Oncological impact of anastomotic leakage after laparoscopic mesorectal excision

Intraoperative Blood Loss Predicts Local Recurrence After Curative Resection for Stage I-III Colorectal Cancer

BACKGROUND

To identify the predictors of local recurrence and distant metastasis after radical surgery for stage I-III colorectal cancer.

MATERIALS AND METHODS

Patient and tumor characteristics, clinicopathological stages, perioperative factors, and postoperative outcomes, including local and distant recurrence, of patients who underwent primary colorectal resection were evaluated in this multicenter retrospective analysis. Univariate and multivariate regression analyses were performed to identify the risk factors for local and distant recurrences, with a focus on the intraoperative blood loss (IBL) ratio [IBL (mL)/total blood volume (mL)] and postoperative complications.

RESULTS

The risk factors for local and distant recurrence pattern differed. The predictors for local recurrence included perioperative factors, such as the IBL ratio and anastomotic leakage, as well as tumor factors, including pT4, rectal cancer, and poorly differentiated histology, in the multivariate analysis. On the other hand, the predictors for distant recurrence included perioperative factors, such as Clavien-Dindo score ≥ 3, and absence of adjuvant chemotherapy as well as tumor factors including pT stage, pN stage, and rectal cancer. The area under the receiver operating characteristic curve (AUC) for local recurrence in the IBL ratio was 0.745, which was higher than the AUCs for other recurrence patterns in the IBL ratio. Patients with a higher IBL ratio had a higher rate of early local recurrence within 2 years postoperatively (Wilcoxon test and p = 0.028).

CONCLUSION

Reducing IBL and formulating perioperative strategies to prevent anastomotic leakage may help decrease the local recurrence rate and improve prognosis.

Laparoscopic approach for rectal cancer surgery: triumph of reason or necessity of evolution?

The role of laparoscopy in rectal cancer surgery has evolved considerably since the early 2000s. Initial randomized trials, such as COLOR II and COREAN, indicated that laparoscopic approaches offered similar pathological outcomes with better postoperative recovery than open surgery. In contrast, trials like ACOSOG Z6051 and ALaCaRT suggested noninferiority could not be established. Variability in trial outcomes, focusing on either disease-free survival or pathological measures, initially hindered consensus. Long-term analyses have shown no significant difference in disease-free survival between laparoscopic and open approaches. Meta-analyses have reinforced the benefits of laparoscopic surgery, with reduced mortality and similar oncologic effectiveness to open surgery. However, new techniques like transanal TME (TaTME) and robotic approaches have introduced alternatives, though each presents unique challenges, from recurrence rates in TaTME to costs in robotics. While laparoscopy remains the preferred method due to accessibility and outcomes, robotic surgery is expected to gain traction in high-volume centers.

Anastomotic leakage after resection for rectal cancer and recurrence-free survival in relation to postoperative C-reactive protein levels

BACKGROUND

Anastomotic leakage after rectal cancer surgery is linked to reduced survival and higher recurrence rates. While an aggravated inflammatory response may worsen outcomes, few studies have explored the combined effects of leakage and inflammation.

METHODS

This is a retrospective multicenter cohort study including patients operated with anterior resection for rectal cancer in Sweden during 2014-2018. Anastomotic leakage within 12 months was exposure and primary outcome was recurrence-free survival. Mediation analysis was performed to evaluate the potential effect of systemic inflammatory response, as measured by the highest postoperative C-reactive protein (CRP) level within 14 days of surgery. Confounders were chosen using a causal diagram.

RESULTS

Some 1036 patients were eligible for analysis, of whom 218 (21%) experienced an anastomotic leakage. At the end of follow-up at a median of 61 months after surgery, recurrence-free survival amounted to 82.6% and 77.8% in the group with and without leakage, respectively. The median highest postoperative CRP value after surgery was higher in the leakage group (219 mg/l), compared with the group without leakage (108 mg/l). Leakage did not lead to worse recurrence-free survival (HR 0.66; 95% CI 0.43-0.94), and there was no apparent effect through postoperative highest CRP (HR 1.12; 95% CI 0.93-1.29).

