Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg. 2013;257:665-671. [PMID: 23333881 DOI: 10.1097/sla.0b013e31827b8ed9]

Advantages of using a robotic stapler in rectal cancer surgery

To compare short-term postoperative outcomes in patients undergoing robotic total mesorectal excision (TME) after the use of robotic and laparoscopic staplers. Over a 5-year period, 196 patients were divided into 2 groups according to the use of laparoscopic (LS) or robotic stapler (RS). Patient demographics and postoperative complications were compared. A total of 145 (74%) robotic TME were performed using the LS and 51 (26%) the RS. No conversions to laparoscopy or laparotomy were observed, in either group. Transection of the rectum using one or two firings was achieved in a higher proportion of RS cases (91%) compared with LS cases (60%; p < 0.001). The anastomotic leakage (AL) rate was 4% in the RS group vs. 7% in the LS group (p > 0.05). However, when three or more firings were needed for the rectal transection, the risk of AL increased (3.4% with ≤ 2 firings vs. 10.7% with ≥ 3 firings, p = 0.006). Our data confirm that multiple stapler firings for rectal transection have a major impact on AL. The robotic stapler simplifies the transaction, so that rectal division requires fewer stapler firings, with a potential reduction in the incidence of AL.

The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery

BACKGROUND

Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma.

OBJECTIVE

The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma.

METHODS

Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak.

RESULTS

Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model's probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity.

CONCLUSIONS

We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online ( http://www.real-score.org ).

Predictive risk factors for anastomotic leakage after anterior resection of rectal cancer in elderly patients over 80 years old: an analysis of 288 consecutive patients

Background

Anastomotic leakage (AL) is a common complication after anterior resection of rectal cancer. Few studies have been conducted to determine whether the traditional predictors of AL can be applied to elderly patients (age ≥ 80) undergoing anterior resection (AR) or low anterior resection (LAR) of rectal cancer. This study was designed to explore the predictive factors for AL after anterior resection of rectal cancer in patients over 80 years old.

Methods

From January 2007 to May 2019, consecutive elderly (age ≥ 80) rectal cancer patients undergoing AR or LAR at our institution were systematically reviewed. The general information, perioperative outcomes, and comorbidities were collected.

Results

A total of 288 consecutive patients were included in this study. The average age was 82.8 ± 2.4 years, and 30 (10.4%) patients developed AL. The univariate analyses showed that neoadjuvant therapy (50.0% vs. 27.9%, P = 0.013), the number of stapler firings ≥ 3 (60.0% vs. 36.0%, P = 0.011), and coronary heart disease (CHD) (46.7% vs. 17.8%, P < 0.001) were associated with an increased incidence of AL. The multivariate analysis showed that the number of stapler firings ≥ 3 (OR = 4.77, 95% CI = 1.33–15.21, P = 0.035) and CHD (OR = 8.33, 95% CI = 1.94–13.05, P = 0.003) were independent risk factors for AL.

Conclusion

The number of stapler firings ≥ 3 and CHD were independent risk factors for AL in elderly patients (age ≥ 80) with rectal cancer. A temporary ileostomy or the Hartmann procedure is recommended for patients with CHD, male patients, patients considered to be obese, and patients with a lower tumor location, which may increase the number of stapler firings. Certainly, we recommend that the number of stapler firings should be minimized to alleviate the economic and physical burden of patients.

Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study

To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.

The Italian ColoRectal Anastomotic Leakage (iCral) study group. Colorectal surgery in Italy: a snapshot from the iCral study group

During a recent prospective trial on early diagnosis of anastomotic leakage (AL) after colorectal surgery, we gathered a large database on more than 1500 procedures performed in 19 surgical centers in Italy over a 12-month period. Main purpose of the present paper is to show the epidemiological data about colorectal procedures and anastomotic leakage. Prospective enrollment for all elective colorectal resections with anastomosis (September 2017-September 2018). Primary endpoint was AL; secondary endpoints were morbidity and mortality rates, readmission and reoperation rates, and length of post-operative hospital stay (ClinicalTrials.gov; Identifier: NCT03560180). There were 1546 enrolled cases (56.9% of 2717 total resected cases). The rate of minimally invasive resections was 83.5%. Overall AL rate was 4.92% (76 cases; range per center 0-12.12%). Mean ± SD time to AL diagnosis was 5.95 ± 4.78 days (median 5, range 1-31). Overall morbidity rate was 30.20%, mortality 1.29% (20 cases; range per center 0-3.27), readmission 0.90%, and reoperation 6.92%. Mean ± SD post-operative LOS was 7.89 ± 5.97 days (median 6; range 1-120). AL significantly influenced all other secondary endpoints. This study offers a good snapshot of colorectal resections in Italy. There was a high rate of laparoscopic resections, reflecting the special interest in this kind of surgery by the participating centers. AL, morbidity, mortality, readmission and reoperation rates are compared to those reported in previous population-based studies. Compared to series dealing with open colorectal resections, the time to diagnosis of AL was shortened by several days.

Single vs. double purse-string anastomosis during laparoscopic low anterior rectal resection (SINGLE-DOUBLE trial): study protocol for a randomized controlled trial

Background

An inappropriate anastomosis method during laparoscopic anterior rectal resection can increase the risk of anastomotic complications and affect surgical, economic, and oncological outcomes. The aim of this study is to compare the incidence of anastomotic complications and the surgical, economic, and oncological outcomes following single versus double purse-string anastomosis during laparoscopic total mesorectal excision (TME) for low rectal cancer.

Methods/design

This randomized controlled trial (the SINGLE–DOUBLE study) will randomly assign middle and low rectal adenocarcinoma patients to receive either single or double purse-string anastomosis during laparoscopic low anterior rectal resection. Patients will be eligible for inclusion only if they (1) have adenocarcinoma confirmed by preoperative colonoscopy and biopsy, (2) have a tumor situated less than 12 cm from the anal verge, (3) do not have the anal sphincter involved, and (4) do not have distant metastases. The primary endpoint measure will be the incidence of anastomotic complications (leakage, narrowing, and bleeding). The secondary endpoints will be surgical, economic, and oncological outcomes. A total of 500 patients will be enrolled in the study. Sample size calculation was based on previous reports and our retrospective analysis.

Discussion

This randomized single-center controlled trial is expected to demonstrate which anastomosis method (single or double purse-string anastomosis) is better for reducing complications and improving prognosis in rectal cancer patients undergoing laparoscopic TME for low or middle rectal cancer.

