early contrast-enhanced computed tomography (CT) (postoperative day [POD] 2-3) after elective colorectal surgery for the diagnosis of AL for patients with elevated CRP levels at POD 2-3.

METHOD

From 2017 to 2022, all patients who underwent elective CRS with an anastomosis and CRP > 150 mg/ml on POD 2-3 underwent enhanced CT during the 24 h following the CRP evaluation and were included in this retrospective, single-center study. The primary endpoint was the diagnostic value of the early CT scan for the detection of AL. The secondary endpoints were the diagnostic value of the early CT scan for the detection of grade C AL according to the type of resection and anastomosis and the quality of the opacification.

RESULTS

A total of 661 patients underwent elective CRS with anastomosis with an overall AL rate of 7.4%. Among the 661 patients, 141 were finally included in the study. The accuracy of early CT for the diagnosis of AL was 83.7%. For grade C AL, the accuracy was 81.6%. Among patients who had an ileocolic anastomosis, the accuracy was 88.2%, among those who had colorectal or ileorectal anastomosis, the accuracy was 83.0%, and among those who had a coloanal, the accuracy was 66.7%. In cases of good opacification by CT, the accuracy was 84.0%.

CONCLUSION

Early CT does not show perfect accuracy for an early diagnosis of AL.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results

BACKGROUND

Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).

METHODS

100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.

RESULTS

Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).

CONCLUSION

When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.

Anastomotic leakage and functional outcomes following total mesorectal excision with delayed and immediate colo-anal anastomosis for rectal cancer: Two single-arm phase II trials

BACKGROUND

Anastomotic leakage (AL) remains a major cause of morbidity following total mesorectal excision (TME). A diverting ileostomy reduces the risk of AL but impairs quality of life (QoL). Delayed colo-anal anastomosis (DCAA) may be an alternative to immediate colo-anal anastomosis (ICAA) without creation of a diverting ileostomy.

STUDY DESIGN

Patients with T3 or N+ rectal tumours were treated with neoadjuvant chemoradiation and TME. To evaluate DCAA or ICAA with diverting ileostomy, a two multicenter single-arm phase II trials was designed. The primary endpoint was the rate of AL requiring a diverting ileostomy up to 30 days postoperatively. Secondary endpoints were 30-day postoperative complications, 1- and 2-year disease-free survival; QoL at baseline, 6 months and anorectal function measured by the low anterior resection syndrome questionnaire and Wexner score at baseline, 6 months and a late assessment at median 8 years following surgery.

RESULTS

AL requiring diverting ileostomy occurred in one patient (2.1%; 95% confidence interval (CI) [0; 11.1]) in the DCAA group and in five patients (8.6%; 95%CI [3.2; 21.0]) in the ICAA group. Thirty-day postoperative complications occurred in 13 patients (27.1%) in the DCAA group and in 10 patients (19.2%) in the ICAA group. Short and long-term functional outcomes showed similar patterns.

CONCLUSION

These two single-arm phase II trials showed that DCAA has low rates of AL requiring a diverting ileostomy and acceptable long-term functional results. DCAA seems a good choice to restore bowel continuity.

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort

OBJECTIVE

To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).

BACKGROUND

AL after RC resection often results in a permanent stoma.

METHODS

This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.

RESULTS

This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).

CONCLUSIONS

The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.

Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR

OBJECTIVES

To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications.

BACKGROUND

DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA).

METHODS

All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included.

RESULTS

Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up.

CONCLUSIONS

DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.

Defunctioning stoma and anastomotic stricture in rectal cancer surgery: a propensity score matching study

BACKGROUND

In cases of rectal cancer surgery, patients at high risk of anastomotic leakage often receive a defunctioning stoma (DS). However, its role in postoperative anastomotic strictures (AS) remains unclear. This study aimed to investigate the correlation between DS and AS and outcomes of transanal endoscopic microsurgery (TEM) in treating rectal AS.

METHODS

This retrospective study was conducted from January 2019 to September 2021 and included patients who underwent rectal cancer surgery. A 1:1 ratio was used for propensity score matching (PSM). Univariate analyses were performed to identify statistically significant variables, and multivariate analyses were conducted to determine the factors affecting AS.

RESULTS

This study included 383 patients. The results of the univariate analysis suggested that surgery time (HR 4.597, 95% CI 1.563-13.525, P=0.006), postoperative anastomotic leakage (HR 11.830, 95% CI 3.773-37.094, P<0.001), and DS (HR 15.475, 95% CI 6.042-39.641, P<0.001) were significantly associated with AS. In the multivariate analysis, postoperative anastomotic leakage (HR 7.596, 95% CI 1.987-29.044, P= 0.003) and DS (HR 11.252, 95% CI 4.113-30.779, P<0.001) were identified as significant risk factors for AS. After matching, the univariate analysis revealed that postoperative anastomotic leakage (HR 8.333, 95% CI 1.541-45.052, P= 0.014) and DS (HR 9.965, 95% CI 2.200-45.142, P= 0.003) were associated with AS. The multivariate analysis indicated that postoperative anastomotic leakage (HR 14.549, 95% CI 1.765-119.913, P= 0.013) and DS (HR 12.450, 95% CI 2.418-64.108, P= 0.003) were significant risk factors for AS.

CONCLUSIONS

This study provides evidence that DS is independently associated with AS, and postoperative anastomotic leakage increases the risk of AS. Furthermore, this study suggests that TEM could be a valuable treatment option for AS.

Evaluation of the SafeHeal Colovac+ anastomosis protection device after low anterior resection for rectal cancer: the safe anastomosis feasibility evaluation (SAFE) 2019 trial

BACKGROUND

Protective ileostomy (PI) is the current standard of care to protect the anastomosis after low anterior resection (LAR) for rectal cancer, but is associated with significant morbidity. Colovac is an anastomosis protection device designed to shield the anastomosis from fecal content. A second version (Colovac+) was developed to limit the migration risk during the implantation period. The objective of this clinical trial was to evaluate the preliminary efficacy and safety of the Colovac+.