CONCLUSIONS

In conclusion, anastomotic leakage, with its accompanying CRP increase, was not found to be associated with recurrence-free survival after anterior resection for rectal cancer in this patient cohort. Larger, even more detailed studies are needed to further investigate this topic.

An Institutional Shift from Routine to Selective Diversion of Low Anastomosis in Robotic TME Surgery for Rectal Cancer Patients Using the KHANS Technique: A Single-Centre Cohort Study

(1) Background: In recent years, there has been a change in practice for diverting stomas in rectal cancer surgery, shifting from routine diverting stomas to a more selective approach. Studies suggest that the benefits of temporary ileostomies do not live up to their risks, such as high-output stomas, stoma dysfunction, and reoperation. (2) Methods: All rectal cancer patients treated with a robotic resection in a single tertiary colorectal centre in the UK from 2013 to 2021 were analysed. In 2015, our unit made a shift to a more selective approach to temporary diverting ileostomies. The cohort was divided into a routine diversion group treated before 2015 and a selective diversion group treated after 2015. Both groups were analysed and compared for short-term outcomes and morbidities. (3) Results: In group A, 63/70 patients (90%) had a diverting stoma compared to 98/135 patients (72.6%) in group B (p = 0.004). There were no significant differences between the groups in anastomotic leakages (11.8% vs. 17.8%, p = 0.312) or other complications (p = 0.117). There were also no significant differences in readmission (3.8% vs. 2.6%, p = 0.312) or reoperation (3.8% vs. 2.6%, p = 1.000) after stoma closure. After 1 year, 71.6% and 71.9% (p = 1.000) of patients were stoma-free. One major reason for the delay in stoma reversal was the COVID-19 pandemic, which only occurred in group B (0% vs. 22%, p = 0.054). (4) Conclusions: A more selective approach to diverting stomas for robotic rectal cancer patients does not lead to more complications or leaks and can be considered in the treatment of rectal cancer tumours.

Predictors of complications after prophylactic ileostomy reversal for rectal cancer: A retrospective study

BACKGROUND

Previous studies have analyzed the risk factors for complications after ileostomy reversal for rectal cancer (RC), but there were significant differences in the reported risk factors for complications after stoma reversal. No studies have analyzed the risk factors for stoma-related complications and overall postoperative complications separately.

AIM

To analyze the risk factors for overall complications and stoma-related complications after ileostomy reversal for patients with RC.

METHODS

This was a retrospective study of 439 patients who underwent ileostomy reversal at a clinical center and were followed up between September 2012 and September 2022. Continuous variables are expressed as the mean ± SD and were analyzed with independent-sample t tests, while frequency variables are expressed as n (%), and the χ2 test or Fisher's exact test was used. Univariate and multivariate logistic regression analyses were used to identify predictors of overall complications and stoma-related complications.

RESULTS

The overall complication rate after ileostomy reversal was 11.4%. Patients with lower preoperative albumin concentration (P < 0.01), greater blood loss (P = 0.017), and longer operative times (P < 0.01) were more likely to experience postoperative complications. The incidence of stoma-related complications was 6.4%. Analysis of the study showed that a higher body mass index (BMI) (P < 0.01), preoperative comorbid hypertension (P = 0.049), time from primary surgery to ileostomy reversal (P < 0.01) and longer operation time (P = 0.010) were more likely to result in stoma-related complications postoperatively. Multivariate logistic regression analysis revealed that a lower preoperative albumin level (P < 0.01, OR = 0.888, 95%CI: 0.828-0.958) was an independent risk factor for overall complications. Moreover, multivariate analysis revealed that BMI (P < 0.01, OR = 1.176, 95%CI: 1.041-1.330) and time from primary surgery to ileostomy reversal (P < 0.01, OR = 1.140, 95%CI: 1.038-1.252) were independent risk factors for stoma-related complications after stoma reversal.

CONCLUSION

The preoperative albumin level was a predictor of overall complications. Preoperative BMI and the time from primary surgery to ileostomy reversal were predictors of stoma-related complications.

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

BACKGROUND

Temporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer.

MATERIALS AND METHODS

We conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer.

RESULTS

A total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure.

CONCLUSION

We identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.

Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre

AIM

Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre.

METHOD

Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome.

RESULTS

In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567).

CONCLUSION

High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.