Trial registration

Registration number: ChiCTR1800016116. Protocol Registration Receipt: May 13, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3411-7) contains supplementary material, which is available to authorized users.

Laparoscopic Low Anterior Resection with Two Planned Stapler Fires

Background:

Anastomotic leakage during laparoscopic low anterior resection (Lap-LAR) for rectal cancer remains challenging for colorectal surgeons. Firing linear staplers multiple times has been reported as a risk factor for iatrogenic anastomotic leakage. Our institute usually performs rectal transection using 2 planned stapler fires followed by anastomosis with the double-stapling technique.

Methods:

Between November 2009 and September 2016, a total of 272 consecutive patients underwent Lap-LAR with double-stapling anastomosis for rectal cancer. We inserted a linear 45-mm stapler cartridge from a port in the lower right quadrant of the abdomen. The first transection was made up to three-quarters of the rectal wall, and the remaining rectum was completely resected using a second stapler. During this procedure, the intersection of the 2 staple lines, which might otherwise cause anastomotic leakage, was located in the center of the stump of the distal rectum, so the intersection at the rectal stump was able to be easily removed using a circular stapler.

Results:

None of our patients were converted to open surgery. Among the 272 Lap-LAR procedures for which use of 2 stapler fires was planned, 3 fires occurred in error only once (0.4%). Rectovaginal fistula and anastomotic leakage occurred in 1 patient (0.4%) and 9 patients (3.3%), respectively, and 49 (18.0%) patients required protective diverting stoma.

Conclusion:

Rectal transection with 2 planned stapler fires appears safe, practical, and straightforward to standardize, and reduces the need for multiple linear fires and the incidence of anastomotic leakage.

Surgical complications after different therapeutic approaches for locally advanced rectal cancer

BACKGROUND

Preoperative radiochemotherapy is widely used in locally advanced rectal cancer. It can improve local control of rectal cancer. However, some researchers believe it increases the incidence of surgical complications. They doubt its safety. Patients with locally advanced rectal cancer receive three different treatments in our hospital, including long-course radiochemotherapy, short-course radiotherapy, and surgery directly. We can compare their differences in postoperative complications.

AIM

To investigate surgical complications caused by different preoperative radiotherapy regimens.

METHODS

We retrospectively analyzed 1197 patients admitted between 2008 and 2010 with locally advanced rectal cancer. Three hundred and forty-six patients were treated with preoperative long-course radiochemotherapy (25 × 2 Gy) followed by total mesorectal excision (TME) 6–8 wk later, and 259 patients received short-course radiotherapy (10 × 3 Gy) and subsequently TME 7–10 d later. The remaining 592 patients underwent TME alone without neoadjuvant therapy. According to Clavien–Dindo classification, surgical complications were evaluated for up to 30 d after discharge from hospital.

RESULTS

There were no deaths in 30 d in all groups after treatment. The major complications were anastomotic leakage and perineal wound complications. The results suggested that both long-course [odds ratio (OR) = 3.624, 95% confidence interval (CI): 1.689–7.775, P = 0.001] and short-course (OR = 5.150, 95%CI: 1.828–14.515, P = 0.002) radiotherapy were associated with anastomotic leakage. Temporary ileostomy was a protective factor for anastomotic leakage (OR = 6.211, 95%CI: 2.525–15.385, P < 0.001). The severity of anastomotic leakage did not increase in patients following preoperative radiotherapy (P = 0.411). Compared with TME alone, short-course radiotherapy was associated with an increase in perineal wound complications (OR = 5.565, 95%CI: 2.203–14.057, P < 0.001), but long-course radiotherapy seemed safe regarding this complication (OR = 1.692, 95%CI: 0.651–4.394, P = 0.280). Although the severity of perineal wound complications increased in patients following short-course radiotherapy (P < 0.001), additional intervention was not necessary.

CONCLUSION

Radiotherapy increased the incidence but not severity of anastomotic leakage. Short-course radiotherapy was also accompanied with perineal wound complications, but intervention appeared unnecessary to ameliorate the complications.

The Clinical and Economic Burden of Colorectal Anastomotic Leaks: Middle-Income Country Perspective

Purpose

Anastomotic leaks (AL) present a significant source of clinical and economic burden on patients undergoing colorectal surgeries. This study was aimed at evaluating the clinical and economic consequences of AL and its risk factors.

Methods

A retrospective cohort study was conducted between 2012 and 2013 based on the billing information of 337 patients who underwent low anterior resection (LAR). The outcomes evaluated were the development of AL, use of antibiotics, 30-day readmission and mortality, and total hospital costs, including readmissions and length of stay (LOS). The risk factors for AL, as well as the relationship between AL and clinical outcomes, were analyzed using multivariable Poisson regression. Generalized linear models (GLM) were employed to evaluate the association between AL and continuous outcomes (LOS and costs).

Results

AL was detected in 6.8% of the patients. Emergency surgery (aRR 2.56; 95% CI: 1.15-5.71, p = 0.021), blood transfusion (aRR 4.44; 95% CI: 1.86-10.64, p = 0.001), and cancer diagnosis (aRR 2.51; 95% CI: 1.27-4.98, p = 0.008) were found to be independent predictors of AL. Patients with AL showed higher antibiotic usage (aRR 1.69; 95% CI: 1.37-2.09, p < 0.001), 30-day readmission (aRR 3.34; 95% CI: 1.53-7.32, p = 0.003) and mortality (aRR 13.49; 95% CI: 4.10-44.35, p < 0.001), and longer LOS (39.6 days, as opposed to 7.5 days for patients without AL, p < 0.001). Total hospital costs amounted to R$210,105 for patients with AL in comparison with R$34,270 for patients without AL (p < 0.001). In multivariable GLM, the total hospital costs for AL patients were 4.66 (95% CI: 3.38-6.23, p < 0.001) times higher than those for patients without AL.

Conclusions

AL leads to worse clinical outcomes and increases hospital costs by 4.66 times. The risk factors for AL were found to be emergency surgery, blood transfusion, and cancer diagnosis.