METHODS

This was a prospective, multicenter, pilot study aiming to enroll 15 patients undergoing LAR with Colovac+ placement. After 10 days, a CT scan was performed to evaluate the anastomosis and the Colovac+ was retrieved endoscopically. During the 10-day implantation and 3-month follow-up period, we collected data regarding predefined efficacy and safety endpoints. The primary endpoint was the rate of major (Clavien-Dindo III-V) postoperative complications related to the Colovac+ or LAR procedure.

RESULTS

A total of 25 patients were included (68% male), of whom 15 were consecutively treated with the Colovac+ and Vacuum Loss Alert System. The Colovac+ was successfully implanted in all 15 patients. No major discomfort was reported during the implantation period. The endoscopic retrieval was performed in 14/15 (93%) patients. The overall major postoperative morbidity rate was 40%, but none of the reported complications were related to the Colovac+. A device migration occurred in 2 (13%) patients, but these were not associated with AL or stoma conversion. Overall, Colovac+ provided effective fecal diversion in all 15 patients and was able to avoid the PI in 11/15 (73%) patients.

CONCLUSIONS

Colovac+ provides a safe and effective protection of the anastomosis after LAR, and avoids the PI in the majority (73%) of patients. The improved design reduces the overall migration rate and limits the clinical impact of a migration.

Laparoscopic vs. open loop ileostomy reversal: a meta-analysis of randomized and non-randomized studies

PURPOSE

The present meta-analysis compares laparoscopic loop ileostomy reversal (LLIR) with open loop ileostomy reversal (OLIR) to evaluate the advantages of the laparoscopic technique compared to the traditional open technique in ileostomy reversal.

METHODS

Primary endpoints were hospital stay and overall complications. Secondary endpoints were operative time, EBL, readmission, medical complications, surgical complications, reoperation, wound infection, anastomotic leak, intestinal obstruction, and cost of the procedures. The included studies were also divided based on the type of anastomotic approach: extracorporeal laparoscopic loop ileostomy reversal (ELLIR) and intracorporeal laparoscopic loop ileostomy reversal (ILLIR).

RESULTS

In the analysis, 4 studies were included. Three hundred fifty-four patients were enrolled. As primary outcomes, a significant difference was found in hospital stay between the LLIR and OLIR groups (MD = -0.67, 95% CI -1.16 to -0.19, P = 0.007). The overall complications outcome resulted in favor of the LLIR group (RR = 0.64, 95% CI 0.43-0.95, P = 0.03). As secondary outcomes, the operative time was in favor of the OLIR group (MD = 19.18, 95% CI 10.20-28.16, P < 0.001). Surgical complications were lower in the LLIR group than in the OLIR group. No other differences between the secondary endpoints were found. Subgroup analysis showed a significant difference in hospital stay between the ILLIR and OLIR groups (MD = -0.92, 95% CI -1.55 to -0.30, P = 0.004). The overall complications outcome significantly favored the ILLIR group (RR = 0.38, 95% CI 0.15-0.96, P = 0.04).

CONCLUSION

Our meta-analysis shows an advantage in terms of shorter post-operative hospitalization and reduction of complications of LLIR compared to OLIR. The sub-group analysis shows that performing an extracorporeal anastomosis exposes the same risks of the open technique.

Risk Factors for Radical Rectal Cancer Surgery with a Temporary Stoma Becoming a Permanent Stoma: A Pooling Up Analysis

Purpose: The aim of this study was to find out the potential risk factors for the formation of a permanent stoma (PS) for rectal cancer patients with a temporary stoma (TS) after surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for eligible studies until November 14, 2022. The patients were divided into the PS group and the TS group. Odds ratio (ORs) and 95% confidence intervals (CIs) were pooled up for describing dichotomous variables. Stata SE 16 was performed for data analysis. Results: After pooling up the data, a total of 14 studies involving 14,265 patients were included in this study. The outcomes showed that age (OR = 1.03, 95% CI = 0.96 to 1.10, I2 = 1.42%, P = .00 < .1), surgery type (P = .00 < .1), tumor stage (P = .00 < .1), preoperative chemoradiotherapy (P = .00 < .1), preoperative radiotherapy (P = .01 < .1), neoadjuvant therapy (P = .00 < .1), American Society of Anesthesiologists (ASA) score of ≥3 (P = .00 < .1), anastomotic leakage (P = .01 < .1), local recurrence (P = .00 < .1), and distant recurrence (P = .00 < .1) were associated with the patient with PS. However, sex (P = .15 > .1), previous abdominal surgery (P = .84 > .1), adjuvant chemotherapy (P = .87 > .1), and defunctioning stoma (P = .1) had little association with PS. Conclusion: Patients who were elderly, had advanced tumor stages, had a high ASA score, and underwent neoadjuvant therapy should be informed of the high risk of PS before surgery. Meanwhile, those who underwent rectal cancer surgery with a TS should beware of anastomotic leakage, local recurrences, and distant recurrences, which could increase the risk of PS.

Anastomotic Leakage after Colorectal Surgery: Risk Factors, Diagnosis and Therapeutic Options

Anastomotic leakage (AL) is the most severe and devastating complication of colorectal surgery. The objectives of this study were to identify the risk factors involved in the development of AL, evaluate diagnostic methods and explore therapeutic options in case of colorectal cancer surgery.

MATERIAL AND METHODS

we conducted a retrospective study on 28 AL recorded after 315 elective colorectal cancer surgeries performed in 1st Surgery Clinic of Craiova over an 8-year period (2014-2022).

RESULTS

The overall incidence of AL was 8.88%. The identified risk factors were rectal cancer (22.38%), low anterior rectal resection (50%), open approach, advanced age (82.15% over 60 years old), male sex (3:1), and the presence of two or more co-morbidities. Medical conservative treatment was the primary line of treatment in all cases. Leakage closure was achieved in 22 cases (78.56%), with exclusive conservative treatment in 15 cases (46.42%) and combined conservative and surgical treatment in 7 cases (25.0%). Overall morbidity was recorded at 64.28%, with 8 cases of general evolving complications and 10 cases of local complications. General mortality was reported at 6 (21.42%), with 3 (16.66%) occurring after conservative treatment and 3 after re-interventions (30%).