Clinical risk factors and Risk assessment model for Anastomotic leakage after Rectal cancer resection

BACKGROUND

Anastomotic leakage (AL) is the most serious complication after rectal cancer surgery. Risk factors associated with AL have been documented in previous studies; however, the consensus is still lacking. In this retrospective study, we aimed to identify risk factors for AL after rectal cancer resection and to create an accurate and effective tool for predicting the risk of this complication.

METHODS

The study cohort comprised of 276 patients with rectal cancer who had undergone anterior resection between 2015 and 2020. Twenty-four selected variables were assessed by univariate and multivariate logistic regression analyses to identify independent risk factors of AL. A risk assessment model for predicting the risk of AL was established on the basis of the regression coefficients of each identified independent risk factor.

RESULTS

Anastomotic leakage occurred in 20 patients (7.2%, 20/276). Multivariate analysis identified the following variables as independent risk or protective factors of AL: perioperative ileus ( P < 0.001, odds ratio [OR] = 14.699), tumor size ≥5 cm ( P = 0.025, OR = 3.925), distance between tumor and anal verge <7.5 cm ( P = 0.045, OR = 3.512), obesity ( P = 0.032, OR = 7.256), and diverting stoma ( P = 0.008, OR = 0.143). A risk assessment model was constructed and patients were allocated to high-, medium-, and low-risk groups on the basis of risk model scores of 5-7, 2-4, and 0-1, respectively. The incidences of AL in these three groups were 61.5%, 11.9%, and 2.0%, respectively ( P < 0.001).

CONCLUSIONS

Our risk assessment model accurately and effectively identified patients at high risk of AL and could be useful in aiding decision-making aimed at minimizing adverse outcomes associated with leakage.

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials

AIM

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery.

METHOD

PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool.

RESULTS

Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG.

CONCLUSION

Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer

Introduction

Previous treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre.

Material and methods

Data regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer.

Results

Patients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60-1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34-4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36-1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32-5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival.

Conclusion

Rectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location.

Diagnostic accuracy of water-soluble contrast enema, contrast-enema computed tomography and endoscopy in detecting anastomotic leakage after (Colo) proctectomy: A meta-analysis

BACKGROUND

Anastomotic leakage (AL) as a result of creation of a colorectal/anal anastomosis still represents a frequent complication of colorectal surgery, with short- and long-term consequences on postoperative morbidity, quality of life and oncological outcomes. However, early diagnosis of AL may result in improved outcomes. The aims of this study were to evaluate the diagnostic accuracy of water-soluble contrast enema (WSCE), contrast enema computed tomography (CECT) and endoscopy in identifying AL and to identify the diagnostic procedure that is most accurate.

METHODS

A systematic review and meta-analysis of 19 studies accounting for a total of 25 tests reporting diagnostic accuracy estimates was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines up to June 2021. For the diagnostic tests we evaluated the pooled estimates and conducted pairwise comparisons.

RESULTS

For WSCE, the pooled sensitivity was 0.50, the pooled specificity was 0.99 and the area under the curve (AUC) was 0.91. For endoscopy, the pooled sensitivity was 0.69, specificity was 1.00 and AUC was 0.99. The pooled sensitivity and specificity for CECT were 0.89 and 1.00, respectively; the AUC was 0.99. The comparison between CECT and WSCE highlighted a significantly greater sensitivity (p = 0.04) for CECT, whereas no difference was found for specificity. Compared with CECT, endoscopy was not significantly more accurate in terms of either sensitivity or specificity. Endoscopy was found to be significantly more specific than WSCE (p = 0.031) but no difference was found for sensitivity.

CONCLUSION

Water-soluble contrast enema, endoscopy and CECT have an elevated diagnostic accuracy. However, WSCE is less accurate than either endoscopy or CECT. Although greater sensitivity was demonstrated for CECT compared with endoscopy, this was not significant.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.

Surgery for synchronous and metachronous colorectal cancer: segmental or extensive colectomy?

PURPOSE

To assess the impact of surgical approach on morbidity, mortality, and the oncological outcomes of synchronous (SC) and metachronous (MC) colorectal cancer (CRC).