Vandenbroucke-Grauls CMJ, Wilschut JA, van Egmond M, C. Stockmann HBA, van der Bij GJ, de Korte N, Oosterling SJ, Acherman YIZ, den Boer FC, Sonneveld DJA, Poort L. Randomized clinical trial of selective decontamination of the digestive tract in elective colorectal cancer surgery (SELECT trial)

Background

Infectious complications and anastomotic leakage affect approximately 30 per cent of patients after colorectal cancer surgery. The aim of this multicentre randomized trial was to investigate whether selective decontamination of the digestive tract (SDD) reduces these complications of elective colorectal cancer surgery.

Methods

The effectiveness of SDD was evaluated in a multicentre, open-label RCT in six centres in the Netherlands. Patients with colorectal cancer scheduled for elective curative surgery with a primary anastomosis were eligible. Oral colistin, tobramycin and amphotericin B were administered to patients in the SDD group to decontaminate the digestive tract. Both treatment and control group received intravenous cefazolin and metronidazole for perioperative prophylaxis. Mechanical bowel preparation was given for left-sided colectomies, sigmoid and anterior resections. Anastomotic leakage was the primary outcome; infectious complications and mortality were secondary outcomes.

Results

The outcomes for 228 patients randomized to the SDD group and 227 randomized to the control group were analysed. The trial was stopped after interim analysis demonstrated that superiority was no longer attainable. Effective SDD was confirmed by interspace DNA profiling analysis of rectal swabs. Anastomotic leakage was observed in 14 patients (6·1 per cent) in the SDD group and in 22 patients (9·7 per cent) in the control group (odds ratio (OR) 0·61, 95 per cent c.i. 0·30 to 1·22). Fewer patients in the SDD group had one or more infectious complications than patients in the control group (14·9 versus 26·9 per cent respectively; OR 0·48, 0·30 to 0·76). Multivariable analysis indicated that SDD reduced the rate of infectious complications (OR 0·47, 0·29 to 0·76).

Conclusion

SDD reduces infectious complications after colorectal cancer resection but did not significantly reduce anastomotic leakage in this trial. Registration number: NCT01740947 (https://www.clinicaltrials.gov).

Near-infrared fluorescence image-guidance in anastomotic colorectal cancer surgery and its relation to serum markers of anastomotic leakage: a clinical pilot study

OBJECTIVE

Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) might help reduce anastomotic leakage (AL) after colorectal surgery. This pilot study aims to analyze whether a relation exists between measured fluorescence intensity (FI) and postoperative inflammatory markers of AL, C-reactive protein (CRP), Intestinal fatty-acid binding protein (I-FABP), and calprotectin, to AL, in order to evaluate the potential of FI to objectively predict AL.

METHODS

Patients scheduled for anastomotic colorectal cancer surgery were eligible for inclusion in this prospective pilot study. During surgery, at three time points (after bowel devascularization; before actual transection; after completion of anastomosis) a bolus of 0.2 mg/kg ICG was administered intravenously for assessment of bowel perfusion. FI was scored in scale from 1 to 5 based on the operating surgeon's judgment (1 = no fluorescence visible, 5 = maximum fluorescent signal). The complete surgical procedure was digitally recorded. These recordings were used to measure FI postoperatively using OsiriX imaging software. Serum CRP, I-FABP, and calprotectin values were determined before surgery and on day 1, 3, and 5 postoperative; furthermore, the occurrence of AL was recorded.

RESULTS

Thirty patients (n = 19 males; mean age 67 years; mean BMI 27.2) undergoing either laparoscopic or robotic anastomotic colorectal surgery were included. Indication for surgery was rectal-(n = 10), rectosigmoid-(n = 2), sigmoid-(n = 10), or more proximal colon carcinomas (n = 8). Five patients (16.7%) developed AL (n = 2 (6.6%) grade C according to the definition of the International Study group of Rectal Cancer). In patients with AL, the maximum fluorescence score was given less often (P = 0.02) and a lower FI compared to background FI was measured at 1st assessment (P = 0.039). However, no relation between FI and postoperative inflammatory parameters could be found.

CONCLUSION

Both subjective and measured FI seem to be related to AL. In this study, no relation between FI and inflammatory serum markers could yet be found.

Novel abdominal negative pressure lavage-drainage system for anastomotic leakage after R0 resection for gastric cancer

BACKGROUND

Anastomotic leakage (AL) is a severe complication associated with high morbidity and mortality after radical gastrectomy (RG) for gastric cancer (GC). We hypothesized that a novel abdominal negative pressure lavage-drainage system (ANPLDS) can effectively reduce the failure-to-rescue (FTR) and the risk of reoperation, and it is a feasible management for AL.

AIM

To report our institution's experience with a novel ANPLDS for AL after RG for GC.

METHODS

The study enrolled 4173 patients who underwent R0 resection for GC at our institution between June 2009 and December 2016. ANPLDS was routinely used for patients with AL after January 2014. Characterization of patients who underwent R0 resection was compared between different study periods. AL rates and postoperative outcome among patients with AL were compared before and after the ANPLDS therapy. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with AL and FTR after AL.

RESULTS

AL occurred in 83 (83/4173, 2%) patients, leading to 7 deaths. The mean time of occurrence of AL was 5.6 days. The AL rate was similar before (2009-2013, period 1) and after (2014-2016, period 2) the implementation of the ANPLDS therapy (1.7% vs 2.3%, P = 0.121). Age and malnourishment were independently associated with AL. The FTR rate and abdominal bleeding rate after AL occurred were respectively 8.4% and 9.6% for the entire period; however, compared with period 1, this significantly decreased during period 2 (16.2% vs 2.2%, P = 0.041; 18.9% vs 2.2%, P = 0.020, respectively). Moreover, the reoperation rate was also reduced in period 2, although this result was not statistically significant (13.5% vs 2.2%, P = 0.084). Additionally, only ANPLDS therapy was an independent protective factor for FTR after AL (P = 0.04).

CONCLUSION

Our experience demonstrates that ANPLDS is a feasible management for AL after RG for GC.

Prediction of anastomotic leakage after anterior rectal resection

OBJECTIVE

Anastomotic Leakage (AL) is one of the most common complications after resection of rectal cancer. Recognition of the incidence and risk factors related to AL is important. This study aimed develops a model that can predict anastomotic leakage after anterior rectal resection.

METHODS

Data from 188 patients undergoing anterior resection of rectal cancer were collected for retrospective analysis. Patients were randomly divided in the development set and validation set at a 1:1 ratio. We first included age, sex, preoperative chemoradiotherapy, tumor size, degree of tumor differentiation, stage, TNM stage, lymph vascular invasion, distance, anastomotic method, diabetes, intraoperative time, intraoperative bleeding and smoking as candidates for variable selection with a LASSO method. A ROC curve was constructed with the validation set to assess the accuracy of the prediction model.