CONCLUSIONS

our study identified advanced age, the presence of two or more co-morbidities, male sex, rectal surgery, and neoadjuvant chemoradiation as the most important risk factors for AL. Medical conservative treatment was the primary treatment modality, while reoperation was necessary in cases of uncontrollable sepsis and MODS. Mortality after re-intervention was nearly double compared to conservative treatment.

Factors predicting successful resolution and long-term outcomes of benign anastomotic strictures following rectal cancer surgery

AIM

Although advances in treatment have improved sphincter-preservation rates in rectal cancer, the incidence of benign anastomotic strictures has also increased. This retrospective single-institution study sought to determine the incidence of benign anastomotic strictures and the factors associated with their successful resolution following treatment.

METHODOLOGY

From January 2010 to December 2019, consecutive patients undergoing endoscopic dilatation and/or surgery for benign anastomotic strictures developing after radical sphincter-sparing resections for rectal cancer were evaluated. To model the relationship between outcomes and potential independent variables, sequential univariate and multivariate analyses were performed using binary logistic regression.

RESULTS

Of 2069 rectal cancer patients undergoing sphincter-preserving surgery, benign anastomotic strictures were identified in 110 (5.3%). Mean age was 48.2 ± 13.98 years; 73.6% were male. Distal tumor-extent was within 6 cm of the anal verge in 60%; 80.9% patients received neoadjuvant radiotherapy. Surgical approach in 71.8% was open, 74.5% being anterior or low anterior resections and 70.9% of anastomoses stapled. Covering stoma was performed in 91.8%. On follow-up, strictures of median length 4 cm were identified at median 3 cm from the anal verge. Endoscopic dilatation was offered in 89.1%, whereas 9.1% required redo-surgery. Overall, 49.1% experienced sustained stricture-resolution with dilatation and 45.4% required re-intervention. At last follow-up, 72.7% were stoma-free. On multivariate analysis, good performance status, absence of anastomotic leak, and short-segment strictures predicted successful stricture-resolution.

CONCLUSION

Endoscopic dilatation is an effective first-line therapy, with redo anastomosis used to salvage those failing conservative measures. Adverse performance status, anastomotic leak and greater stricture length may predict detrimental outcomes in terms of stricture resolution.

One Decade of Declining Use of Defunctioning Stomas After Rectal Cancer Surgery in the Netherlands: Are We on the Right Track?

BACKGROUND

The beneficial effect of a defunctioning stoma in mitigating the consequences of anastomotic leakage after rectal cancer surgery is still debated.

OBJECTIVE

This study aims to reflect on a decade of rectal cancer surgery in terms of stoma construction and anastomotic leakage.

DESIGN

Retrospective observational study.

SETTING

This study used data from the Dutch Colorectal Audit from 2011 to 2020.

PATIENTS

Patients undergoing rectal cancer surgery with a primary anastomosis.

MAIN OUTCOME MEASURES

Primary outcome was anastomotic leakage. Secondary outcomes were minor complications, admission to intensive care, length of stay, readmission, and patient death.

RESULTS

A total of 13,263 patients were included in this study. A defunctioning stoma was constructed in 7106 patients (53.6%). Patients with a defunctioning stoma were less likely to develop anastomotic leakage (7.9% vs 13.0%), and if anastomotic leakage occurred, fewer patients needed surgical reintervention (37.7% vs 81.1%). An annual decrease in the construction of a defunctioning stoma was seen (69.8% in 2011 vs 51.8% in 2015 vs 29.7% in 2020), accompanied by a 5% increase in anastomotic leakage (9.1% in 2011 vs 14.1% in 2020). A defunctioning stoma was associated with a higher occurrence of minor complications, increased admissions to the intensive care unit, longer length of stay, and more readmissions within 90 days.

LIMITATION

This retrospective study is susceptible to confounders by indications, and there could be risk factors for anastomotic leakage and the use of a stoma that were not regarded.

CONCLUSIONS

The reduction in defunctioning stomas is paralleled with an increase in anastomotic leakage. However, patients with a defunctioning stoma also showed more minor complications, a prolonged length of stay, more intensive care admissions, and more readmissions. In our opinion, the trade-offs of selective use should be individually considered. See Video Abstract at http://links.lww.com/DCR/C137 .

UNA DCADA DISMINUYENDO EL USO DE ESTOMAS DISFUNCIONANTES EN LOS CASOS DE CNCER DE RECTO EN HOLANDA ESTAMOS HACIENDO LO CORRECTO

ANTECEDENTES:Aún se debate el efecto benéfico de la confección de un estoma disfuncionante para limitar las consecuencias de la fuga anastomótica en los casos de cirugía por cáncer de recto.OBJETIVO:Reflexiones sobre una década de cirugía por cáncer de recto en términos de confección de estomas y de fugas anastomóticas.DISEÑO:Estudio retrospectivo y observacional.AJUSTE:El presente estudio utilizó datos de la Auditoría Colorectal Holandesa entre 2011 y 2020.PACIENTES:Todos aquellos intervenidos por cáncer de recto con anastomosis primaria.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la fuga anastomótica. Los resultados secundarios fueron las complicaciones menores, la permanencia en cuidados intensivos, la duración de la hospitalización, las rehospitalizaciones y las causas de muerte en los pacientes.RESULTADOS:Un total de 13.263 pacientes fueron incluidos en el presente estudio. Se confeccionó un estoma disfuncionante en 7.106 (53,6%) pacientes. Aquellos portadores de un estoma disfuncionante tenían menos probabilidades de desarrollar una fuga anastomótica (7,9 % frente a 13,0 %) y, si ocurría una fuga anastomótica, menos pacientes necesitaban reintervención quirúrgica (37,7 % frente a 81,1 %). Se observó una disminución anual en la confección de un estoma disfuncionante (69,8 % en 2011 frente a 51,8 % en 2015 frente a 29,7 % en 2020), acompañada de un aumento del 5 % en la fuga anastomótica (9,1 % en 2011 frente a 14,1 % en 2020). Un estoma disfuncionante se asoció con una mayor incidencia de complicaciones menores, permanencia en la unidad de cuidados intensivos, una estadía más prolongada y más rehospitalizaciones dentro de los 90 días.LIMITACIÓN:Estudio retrospectivo susceptible de factores de confusión según las indicaciones, donde podrían no haber sido considerados ciertos factores de riesgo con relación a la fuga anastomótica y a la confección de un estoma disfuncionante.CONCLUSIÓN:La reducción de estomas disfuncionantes es paralela con el aumento de la fuga anastomótica. Sin embargo, los pacientes con un estoma disfuncionante también mostraron más complicaciones menores, una estadía prolongada, más admisiones a cuidados intensivos y más rehospitalizaciones. En nuestra opinión, las ventajas y desventajas del uso selectivo de estomas disfuncionantes deben ser consideradas caso por caso. Consulte Video Resumen en https://links.lww.com/DCR/C137 . (Traducción-Dr. Xavier Delgadillo ).

Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis

BACKGROUND

Anastomotic leakage (AL) following rectal cancer surgery is an important cause of mortality and recurrence. Although transanal drainage tubes (TDTs) are expected to reduce the rate of AL, their preventive effects are controversial.

AIM

To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery.

METHODS

A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases. We included randomized controlled trials (RCTs) and prospective cohort studies (PCSs) in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated. The results of the studies were synthesized using the Mantel-Haenszel random-effects model, and a two-tailed P value > 0.05 was considered statistically significant.

RESULTS

Three RCTs and two PCSs were included in this study. Symptomatic AL was examined in all 1417 patients (712 with TDT), and TDTs did not reduce the symptomatic AL rate. In a subgroup analysis of 955 patients without a diverting stoma, TDT reduced the symptomatic AL rate (odds ratio = 0.50, 95% confidence interval: 0.29-0.86, P = 0.012).

CONCLUSION

TDT may not reduce AL overall among patients undergoing rectal cancer surgery. However, patients without a diverting stoma may benefit from TDT placement.

Defunctioning stoma in anterior resection for rectal cancer does not impact anastomotic leakage: a national population-based cohort study

BACKGROUND

Anterior resection (AR) is considered the gold standard for curative cancer treatment in the middle and upper rectum. The goal of the sphincter-preserving procedure, such as AR, is vulnerable to anastomotic leak (AL) complications. Defunctioning stoma (DS) became the protective measure against AL. Often a defunctioning loop-ileostomy is used, which is associated with substantial morbidity. However, not much is known if the routine use of DS reduces the overall incidence of AL.

METHODS

Elective patients subjected to AR in 2007-2009 and 2016-18 were recruited from the Swedish colorectal cancer registry (SCRCR). Patient characteristics, including DS status and occurrence of AL, were analyzed. In addition, independent risk factors for AL were investigated by multivariable regression.

RESULTS

The statistical increase of DS from 71.6% in 2007-2009 to 76.7% in 2016-2018 did not impact the incidence of AL (9.2% and 8.2%), respectively. DLI was constructed in more than 35% of high-located tumors ≥ 11 cm from the anal verge. Multivariable analysis showed that male gender, ASA 3-4, BMI > 30 kg/m², and neoadjuvant therapy were independent risk factors for AL.

CONCLUSION

Routine DS did not decrease overall AL after AR. A selective decision algorithm for DS construction is needed to protect from AL and mitigate DS morbidities.

Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis

BACKGROUND

Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored.

METHODS

This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival.

RESULTS

Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001).

CONCLUSION

Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.

Prediction model of anastomotic leakage after anterior resection for rectal cancer-based on nomogram and multivariate analysis with 1995 patients

BACKGROUND

Postoperative anastomotic leakage for rectal cancer shows higher morbidity with grievous concomitant symptoms. Accurate assessment of the incidence of anastomotic leakage, multivariate analysis, and establishment of a scientific prediction model can be useful to dispose of its possible severe clinical consequences.

METHODS

This retrospective study collected 1995 consecutive patients who underwent anterior resection of rectal cancer with primary anastomosis at Northern Jiangsu People's Hospital between January 2016 and June 2022. Independent risk factors associated with anastomotic leakage were analyzed by univariate and multivariate logistic regression. The chosen independent risk factors were used to construct a nomogram risk prediction model whose availability was evaluated by using a bootstrapped-concordance index and calibration plots with R software.

RESULTS

A total of 1995 patients who underwent anterior resection for rectal cancer were included while 120 patients were diagnosed with anastomotic leakage, an incidence of 6.0%. Univariate analysis and its concomitant multivariate cox regression analysis indicated that independent risk factors associated with anastomotic leakage included male gender (odds ratio (OR) = 2.873), diabetes (OR = 2.480), neoadjuvant therapy (OR = 5.283), tumor's distance from the anus verge < 5 cm (OR = 5.824), tumor size ≥ 5 cm (OR = 4.888), and the blood lose > 50 mL (OR = 9.606).We established a nomogram prediction model with proper applicability (concordance index, 0.83) and the calibration curve to justify its predictive ability that the predicted occurrence probability keeps a high degree of consistency with the actual occurrence probability. Meanwhile, the area under the receiver operating characteristic (ROC) curve was 0.83.

CONCLUSIONS

The characteristics of patients and tumor surgery-related conditions can affect the incidence of anastomotic leakage. However, whether the surgical method will affect morbidity is still controversial. Our nomogram can be seen as an effective instrument to predict anastomotic leakage after anterior resection for rectal cancer precisely.

Transanal drainage tube for the prevention of anastomotic leakage after rectal cancer surgery: a meta-analysis of randomized controlled trials

Background

Anastomotic leakage (AL) is a serious complication of anterior resection for rectal cancer. The use of transanal drainage tubes (TDT) during surgery to prevent AL remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of TDT in reducing AL.

Methods

Relevant data and studies published from inception until November 1, 2022, were retrieved from PubMed, Embase, and Cochrane Library databases to compare the incidence of AL after anterior resection for rectal cancer with and without TDT.