METHODS

All patients undergoing resection for double location CRC (SC or MC) between 2006 and 2020 were included. The exclusion criteria were polyposis or SC located on the same side.

RESULTS

Sixty-seven patients (age, 64.8 years; male, 78%) with SC (n = 41; 61%) or MC (n = 26; 39%) were included. SC was treated with segmental colectomy (right and left colectomy/proctectomy; n = 19) or extensive colectomy (subtotal/total colectomy or restorative proctocolectomy with pouch; n = 22). Segmental colectomy was associated with a higher incidence of anastomotic leakage (47.4 vs. 13.6%; p = 0.04) and a higher rate of medical morbidity (47.4 vs. 16.6%; p = 0.04). The mean number of lymph nodes harvested was similar. For MC, the second cancer was treated by iterative colectomy (n = 12) or extensive colectomy (n = 14) and there was no significant difference in postoperative outcomes between the two surgical approaches. The median follow-up period was 42.4 ± 29.1 months. The 5-year overall and disease-free survival of the SC and MC groups did not differ to a statistically significant extent.

CONCLUSIONS

Extensive colectomy should be preferred for SC to reduce morbidity and improve the prognosis. In contrast, iterative colectomy can be performed safely for patients with MC.

Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients

Temporary loop ileostomy is usually performed to protect distal anastomosis or to treat urgent surgical cases. The aim of this study is to evaluate whether, after primary urgent stoma construction, patients undergoing ileostomy reversal have different postoperative outcomes compared with patients who have protective stoma performed in an elective setting. A retrospective observational study was conducted including patients who underwent ileostomy reversal. Baseline patient characteristics and perioperative outcomes were collected in a single database. The overall morbidity rate during recovery was fixed as a primary outcome. Between 2011 and 2021, the complete data records of 145 patients were evaluated. After ileostomy reversal, the postoperative morbidity rate did not differ between groups (14.4% vs. 11.5%, p = 0.790). Even considering each complication, such as ileus, small bowel obstruction, bleeding and wound infection, no significant difference was detected. Similarly, the time to first flatus was 2.25 ± 1.24 vs. 2.1 ± 0.99 (p = 0.379) and the length of hospital stay was 5.43 ± 3.03 vs. 5.84 ± 5.15 (p = 0.568). The only significant factor associated with postoperative complications on logistic regression analysis was the presence of comorbidities (OR 4.49; 95% CI 1.19-29.4, p = 0.05). In the present cohort of patients, there was no difference in the postoperative complication rate after stoma closure following elective or urgent indication for surgery.

Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors

BACKGROUND

Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.

AIM

To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.

METHODS

To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.

RESULTS

The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.

CONCLUSION

Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients

OBJECTIVE

Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients.

METHODS

A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019.

RESULTS

The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001).

CONCLUSION

The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.

Association between circular stapler size and anastomotic leakage after laparoscopic low anterior resection for rectal cancer

Background

Anastomotic leakage (AL) is one of the most severe and frequent complications occurring after laparoscopic low anterior resection (LAR) for rectal cancer. This study aimed to examine the association between circular stapler size and AL after laparoscopic LAR.

Methods

This retrospective single-institution study involved 181 patients with rectal cancer who underwent laparoscopic LAR performed by a single surgical team between July 2016 and June 2021. The characteristics of the patients were analyzed. Risk factors for AL were identified via univariate and multivariate analyses. Additionally, a further propensity score matching (PSM) analysis was performed to reduce the selection bias.

Results

Among the 181 patients who underwent laparoscopic LAR for rectal cancer, 17 (9.4%) developed clinical AL. In the univariate and multivariate analyses, male sex, incomplete intestinal obstruction, and the usage of a 32-mm stapler during the surgery were independent risk factors for the occurrence of AL. Furthermore, the PSM analysis confirmed that the incidence of AL with a 32-mm stapler was higher than that with a 29-mm stapler after laparoscopic low anterior resection. However, there was no difference in the incidence of anastomotic bleeding and stenosis.

Conclusion

Choosing a smaller-diameter circular stapler may reduce the incidence of AL after laparoscopic LARfor rectal cancer without increasing the incidence of anastomotic stenosis.