RESULTS

AL occurred in 20 of 188 patients (10.6%). Preoperative chemoradiotherapy (p=0.04), medium degree of tumor differentiation (p=0.04), anastomotic method (p<0.01), intraoperative bleeding≥400ml (p<0.01), smoking (p<0.01), diabetes (p<0.01) were significantly related to AL. The area under the ROC curve of the prediction model is 0.952.

CONCLUSIONS

This study developed a model that can predict anastomotic leakage after anterior rectal resection, which may aid the selection of preventive ileostomy and postoperative management.

Laparoscopic surgery may decrease the risk of clinical anastomotic leakage and a nomogram to predict anastomotic leakage after anterior resection for rectal cancer

INTRODUCTION

Anastomotic leakage is still one of the most dreaded complications after anterior resection for rectal cancer. This study aimed to identify risk factors for anastomotic leakage and to create a nomogram for precise prediction of anastomotic leakage after anterior resection for rectal cancer.

METHODS

Two thousand six hundred eighteen consecutive patients who underwent anterior resection for rectal cancer with primary anastomosis, with or without diverting stoma, were retrospectively analyzed as a training dataset. Univariate and multivariable Cox regression analyses were used to determine independent risk factors associated with anastomotic leakage. A nomogram was constructed to predict anastomotic leakage. Data containing 611 patients were prospectively collected as a test dataset. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots.

RESULTS

The rate of clinical anastomotic leakage was 9.3% in the training dataset. Multivariate analysis identifies the following variables as independent risk factors for anastomotic leakage: gender (male) (odds ratio (OR) = 2.286), distance of tumor to anal verge (OR = 0.791), tumor size (OR = 1.175), operating time (OR = 1.009), diabetes mellitus (OR = 1.704), laparoscopic surgery (OR = 0.445), anastomotic bleeding (OR = 13.46), and diverting stoma (OR = 0.386). We created a nomogram with high discriminative ability (concordance index, 0.722). The area under the curve value, which evaluated the predictive performance of external validation, was 0.723.

CONCLUSIONS

A protective diverting stoma and laparoscopic surgery significantly decrease the risk of anastomotic leakage. Our nomogram was a useful tool for precise prediction of anastomotic leakage after anterior resection for rectal cancer.

Different clinical features according to the anastomotic leakage subtypes after rectal cancer surgeries: contained vs. free leakages

Background

Anastomotic leakage can be classified by free and contained leakage according to clinical manifestations. The risk factors and their comparison between these leakage subtypes are uncertain. This study aims to evaluate anastomotic leakage patterns and to compare clinical features between free and contained leakages after low anterior resection for rectal cancer.

Materials and methods

Between January 2005 and December 2012, a total of 2035 consecutive patients who underwent low anterior resection for primary rectal cancer were evaluated retrospectively at two-tertiary referral centers. The primary end points of this study were to assess detailed clinical features among leakage subtypes. The secondary end point was to compare risk factors between free and contained leakages.

Results

Patients were subdivided into a no leakage group (n = 1890), free leakage group (n = 73), and contained leakage group (n = 72). Free leakage occurred more frequently in laparoscopic and robotic surgeries than open surgery (p = 0.015). On the other hand, contained leakage was developed in a higher rate of patients who received preoperative chemoradiotherapy (p<0.001). The mean development time was 4.6 days in the free leakage group, and 23.6 days in the contained leakage group. Patients with free leakage had a lower rate of a defunctioning stoma than contained leakage (5.5% vs. 29.2%, p<0.001). Risk factors for free leakage were smoking, tumor location, and laparoscopic surgery. However, tumor location and preoperative chemoradiotherapy increased the risk for contained leakage.

Conclusions

Contained leakage in rectal cancer surgery showed different clinical manifestations and risk factors compared to free leakage. It is necessary to pay more attention to patients with particular risk factors for anastomotic leakage subtypes.

Radiation-induced injury on surgical margins: a clue to anastomotic leakage after rectal-cancer resection with neoadjuvant chemoradiotherapy?

Background

Few studies on anastomotic condition after rectal-cancer resection and its effect on anastomotic leakage (AL) are available up to now. This study aimed to investigate potential radiation-induced injury left on surgical margins of anterior resection after neoadjuvant chemoradiotherapy (nCRT) and its association with AL.

Methods

We retrospectively identified 161 consecutive patients who underwent anterior resection with nCRT, neoadjuvant chemotherapy without radiation (nCT) or no neoadjuvant therapy between 2014 and 2015. Tissue samples of resection margins were assessed using a specific histopathological score and microvessel density in submucosa. Propensity score matching was used to balance the baseline characteristics. Association between AL and histopathological features was analysed.

Results

AL occurred in 13 of 54 patients undergoing nCRT, 5 of 48 patients undergoing nCT and 7 of 59 patients without neoadjuvant therapy. Comparisons after matching showed median (range) histopathological scores as follows: 3 (0–8) vs 0 (0–3) vs 0 (0–2) for the proximal margin (P < 0.001); 4 (2–9) vs 0 (0–4) vs 0 (0–3) for the distal margin (P < 0.001). Correspondingly, mean (SD) microvessel densities were as follows: 21.7 (7.9) vs 27.2 (8.6) vs 27.3 (9.4) for the proximal margin (P = 0.003); 18.1 (9.3) vs 25.2 (12.9) vs 24.9 (7.4) for the distal margin (P < 0.001). Among patients undergoing nCRT, AL was associated with increased histopathological score (P = 0.003) and decreased microvessel density (P = 0.004) on the proximal margin.

Conclusions

Surgical margins of rectal-cancer resection are exposed to certain radiation-induced injury after nCRT. AL is associated with aggravated radiation damage on the proximal margin.

Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography

BACKGROUND

The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC).

METHODS

This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates.

RESULTS

Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%.

CONCLUSIONS

FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis

Purpose

Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients.

Methods

Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up.

Results

A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444).

Conclusion

In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

Transanal total mesorectal excision (TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes

BACKGROUND

While a shift to minimally invasive techniques in rectal cancer surgery has occurred, non-inferiority of laparoscopy in terms of oncological outcomes has not been definitely demonstrated. Transanal total mesorectal excision (TaTME) has been pioneered to potentially overcome difficulties experienced when operating with a pure abdominal approach deep down in the pelvis. This study aimed to compare short-term oncological results of TaTME versus laparoscopic TME (lapTME), based on a strict anatomical definition for low rectal cancer on MRI.