Results

This meta-analysis included 5 RCTs comprising 1385 patients. The results showed that the intraoperative use of TDT could not reduce the incidence of AL after rectal cancer surgery (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.52-1.59; p = 0.75). A subgroup analysis of different degrees of AL revealed that TDT did not reduce the incidence of postoperative grade B AL (RR, 1.18; 95% CI, 0.67-2.09; p = 0.56) but decreased the incidence of grade C AL (RR, 0.28; 95% CI: 0.12-0.64; p = 0.003). Further, TDT did not reduce the incidence of AL in patients with rectal cancer and a stoma (RR, 2.40; 95% CI, 1.01-5.71; p = 0.05).

Conclusion

TDT were ineffective in reducing the overall incidence of AL, but they might be beneficial in reducing the incidence of grade C AL in patients who underwent anterior resection. However, additional multicenter RCTs with larger sample sizes based on unified control standards and TDT indications are warranted to validate these findings.

Ten-Year Multicenter Retrospective Study Utilizing Machine Learning Algorithms to Identify Patients at High Risk of Venous Thromboembolism After Radical Gastrectomy

Purpose

This study aims to construct a machine learning model that can recognize preoperative, intraoperative, and postoperative high-risk indicators and predict the onset of venous thromboembolism (VTE) in patients.

Patients and Methods

A total of 1239 patients diagnosed with gastric cancer were enrolled in this retrospective study, among whom 107 patients developed VTE after surgery. We collected 42 characteristic variables of gastric cancer patients from the database of Wuxi People's Hospital and Wuxi Second People's Hospital between 2010 and 2020, including patients' demographic characteristics, chronic medical history, laboratory test characteristics, surgical information, and patients' postoperative conditions. Four machine learning algorithms, namely, extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM), and k-nearest neighbor (KNN), were employed to develop predictive models. We also utilized Shapley additive explanation (SHAP) for model interpretation and evaluated the models using k-fold cross-validation, receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and external validation metrics.

Results

The XGBoost algorithm demonstrated superior performance compared to the other three prediction models. The area under the curve (AUC) value for XGBoost was 0.989 in the training set and 0.912 in the validation set, indicating high prediction accuracy. Furthermore, the AUC value of the external validation set was 0.85, signifying good extrapolation of the XGBoost prediction model. The results of SHAP analysis revealed that several factors, including higher body mass index (BMI), history of adjuvant radiotherapy and chemotherapy, T-stage of the tumor, lymph node metastasis, central venous catheter use, high intraoperative bleeding, and long operative time, were significantly associated with postoperative VTE.

Conclusion

The machine learning algorithm XGBoost derived from this study enables the development of a predictive model for postoperative VTE in patients after radical gastrectomy, thereby assisting clinicians in making informed clinical decisions.

Mechanical bowel preparation and antibiotics in elective colorectal surgery: network meta-analysis

BACKGROUND

The use of intravenous antibiotics at anaesthetic induction in colorectal surgery is the standard of care. However, the role of mechanical bowel preparation, enemas, and oral antibiotics in surgical site infection, anastomotic leak, and other perioperative outcomes remains controversial. The aim of this study was to determine the optimal preoperative bowel preparation strategy in elective colorectal surgery.

METHODS

A systematic review and network meta-analysis of RCTs was performed with searches from PubMed/MEDLINE, Scopus, Embase, and the Cochrane Central Register of Controlled Trials from inception to December 2022. Primary outcomes included surgical site infection and anastomotic leak. Secondary outcomes included 30-day mortality rate, ileus, length of stay, return to theatre, other infections, and side effects of antibiotic therapy or bowel preparation.

RESULTS

Sixty RCTs involving 16 314 patients were included in the final analysis: 3465 (21.2 per cent) had intravenous antibiotics alone, 5268 (32.3 per cent) had intravenous antibiotics + mechanical bowel preparation, 1710 (10.5 per cent) had intravenous antibiotics + oral antibiotics, 4183 (25.6 per cent) had intravenous antibiotics + oral antibiotics + mechanical bowel preparation, 262 (1.6 per cent) had intravenous antibiotics + enemas, and 1426 (8.7 per cent) had oral antibiotics + mechanical bowel preparation. With intravenous antibiotics as a baseline comparator, network meta-analysis demonstrated a significant reduction in total surgical site infection risk with intravenous antibiotics + oral antibiotics (OR 0.47 (95 per cent c.i. 0.32 to 0.68)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.55 (95 per cent c.i. 0.40 to 0.76)), whereas oral antibiotics + mechanical bowel preparation resulted in a higher surgical site infection rate compared with intravenous antibiotics alone (OR 1.84 (95 per cent c.i. 1.20 to 2.81)). Anastomotic leak rates were lower with intravenous antibiotics + oral antibiotics (OR 0.63 (95 per cent c.i. 0.44 to 0.90)) and intravenous antibiotics + oral antibiotics + mechanical bowel preparation (OR 0.62 (95 per cent c.i. 0.41 to 0.94)) compared with intravenous antibiotics alone. There was no significant difference in outcomes with mechanical bowel preparation in the absence of intravenous antibiotics and oral antibiotics in the main analysis.

CONCLUSION

A bowel preparation strategy with intravenous antibiotics + oral antibiotics, with or without mechanical bowel preparation, should represent the standard of care for patients undergoing elective colorectal surgery.

Risk factors of acute renal failure in patients with protective ileostomy after rectal cancer surgery

BACKGROUND

Despite the potential benefits of protective ileostomy in rectal surgery, diverting loop ileostomy construction is not free of specific medical consequences implying unplanned hospital readmissions. The most common reason for readmission in these patients is a dehydration with a prevalence of acute renal failure (ARF) of 20%. The objective of this study was to establish the predictive factors of ARF in patients with protective ileostomy after surgery for rectal cancer from a bicentric study.