METHODS

From June 2013, all consecutive TaTME cases were included and compared to lapTME in a single institution. Propensity score-matching was performed for nine relevant factors. Primary outcome was resection margin involvement (R1), secondary outcomes included intra- and post-operative outcomes.

RESULTS

After matching, forty-one patients were included in each group; no significant differences were observed in patient and tumor characteristics. The resection margin was involved in 5 cases (12.2%) in the laparoscopic group, versus 2 (4.9%) TaTME cases (P = 0.432). The TME specimen quality was complete in 84.0% of the laparoscopic cases and in 92.7% of the TaTME cases (P = 0.266). Median distance to the circumferential resection margin (CRM) was 5 mm in lapTME and 10 mm in TaTME (P = 0.065). Significantly more conversions took place in the laparoscopic group, 9 (22.0%) compared to none in the TaTME group (P < 0.001). Other clinical outcomes did not show any significant differences between the two groups.

CONCLUSION

This is the first study to compare results of TaTME with lapTME in a highly selected patient group with MRI-defined low rectal tumors. A significant decrease in R1 rate could not be demonstrated, although conversion rate was significantly lower in this TaTME cohort.

Indocyanine Green Fluorescence Angiography and the Incidence of Anastomotic Leak After Colorectal Resection for Colorectal Cancer: A Meta-analysis

BACKGROUND

Anastomotic leak is a life-threatening complication of colorectal surgery. Recent studies showed that indocyanine green fluorescence angiography might be a method to prevent anastomotic leak.

OBJECTIVE

The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak.

DATA SOURCES

Potential relevant studies were identified from the following databases: PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure.

STUDY SELECTION

This meta-analysis included comparative studies investigating the association between indocyanine green fluorescence angiography and anastomotic leak in patients undergoing surgery for colorectal cancer where the diagnosis of anastomotic leak was confirmed by CT and the outcomes of the indocyanine green group were compared with a control group.

INTERVENTION

Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis.

MAIN OUTCOME MEASURES

The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies. ORs and 95% CIs were used to assess the association between indocyanine green and anastomotic leak.

RESULTS

In 4 studies with a total sample size of 1177, comparing the number of anastomotic leaks in the indocyanine green and control groups, the ORs were 0.45 (95% CI, 0.18-1.12), 0.30 (95% CI, 0.03-2.98), 0.17 (95% CI, 0.01-3.69), and 0.12 (95% CI, 0.03-0.52). The combined OR was 0.27 (95% CI, 0.13-0.53). The difference was statistically significant (p < 0.001), and there was no significant heterogeneity (p = 0.48; I = 0).

LIMITATIONS

Data could not be pooled because of the small number of studies; some differences between studies may influence the results. Also, the pooled data were not randomized.

CONCLUSIONS

The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.

[Prevention of colorectal anastomotic leakage by using of intraoperative fluorescent angiography: prospective trial data]

AIM

To evaluate the effect of intraoperative fluorescent angiography on the incidence of colorectal anastomosis failure.

MATERIAL AND METHODS

Prospective, non-comparative study included 52 patients with rectal or sigmoid cancer who underwent surgery with stapled colorectal anastomosis. Intraoperative fluorescent angiography with indocyanine green was performed to determine colon perfusion. All patients underwent proctography with water-soluble contrast agent in 6-8 days after surgery in order to determine anastomotic leakage.

RESULTS

Fluorescent angiography was followed by changed volume of proximal colectomy in 14 (27%) patients due to inadequate blood supply of intestinal wall at previous surgical level. Additionally, 1-5 cm of intestinal wall were excised. Postoperative anastomotic leakage occurred in 3 (5.8%) patients.

CONCLUSION

Fluorescent angiography with indocyanine green is accompanied by reduced incidence of anastomotic failure in colorectal suregry.

Laparoscopic sphincter-saving surgery for low rectal cancer through marker meeting approach

Laparoscopic low anterior resection (LAR) with sphincter preservation for ultra-low rectal cancer is always a challenging operation in colorectal surgery. To achieve negative margins, reducing the difficulty and risks of the procedure are major goals for us. The marker meeting approach we reported can help to accomplish this goal. The key technique for the marker meeting approach is to ensure a clear distal margin in a low resection of the rectum by transanal dissection. This procedure allows access to the space around the distal rectum and mesorectum and to pack the gauzes in the distal part of the space as a landmark. Routine laparoscopic LAR was performed to dissect the space until reaching the gauzes packed above and achieve complete mobilization of the rectum and mesorectum. This surgical procedure is simpler and reduces the difficulty of the operation. Therefore, it is expected to reduce the risk of surgery-related complications and positive margins and is suitable to be widely applied and extended in clinical practice. The short-term and long-term clinical outcomes of the marker meeting approach need more research in large samples.

Impact of Left Colonic Artery Preservation on Anastomotic Leakage in Laparoscopic Sigmoid Resection and Anterior Resection for Sigmoid and Rectosigmoid Colon Cancer

OBJECTIVES

To investigate the effect of left colonic artery (LCA) preservation on laparoscopic sigmoidectomy outcomes METHODS: We identified 447 consecutive patients who underwent laparoscopic sigmoidectomy at our hospital group between January 2010 and December 2016. We divided the patients into groups with and without LCA preservation and with and without anastomotic leakage (AL). We compared the patient age and gender, tumor location, stage, D2/D3 lymph node dissection, comorbidities, operating time, and blood loss between these groups. Univariate and multivariate analyses were performed to determine the risk factors for AL.

RESULTS

There were significant differences in age, sex, tumor location, D2/D3 lymph node dissection, hypertension, operating time, blood loss, and AL for groups with and without LCA preservation. There were significant differences in sex, tumor location, and LCA preservation for groups with and without AL. Multivariate analysis showed male sex (hazard ratio (HR) = 6.37, 95% confidence interval (CI) 2.39-20.6; p < 0.0001), non-LCA preservation (HR = 5.01, 95% CI 1.41-31.8.0; p = 0.01), and rectosigmoidal tumor location (HR = 2.51, 95% CI 1.15-5.61; p = 0.01) as significant independent risk factors for AL.

CONCLUSIONS

Based on the results obtained by performing laparoscopic operation for sigmoid colon cancer and rectosigmoid cancer, the LCA preservative procedure is warranted for prevention of AL.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Standardization of surgical procedures to reduce risk of anastomotic leakage, reoperation, and surgical site infection in colorectal cancer surgery: a retrospective cohort study of 1189 patients

PURPOSE

Anastomotic leakage (AL) and surgical site infection (SSI) are prevalent complications of colorectal surgery. To lower this risk, we standardized our surgical procedures in 2012, with a preferential use of laparoscopic approach (LS) for both colon and rectal surgery, combined with triangulating anastomosis (TA) for colon surgery and defunctioning ileostomy (DI) for low anterior resection. Our aim was to evaluate the outcomes of our standardized procedures.

METHODS

The incidence rate of AL (primary outcome) and of reoperation and SSI (secondary outcome) was compared before (early period, n = 648) and after (late period, n = 541) standardization, through a retrospective analysis.

RESULTS

The incidence rate of AL (6.6 versus 1.8%; P = 0.001), reoperation (3.5 versus 0.7%; P = 0.0012), and SSI (7.7 versus 4.6%; P = 0.029) was lower in late than in the early period. For colon cancer, TA and LS reduced the risk of AL (2.1 versus 0.3%, P = 0.020, for TA, and 3.2 versus 0.4%, P = 0.0027, for LS) and reoperation (2.9 versus 0.3%, P = 0.003, for TA, and 2.5 versus 0.2%, P = 0.0040, for LS). For rectal cancer, the incidence of all adverse outcomes (AL, reoperation, and SSI) was lower in cases treated by LS. However, the incidence of AL was lower in the late than in early period (P = 0.002) and with LS (P = 0.002). On multivariate analysis, late period and LS were independent factors of a lower risk of adverse outcomes.

CONCLUSIONS

Our surgical standardization seems to be effective in lowering the risks of AL, reoperation, and SSI after colorectal cancer surgery.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Smoking and tumor obstruction are risk factors for anastomotic leakage after laparoscopic anterior resection during rectal cancer treatment

Objectives: To clarify the surgical outcomes and risk factors for anastomotic leakage (AL) following laparoscopic anterior resection (Lap-AR) for the treatment of rectal cancer. Methods: We retrospectively reviewed the records of 175 consecutive primary rectal cancer patients who had undergone Lap-AR at our institution between April 2012 and November 2015. Patient, tumor, and surgical variables were analyzed using univariate analyses. Results: Of 175 patients, 116 were men (66.3%). All four patients who had AL (2.3%) were men and current smokers with heavy smoking histories. In three of the AL cases, preoperative total colonoscopy was impossible owing to tumor obstruction, and the other case had concomitant obstructive colitis after oral bowel preparation. Univariate analysis identified tumor size, tumor obstruction, and smoking history as factors significantly associated with AL development. Conclusions: Tumor size, tumor obstruction, and smoking history were risk factors for AL following Lap-AR for the treatment of primary rectal cancer.

The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery

Purpose:

Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery.

Materials and Methods:

In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups.

Results:

Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis.

Conclusions:

The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

2-Octylcyanoacrylate for the prevention of anastomotic leak

BACKGROUND

Anastomotic leak after colorectal surgery is a significant cause of morbidity and mortality. The aim of this study was to evaluate the impact of a reinforced colo-colonic anastomosis with tissue adhesive, 2-octylcyanoacrylate (2-OCA), on the integrity of anastomotic healing as measured by anastomotic bursting pressure.

METHODS

Sixty-eight female Sprague-Dawley rats underwent a rectosigmoid colon transection and a sutured end-to-end anastomosis followed by randomization to receive no further intervention or reinforcement with the tissue adhesive, 2-OCA. After seven postoperative days, a macroscopic assessment of the anastomosis, mechanical assessment to determine anastomotic bursting pressure, and a detailed semi-quantitative histopathologic healing assessment were performed.

RESULTS

Thirty-four animals were randomized to each group. Study characteristics did not differ between the groups. There was also no difference in the degree of adhesions present postoperatively. Although there was no difference between the net proximal and distal luminal areas in the two groups (0.37 cm²versus 0.55 cm², P = 0.26), the 2-OCA group exhibited evidence of stricture in 15% of anastomoses as compared with 3% in the suture-only group (P < 0.0001). Histologically, the presence of only fibroblasts density was statistically more evident in the 2-OCA group compared with the sutured-only anastomosis (P = 0.0183). There was not a significant increase in mechanical strength in the 2-OCA group (238.9 mm Hg) versus in the suture-only group (231.8 mm Hg). There was no difference in the rate of anastomotic leak in the 2-OCA as compared with the suture-only group (9.1 versus 8.8%).

CONCLUSIONS

Application of 2-OCA to reinforce a colo-colonic anastomosis clinically provides no benefit to its mechanical strength and detrimentally increases the rate of obstruction and/or stricture in this in vivo model.

Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis

Objectives

The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME.

Methods

MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission.

Results

Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences.

Conclusion

A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.

Intraoperative colonic pulse oximetry in left-sided colorectal surgery: can it predict anastomotic leak?

BACKGROUND

An anastomotic leak is a fairly common and a potentially lethal complication in colorectal surgery. Objective methods to assess the viability and blood circulation of the anastomosis could help in preventing leaks. Intraoperative pulse oximetry is a cheap, easy to use, fast, and readily available method to assess tissue viability. Our aim was to study whether intraoperative pulse oximetry can predict the development of an anastomotic leak.

METHODS

The study was a prospective single-arm study conducted between the years 2005 and 2011 in Helsinki University Hospital. Patient material consisted of 422 patients undergoing elective left-sided colorectal surgery. The patients were operated by one of the three surgeons. All of the operations were partial or total resections of the left side of the colon with a colorectal anastomosis. The intraoperative colonic oxygen saturation was measured with pulse oximetry from the colonic wall, and the values were analyzed with respect to post-operative complications.

RESULTS

2.3 times more operated anastomotic leaks occurred when the colonic StO₂ was ≤ 90% (11/129 vs 11/293). The mean colonic StO₂ was 91.1 in patients who developed an operated anastomotic leak and 93.0 in patients who did not. With logistic regression analysis, the risk of operated anastomotic leak was 4.2 times higher with StO₂ values ≤ 90%.

CONCLUSIONS

Low intraoperative colonic StO₂ values are associated with the occurrence of anastomotic leak. Despite its handicaps, the method seems to be useful in assessing anastomotic viability.