METHODS

we conducted a bicentric retrospective cohort study to identify the risk factor of ARF. This study was carried out on 277 patients operated for rectal cancer with necessity of a protective ileostomy during the study period. ARF was measured at any endpoint between ileostomy creation and reversal. Multiple logistic regressions were performed to identify independent risk factors.

RESULTS

A total of 277 patients were included, and 18% (n = 50) were readmitted for ARF. In multivariate logistic regression, increased age (OR 1.02, p = 0.01), Psychiatric diseases (OR 4.33, p = 0.014), Angiotensin II receptor blockers (OR 5.15, p < 0.001) and the ASA score ≥ 3 (OR 9.5, p < 0.001) were significantly associated with ARF.

CONCLUSION

Acute renal failure is a prevalent and significant event in the postoperative course of ileostomy patients. Patients at risk should be risk stratified before discharge and targeted for intensive preventive measures.

Short-term outcome of diverting loop ileostomy reversals performed by residents: a retrospective cohort prognostic factor study

AIM

The reversal of diverting loop ileostomy (DLI) is one of surgical trainees' first procedures. Complications of DLI reversal can cause life-threatening complications and increase patient morbidity. This study compared DLI reversals performed by surgical trainees with those by attending surgeons.

METHOD

This retrospective cohort study was performed at a single primary care center on 300 patients undergoing DLI reversal. The primary outcome was morbidity, according to the Clavien-Dindo classification (CDC), with special attention paid to the surgeon's level of training. The secondary endpoint was postoperative intestinal motility dysfunction.

RESULTS

Surgical trainees had significantly longer operation times (p < 0.001) than attending surgeons. Univariate analyses revealed no influence on the level of training for postoperative morbidity. First bowel movement later than 3 days after surgery was a significant risk factor for CDC [Formula: see text] 3 (OR, 4.348; 96% CI, 1670-11.321; p = 0.003). Independent risk factors for surgical site infections (SSIs) were an elevated BMI (OR, 1.162; 95% CI, 1.043-1.1294; p = 0.007) and a delayed bowel movement (OR, 3.973; 95% CI, 1.300-12.138; p = 0.015). For postoperative intestinal motility dysfunction, an independent risk factor was a primary malignant disease (OR, 1.980; 95% CI, 1.120-3.500; p = 0.019), and side-to-side stapled anastomosis was a protective factor (OR, 0.337; 95% CI 0.155-0.733; p = 0.006).

CONCLUSION

Even though surgical trainees needed significantly more time to perform the surgery, the level of surgical training was not a risk factor for increased postoperative morbidity. Instead, delayed first bowel movement was predictive of SSI.

Early stoma closure after low anterior resection is not recommended due to postoperative complications and asymptomatic anastomotic leakage

The safety of early stoma closure after lower anterior resection (LAR) for rectal cancer remains controversial. In this study, patients scheduled to undergo LAR and stoma creation for rectal cancer were recruited. In absence of anastomotic leakage on radiological examination, closure of the diverting ileostomy was performed within 2 weeks. The primary endpoint was incidence of the colorectal anastomosis leakage after early stoma closure. Because of the slow accrual rate, the study was closed before recruitment reached the planned number of patients (n = 20). Among the 13 patients enrolled between April 2019 and March 2021, early stoma closure was performed in seven patients (53.8%). Non-clinical anastomotic leakage, leakage identified only on radiological examination, occurred in five cases, resulting in rescheduling of stoma closure. One patient did not undergo early stoma closure due to ileus. After stoma closure, colorectal anastomotic leakage manifested in one case; its incidence rate was 14.2%. Surgical site infection occurred in 42.8% of patients. This study revealed that asymptomatic anastomotic leakage occurred frequently. Considering the low rate of successful cases and the high rate of complications, early stoma closure within 2 weeks after LAR should not be performed routinely. Trial registration: (UMIN000036382 registered on 03/04/2019).

Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study

BACKGROUND

Protective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision.

METHODS

A retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured.

RESULTS

Univariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure.

CONCLUSION

Compared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.

A comparative study of stoma-related complications from diverting loop ileostomy or colostomy after colorectal surgery

PURPOSE

Even though minor, stoma-related complications significantly impact quality of life, they are often excluded from clinical analyses that compare short-term postoperative outcomes of loop ileostomy and loop colostomy. This study compares stoma-related complications between loop ileostomy and loop colostomy after rectal resection, including minor complications, and discusses the characteristics of diverting stoma types.

METHODS

A retrospective review was conducted in patients who underwent diverting stoma construction after rectal resection. Data on patient background and postoperative short-term outcomes, including stoma-related complications and morbidity after stoma closure, were collected and compared between loop ileostomy and loop colostomy groups. Morbidities of all severity grades were targeted for analysis.

RESULTS

A total of 47 patients (27 loop ileostomy, 20 loop colostomy) underwent diverting stoma construction following rectal resection. Overall stoma-related complications, incidence of skin irritation, high-output stoma, and outlet obstruction were significantly higher in the loop ileostomy group but high-output stoma and outlet obstruction were absent in the loop colostomy group. Regarding morbidity after stoma closure, operation times and surgical site infections were significantly higher in the loop colostomy group while anastomotic leakage after diverting stoma closure occurred (2 cases; 15%) in the loop colostomy group but not the loop ileostomy group.

CONCLUSION

Because stoma-related complications were significantly higher in the loop ileostomy group, and even these minor complications may impair QOL, early loop ileostomy closure is recommended. For loop colostomy, stoma-related morbidities are lower but post-closure leakage is a calculated risk.

Hand-sewn direct repair versus resection and hand-sewn anastomosis techniques for the reversal of diverting loop ileostomy after lower anterior rectal resection surgery: A randomized clinical trial

INTRODUCTION

Several techniques have been proposed for the closure of loop ileostomy. This is the first study comparing bowel function and outcomes of two different hand-sewn surgical techniques used for the closure of diverting protective loop ileostomy.

METHOD

In this prospective, randomized, double-blind clinical trial, 40 patients with a history of rectal cancer, low anterior resection, and diverting loop ileostomy who were candidates for ileostomy reversal were included and randomly assigned into two groups, hand-sewn direct repair of the ileal defect (group A) and resection and hand-sewn anastomosis of the ileum (group B).