Nutritional risk screening score is an independent predictive factor of anastomotic leakage after rectal cancer surgery

BACKGROUND/OBJECTIVES

Nutritional risk screening (NRS) score has been reported as a predictor of postoperative outcomes in patients undergoing abdominal surgery, although the correlation between NRS and anastomotic leakage (AL) after rectal cancer surgery is uncertain. This study aimed to evaluate the association between NRS score and AL following rectal cancer surgery.

SUBJECT/METHODS

We retrospectively reviewed data of rectal cancer patients from a tertiary referral center in South Korea, and included 1063 patients with primary rectal cancer who underwent sphincter-preserving surgery between January 2011 and December 2015. We utilized the Chonnam National University Hwasun Hospital-Nutritional Risk Screening Tool (CNUHH-NRST), which was developed and cross-validated on the basis of the NRS 2002 and MST, as a screening tool of nutritional risk. Patients with NRS scores ≥4 were compared with those with NRS scores <4, and the risk factors for AL were analyzed.

RESULTS

One-hundred-nineteen (11.2%) patients had high nutritional risk (NRS score ≥4). The patients with a nutritional risk had more advanced tumor stages than those without nutritional risk. AL occurred in 69 (6.5%) patients. The multivariate logistic regression analysis showed high American Society of Anesthesiologists score (odds ratio (OR) = 2.435, 95% confidence interval (CI) = 1.085-5.469), long operative time (OR = 1.975, 95% CI = 1.177-3.313), and high NRS score (OR = 2.044, 95% CI = 1.085-3.851) as independent risk factors of AL.

CONCLUSIONS

The NRS score was an independent predictive factor of AL after rectal cancer surgery. Patients with nutritional risks who require rectal cancer surgery should be carefully managed.

Conversion is a risk factor for postoperative anastomotic leak in rectal cancer patients - A retrospective cohort study

AIM

The impact of conversion from laparoscopic surgery to laparotomy on the development of anastomotic leak (AL) in rectal cancer patients following laparoscopic low anterior resection (LAR) with total mesorectal excision (TME) has not been evaluated. The aim of this study was to evaluate the impact of conversion on the risk of AL and develop a prediction nomogram for postoperative AL.

METHODS

All rectal cancer patients following laparoscopic LAR with TME from January 2010 to October 2014 were enrolled in the primary cohort. Comparisons of the postoperative anastomotic leak incidence rate between converted patients and non-converted patients were performed using both univariate and multivariate logistic regression analyses. The result of multivariable analysis was used to develop the predicting model and the performance of nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort containing 200 patients from November 2014 to October 2015 was assessed.

RESULTS

Of all patients enrolled (n=646), 592 (91.6%) patients underwent totally laparoscopic surgery, and 54 (8.4%) were converted from laparoscopic surgery to laparotomy. Converted group patients were more likely to have a higher body mass index (BMI), prolonged length of stay (LOS), increased overall postoperative complication rates and advanced clinical T stage (T3 or T4), pathological N stage (N1 or N2) and pathological TNM stage (III or IV). The percentage of patients who had preoperative radiotherapy for rectal cancer was higher in non-converted patients. Patients who underwent conversion to laparotomy (n=10, 18.5%) were more likely to suffer from postoperative AL than those undergoing totally laparoscopic surgery (n=38, 6.4%) (P=0.004). Multivariate logistic regression analyses confirmed the association between conversion and postoperative AL (Odds ratio [OR], 95% confidence interval [CI]: 2.71 [1.31-5.63], P=0.007). Conversion, gender, and clinical N stage incorporated in the individualized prediction nomogram showed good discrimination, with a C-index of 0.697 (C-index, 0.621 and 0.772 through internal validation), and good calibration. In the validation cohort, the main results were consistent with the findings of the primary cohort, with a C-index of 0.670 (C-index, 0.562 and 0.777 through internal validation). Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Conversion during laparoscopic LAR was found to be associated with an increased risk for the postoperative AL in RC patients. A nomogram model incorporating conversion, gender and patient's clinical N stage seems to offers a useful tool for predicting postoperative AL in these patients.

Application of spontaneously closing cannula ileostomy in laparoscopic anterior resection of rectal cancer

An anastomotic leak (AL) is the most serious complication observed in laparoscopic anterior resection of rectal cancer (LARRC). In order to protect anastomosis from AL and avoid stoma reversal surgery in patients with ileostomy, spontaneously closing cannula ileostomy (SCCI) was used in LARRC and its safety and feasibility were assessed in the present study. To the best of our knowledge, this is the first time that SCCI has been used in such a case. A total of 41 patients who underwent LARRC with SCCI or ileostomy procedures between November 2013 and August 2014 were retrospectively analyzed. The patient demographics, clinical features and surgical data were evaluated using a Mann-Whitney U-test, Fisher's exact test or linear-by-linear association. Demographics, surgical data and the majority of clinical features of the two groups were consistently similar. In the SCCI group, the length of postoperative stay, total cost and stoma period were significantly improved compared with those in the ileostomy group. Additionally, the median protective period in the SCCI group was 22 days [interquartile range (IQR), 19-22 days], the median time to cannula removal was 23 days (IQR, 20-24 days) and the median time to cannula stoma closure was 12 days (IQR, 11-13 days). No SCCI-associated complications occurred. No significant differences in routine complications, including staple-line bleeding, anastomotic leak, anastomotic dehiscence, anastomotic stenosis and wound infection, were identified between the two groups. In LARRC, the SCCI procedure was demonstrated to be a safe and feasible diverting technique to protect anastomosis from AL. In contrast to ileostomy, the SCCI procedure obviated the requirement for stoma reversal surgery, which resulted in decreased lengths of postoperative hospital stay, hospitalization costs and stoma periods.

Tumor Size as an Independent Risk Factor for Postoperative Complications in Laparoscopic Low Anterior Resection for Advanced Rectal Cancer: A Multicenter Japanese Study

This study aimed to identify the risk factors for postoperative complications after laparoscopic low anterior resection for the treatment of advanced rectal cancers. A prospectively maintained database was retrospectively analyzed. Oncological parameters in resected specimens and clinical risk factors for postoperative complications, including anastomotic leakage, were examined in patients with clinical stage II and III upper rectal cancer who underwent laparoscopic low anterior resection, including total mesorectal excision. Pathologic resection margins were negative in all patients. Postoperative complications occurred in 22 patients (25.9%), which is similar to incidence rates in previous studies. In multivariate analysis, tumor size (≥4 cm) and tumor category (T4) were independent risk factors for postoperative complications. Precise pretreatment diagnoses with locoregional evaluations are essential for the selection of appropriate patients for laparoscopic rectal resection. Despite quality results from laparoscopic low anterior resection for the treatment of advanced rectal cancer, we must attempt to reduce postoperative complications.