RESULTS

The mean age of patients was 56.42 and 52.10 years in groups A and B, respectively. Regarding early postoperative period, group A developed earlier first gas passage (1.68 vs. 2.25 days, p = 0.041) and stool passage (2.10 vs. 2.80 days, p = 0.032). Group A also revealed shorter operating time (83.68 vs. 89.50 min, p = 0.040) and hospital stay (4.73 vs. 6.80 days, p = 0.001). None of the participants in both groups developed signs of bowel obstruction during the early and late postoperative follow-up period.

CONCLUSIONS

Direct hand-sewn repair for the closure of diverting loop ileostomy is a safe technique with better postoperative bowel function, oral diet tolerance, and less hospital stay compared to resection and hand-sewn anastomosis of the ileum.

Operative management of anastomotic leak after sigmoid colectomy for left-sided diverticular disease: Ileostomy creation may be as safe as colostomy creation

AIM

The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes.

METHODS

We performed a retrospective cohort study using the NSQIP Colectomy Module (2012-2019) and single-institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak.

RESULTS

Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation - 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single-institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies.

CONCLUSIONS

In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

A phase III randomized trial evaluating the quality of life impact of a tailored versus systematic use of defunctioning ileostomy following total mesorectal excision for rectal cancer-GRECCAR 17 trial protocol

AIM

The systematic use of a defunctioning ileostomy for 2-3 months postoperatively to protect low colorectal anastomosis (<7 cm from the anal verge) has been the standard practice after total mesorectal excision (TME). However, stoma-related complications can occur in 20%-60% of cases, which may lead to prolonged inpatient care, urgent reoperation and long-term definitive stoma. A negative impact on quality of life (QoL) and increased healthcare expenses are also observed. Conversely, it has been reported that patients without a defunctioning stoma or following early stoma closure (days 8-12 after TME) have a better functional outcome than patients with systematic defunctioning stoma in situ for 2-3 months.

METHOD

The main objective of this trial is to compare the QoL impact of a tailored versus systematic use of a defunctioning stoma after TME for rectal cancer. The primary outcome is QoL at 12 months postoperatively using the European Organization for. Research and Treatment of Cancer QoL questionnaire QLQ-C30. Among 29 centres of the French GRECCAR network, 200 patients will be recruited over 18 months, with follow-up at 1, 4, 8 and 12 months postoperatively, in an open-label, randomized, two-parallel arm, phase III superiority clinical trial. The experimental arm (arm A) will undergo a tailored use of defunctioning stoma after TME based on a two-step process: (i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leak (defunctioning stoma only if modified anastomotic failure observed risk score ≥2) and (ii) if a stoma is fashioned, whether to perform an early stoma closure at days 8-12, according to clinical (fever), biochemical (C-reactive protein level on days 2 and 4 postoperatively) and radiological postoperative assessment (CT scan with retrograde contrast enema at days 7-8 postoperatively). The control arm (arm B) will undergo systematic use of a defunctioning stoma for 2-3 months after TME for all patients, in keeping with French national and international guidelines. Secondary outcomes will include comprehensive analysis of functional outcomes (including bowel, urinary and sexual function) again up to 12 months postoperatively and a cost analysis. Regular assessments of anastomotic leak rates in both arms (every 50 randomized patients) will be performed and an independent data monitoring committee will recommend trial cessation if this rate is excessive in arm A compared to arm B.

CONCLUSION

The GRECCAR 17 trial is the first randomized trial to assess a tailored, patient-specific approach to decisions regarding defunctioning stoma use and closure after TME according to personalized risk of anastomotic leak. The results of this trial will describe, for the first time, the QoL and morbidity impact of selective use of a defunctioning ileostomy and the potential health economic effect of such an approach.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.

METHODS

Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.

RESULTS

In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.

CONCLUSIONS

The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis

BACKGROUND

Whether to ligate the inferior mesenteric artery at its root during anterior resection for sigmoid colon or rectal cancer is still under debate. This study compared the surgical outcomes, postoperative recovery, and anastomotic leakage between high and low ligation of the inferior mesenteric artery through a subgroup analysis.

METHODS

This was a retrospective analysis of prospectively collected data. All patients who underwent colorectal resection for rectosigmoid cancer between December 2016 and December 2019 were enrolled. According to the surgical ligation level of the inferior mesenteric artery, the patients were categorized into either the high or low ligation group. The investigated population was matched using the propensity score method.

RESULTS

Overall, 894 patients with sigmoid or rectal cancer underwent elective anterior resection with high (577 patients) or low (317 patients) ligation of the inferior mesenteric artery. After the propensity score matching, 245 patients in each group were compared. High ligation of the inferior mesenteric artery was associated with higher incidence of anastomotic leakage (14.9% vs. 5.6%, P = 0.041) for mid- to low-rectum tumors and a higher incidence of complications (8.6% vs. 3.3%, P = 0.013) of grades 1-2 according to the Clavien-Dindo classification system.

CONCLUSION

Compared with high ligation, low ligation of the inferior mesenteric artery resulted in lower likelihood of morbidity and mortality in rectal and sigmoid cancers. Moreover, low ligation was less likely to result in anastomosis leakage in mid- to low-rectal cancers.

Artificial intelligence assists surgeons' decision-making of temporary ileostomy in patients with rectal cancer who have received anterior resection

BACKGROUND

Due to the difficult evaluation of the risk of anastomotic leakage (AL) after rectal cancer resection, the decision to perform a temporary ileostomy is not easily distinguishable. The aim of the present study was to develop an artificial intelligence (AI) model for identifying the risk of AL to assist surgeons in the selective implementation of a temporary ileostomy.

MATERIALS AND METHODS

The data from 2240 patients with rectal cancer who received anterior resection were collected, and these patients were divided into one training and two test cohorts. Five AI algorithms, such as support vector machine (SVM), logistic regression (LR), Naive Bayes (NB), stochastic gradient descent (SGD) and random forest (RF) were employed to develop predictive models using clinical variables and were assessed using the two test cohorts.

RESULTS

The SVM model indicated good discernment of AL, and might have increased the implementation of temporary ileostomy in patients with AL in the training cohort (p < 0.001). Following the assessment of the two test cohorts, the SVM model could identify AL in a favorable manner, which performed with positive predictive values of 0.150 (0.091-0.234) and 0.151 (0.091-0.237), and negative predictive values of 0.977 (0.958-0.988) and 0.986 (0.969-0.994), respectively. It is important to note that the implementation of temporary ileostomy in patients without AL would have been significantly reduced (p < 0.001) and which would have been significantly increased in patients with AL (p < 0.05).

CONCLUSION

The model (https://alrisk.21cloudbox.com/) indicated good discernment of AL, which may be used to assist the surgeon's decision-making of performing temporary ileostomy.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Excision of Deep Rectovaginal Endometriosis Nodules with Large Infiltration of Both Rectum and Vagina: What Is a Reasonable Rate of Preventive Stoma? A Comparative Study

STUDY OBJECTIVE

To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during 2 time periods with differing policies for preventive stoma confection.

DESIGN

Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared with those managed from April 2020 to June 2022 (second period).

SETTING

Endometriosis Institute.

PATIENTS

One hundred sixty-eight patients presenting with deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma.

INTERVENTIONS

Rectal disc excision or colorectal resection, concomitantly with large vaginal excision.

MEASUREMENTS AND MAIN RESULTS

A total of 87 and 81 women received surgery during the first and the second period, respectively, during which the rate of preventive stoma was, respectively, 32.2% and 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were, respectively, 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were 11.4% and 9.8%, respectively (p = .76). The rates of fistula recorded during the first and the second period were, respectively, 9.2% and 11.1% (p = .80), and that of overall early main complications were 31% and 29.6% (p = .84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95% CI 0.3-10.1 related to robotic assistance), and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared with colorectal resection).

CONCLUSION

No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision after a decision to no longer routinely perform preventive stoma.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

Objectives

This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state.

Methods

We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method.

Results

Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01).

Conclusions

This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.

A nomogram to predict the risk of colorectal anastomotic leakage combining inflammatory-nutritional and abdominal aorta calcium index

Background

Anastomotic leakage is a serious complication after colorectal cancer surgery, which affects the quality of life and the prognosis. This study aims to create a novel nomogram to predict the risk of anastomotic leakage for patients with colorectal cancer based on the preoperative inflammatory-nutritional index and abdominal aorta calcium index.

Methods

292 patients at Tianjin Medical University General Hospital (Tianjin, China) from January 2018 to October 2021 who underwent colorectal cancer surgery with a primary anastomosis were retrospectively reviewed. A nomogram was constructed based on the results of multivariate logistic regression model. The calibration curves and receiver operating characteristic curves were used to verify the efficacy of the nomogram.

Results

Univariate and multivariate analyses showed that tumor location (P = 0.002), preoperative albumin (P = 0.006), preoperative lymphocyte (P = 0.035), preoperative neutrophil to lymphocyte ratio (P = 0.024), and superior mesenteric artery calcium volumes score (P = 0.004) were identified as the independent risk factors for postoperative anastomotic leakage in patients with colorectal carcinoma. A nomogram was constructed based on the results of the multivariate analysis, and the C-index of the calibration curves was 0.913 (95%CI: 0.870-0.957) in the training cohort and 0.840 (95%CI: 0.753-0.927) in the validation cohort.

Conclusion

The nomogram, combining basic variables, inflammatory-nutritional index and abdominal aorta calcium index, could effectively predict the possibility of postoperative anastomotic leakage for patients with colorectal cancer, which could guide surgeons to carry out the appropriate treatment for the prevention of anastomotic leakage.

Early and late anastomotic leak after colorectal surgery: A systematic review of the literature

The aim of this study was to review and to assess the quality of the scientific articles regarding early and late anastomotic leak (AL) after colorectal surgery and their risk factors. An electronic systematic search for articles on Colorectal Surgery, AL and its timing was undertaken using the MEDLINE database via PubMed, Cochrane and Embase. The selected articles were thoroughly reviewed and assessed for methodological quality using a validated methodology quality score (MINCIR score). This review was registered in the PROSPERO registry under ID: CRD42022303012. 9 articles were finally reviewed in relation to the topic of early and late anastomotic leak. There is a lack of consensus regarding the exact cut-off in time to define early and late anastomotic leak, but it is clear that they are two differentiated entities. The first, occurring in relation to technical factors; whereas the latter, is related to impaired healing.

Effect of placing double-lumen irrigation-suction tube on closure of anastomotic defect following rectal cancer surgery

PURPOSE

This study aimed to investigate the effect of placement of double-lumen irrigation-suction tubes (DLIST) on the closure of anastomotic defect (AD) after rectal cancer surgery.

METHODS

The study was carried out at two centers managed by one surgeon, both adopted the same treatments. Patients with postoperative AD after rectal cancer surgery from January 2011 to June 2020 were eligible and were divided into a passive drainage (PD) group and a DLIST group according to whether the PD, placed in the rectal cancer surgery, had been replaced with the DLIST. The effect of DLIST on the AL was evaluated.

RESULT

There distributed 76 patients in the DLIST group and 52 in the PD group. A higher closure rate was reported in the DLIST group (46 patients in DLIST group, for a closure rate of 60.5%, and 21 patients in PD group, for a closure rate of 40.4%. HR = 3.05; 95% CI: 1.79-5.19; P < 0.001). Both length of stay and costs of the treatment in the DLIST group were lower (54 days [interquartile range, IQR: 41-17] days vs. 112 days [IQR: 66-27] days, P = 0.005; and $18,721 [IQR: $14,982-4,960] vs. $40,840 [IQR: $20,932-50,529], P < 0.001).

CONCLUSION

Placement of DLIST might serve as an effective method for treating AD following rectal cancer surgery. In comparison with PD, it costs lower to apply DLIST in the treatment of AD and the length of stay is shorter.