Risk factor for permanent stoma and incontinence quality of life after sphincter-preserving surgery for low rectal cancer without a diverting stoma

The goal of the present study was to evaluate permanent stoma formation and defecation function in long-term follow up after surgery for low rectal cancer without a diverting stoma. Subjects were 275 patients who underwent sphincter-preserving surgery for low rectal cancer between 2000 and 2012. Clinical outcomes were evaluated and defecation function was assessed based on a questionnaire survey, using Wexner and modified fecal incontinence quality of life (mFIQL) scores. Incidence of anastomotic leakage was 21.8%, and surgery-related death as a result of anastomotic leakage occurred in one male patient. Median follow-up period was 4.9 years and permanent stoma formation rate was 16.7%. Anastomotic leakage was an independent predictor of permanent stoma formation (odds ratio [OR] 5.86, P<0.001). Age <65 years (OR 1.99, P=0.001) and male gender (OR 4.36, P=0.026) were independent predictors of anastomotic leakage. A permanent stoma was formed as a result of poor healing of anastomotic leakage in 29.6% of males, but in no females. Defecation function was surveyed in 27 and 116 patients with and without anastomotic leakage, respectively. These groups had no significant differences in median follow-up period (63.5 vs 63 months), Wexner scores (quartile) (6 (2.5-9) vs 6 (3-11)), and mFIQL scores (26.1 (4.8-64.2) vs 23.8 (5.9-60.7). Defecation function associated with anastomotic leakage showed no significant dependence on gender or resection procedure. Sphincter-preserving surgery without a diverting stoma may be indicated for females with low rectal cancer. In this procedure, male gender is a risk factor for anastomotic leakage and subsequent formation of a permanent stoma in one in three patients.

Liquid biopsy in patients with hepatocellular carcinoma: Circulating tumor cells and cell-free nucleic acids

Hepatocellular carcinoma (HCC), with its high incidence and mortality rate, is one of the most common malignant tumors. Despite recent development of a diagnostic and treatment method, the prognosis of HCC remains poor. Therefore, to provide optimal treatment for each patient with HCC, more precise and effective biomarkers are urgently needed which could facilitate a more detailed individualized decision-making during HCC treatment, including the following; risk assessment, early cancer detection, prediction of treatment or prognostic outcome. In the blood of cancer patients, accumulating evidence about circulating tumor cells and cell-free nucleic acids has suggested their potent clinical utilities as novel biomarker. This concept, so-called "liquid biopsy" is widely known as an alternative approach to cancer tissue biopsy. This method might facilitate a more sensitive diagnosis and better decision-making by obtaining genetic and epigenetic aberrations that are closely associated with cancer initiation and progression. In this article, we review recent developments based on the available literature on both circulating tumor cells and cell-free nucleic acids in cancer patients, especially focusing on Hepatocellular carcinoma.

Impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after restorative surgery for rectal cancer

AIM

The aim of this study was to investigate the impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after rectal cancer surgery.

METHODS

Patients undergoing restorative proctectomy for rectal cancer between January 2008 and December 2013 were divided into four groups according to the perioperative lowest haemoglobin (Hgb) level and transfusion status: group 1 with Hgb level ≥ 10 g/dl; group 2 with Hgb level ≥ 7 and < 10 g/dl who did not receive transfusion; and group 3 with Hgb level ≥ 7 and < 10 g/dl and group 4 with Hgb level < 7 g/dl, both of which received a transfusion. Clinical characteristics, anastomotic leakage and infectious complications within 30 days of surgery were compared.

RESULTS

There were 398 patients (66% men) with a mean age of 59.3 ± 11.9 years. Groups 1, 2, 3 and 4 included 162 (40.7%), 163 (41.0%), 47 (11.8%) and 26 (6.5%) patients, respectively. Perioperative characteristics were significantly different among groups regarding neoadjuvant chemo/radiotherapy use, preoperative albumin and Hgb levels, operative approach and blood loss, tumour size and stage, surgical margin involvement and histological differentiation. The unadjusted rates of overall infectious complications were 17.2%, 27.6%, 36.2% and 50% in groups 1, 2, 3 and 4, respectively (P = 0.001). In the multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of organ/space surgical site infections (SSIs) (OR 3.63, 95% CI 1.29-10.22, P = 0.01) with no significant differences in terms of anastomotic leakage, overall SSIs or overall infectious complications.

CONCLUSION

Blood transfusion of haemodynamically stable patients with Hgb level ≥ 7 g/dl is associated with increased organ/space SSIs in rectal cancer surgery.

Intracorporeal Traction of the Rectum with a Beaded Plastic Urinary Drainage Bag Hanger: Comparison with Conventional Laparoscopic Rectal Cancer Surgery

BACKGROUND

Laparoscopic rectal cancer surgery with proper total mesorectal excision is a challenge for colorectal surgeons during trouble shooting. We used a beaded plastic urinary drainage bag hanger to encircle the rectum and clamp laparoscopic rectal transaction in this study.

METHODS

Sixty-three patients with rectal cancer underwent laparoscopic radical rectal resection with curative intent between February 2015 and December 2015. Plastic beaded form urinary Foley catheter bag hanger was inserted intracorporeally via right lower 12-mm trocar, encircling the rectal tube distal to the rectal lesion followed by fastening. Thirty patients in the rectal resection group (28 laparoscopic, 2 robotic-assisted) using the commercial beaded plastic hanger for Foley catheter drainage were compared to 33 patients who underwent conventional laparoscopic rectal resection.

RESULTS

Low anterior resection was performed for both groups. The Foley bag hanger group had less operation time (162.6 min vs. 187.3 min, p = 0.006) and fewer numbers of stapler cartilage (1.6 vs. 2.1, p = 0.001).

CONCLUSIONS

Intracorporeal ligation of the rectum with a beaded plastic Foley catheter bag hanger could be used as a valuable method for rectal handling and transaction in laparoscopic rectal cancer surgery.