The role of transanal drainage tube in preventing the anastomotic leakage in rectal cancer surgery without a defunctioning stoma: A meta-analysis

BACKGROUND

Anastomotic leakage is a common and serious complication after rectal cancer surgery. The role of transanal drainage tube (TDT) in the prevention of anastomotic leakage is still controversial. The aim of this study was to evaluate the role of TDT in preventing anastomotic leakage.

METHODS

Two reviewers individually searched the PubMed, Embase and Cochrane Library ranging from January 2000 to June 2022. The pooled odds ratio (ORs) and weighted mean difference (WMD) with the 95% confidence interval (95% CI) were used to assess anastomotic leakage and other parameters.

RESULTS

A total of 3383 patients (1508 in the TDT group and 1875 in the cohort study group) were included in 13 studies. The study found that patients treated with TDT had a lower incidence of anastomotic leakage with or without neoadjuvant radiotherapy. Moreover, patients who received TDT had lower rates of reoperation and tended to reduce the severity of anastomotic leakage.

CONCLUSIONS

For rectal cancer patients without defunctioning stoma, TDT could reduce the incidence of anastomotic leakage, decrease the reoperation rate of patients, and tend to reduce the severity of anastomotic leakage. More RCT are needed to assess the role of TDT in rectal cancer surgery.

Oncological outcomes of rectal cancer patients with anastomotic leakage: A multicenter case-control study

INTRODUCTION

This study aimed to evaluate the impact of anastomotic leakage (AL) on oncological outcomes after restorative rectal cancer surgery.

METHODS

Patients who underwent anterior resection for rectal adenocarcinoma between January 2011 and December 2017 were retrospectively reviewed. Data were collected from three colorectal surgery centers. Patients with grade B and C leaks according to the International Study Group of Rectal Cancer classification were identified and compared with the control group. Estimated recurrence and survival rates were compared using the log-rank method and Cox regression analysis.

RESULTS

A total of 367 patients were included in the study, with a mean follow-up of 59.21 months. AL occurred in 64 patients (17.4%). Fifteen patients with AL (23.5%) developed local recurrence (LR) compared to 17 (4.8%) in the control group (p < 0.001). However, distant recurrence rates were similar (10.9% vs. 9.6%; p = 0.914) between the groups. Kaplan-Meier curves showed that patients with AL had a reduced 5-years local recurrence-free survival (96% vs. 78%, log-rank p < 0.001). AL (OR 4.576; 95% CI, 2.046-10.237; p < 0.001) and node involvement (OR 2.911; 95% CI, 1.240-6.835; p = 0.014) were significantly associated with LR in multivariate analysis. AL was significantly associated with DFS only at univariate analysis (HR 1.654; 95% CI: 1.024-2.672; p = 0.037), with a difference between 5-year DFS of patients with and without AL (71.6% vs. 86.4%, log-rank p = 0.04). Only male gender, pT3-4 stage, and node involvement were identified as independent prognostic factors for reduced DFS in the multivariate Cox regression analysis.

CONCLUSION

In this cohort of patients, AL was associated with a significant risk of LR after rectal cancer surgery.

Intracorporeal reinforcement with barbed suture is associated with low anastomotic leakage rates after laparoscopic low anterior resection for rectal cancer: a retrospective study

Background

Anastomotic leakage (AL) is one of most severe postoperative complications following low anterior resection (LAR) for rectal cancer, and has an adverse impact on postoperative recovery. The occurence of AL is associated with several factors, while few studies explored the role of intracorporeal barbed suture reinforcement in it.

Methods

Consecutive cases underwent laparoscopic LAR for rectal cancer from Mar. 2018 to Feb. 2021 in our center were retrospectively collected. Cases were classified into the intracorporeal barbed suture reinforcement group and the control group according to whether performing intracorporeal reinforcement with barbed suture, and AL incidences were compared between two groups. Propensity score matching (PSM) was then performed based on identified risk factors to reduce biases from covariates between two groups. AL incidences in the matched cohort were compared.

Results

A total of 292 cases entered into the study, and AL incidences were significantly lower in the intracorporeal barbed suture reinforcement group compared with the control group (10.00% vs 2.82%, P = 0.024). Sex, BMI, preoperative adjuvant chemoradiotherapy and anastomotic level were chose for PSM analyses based on previous studies. In the matched cohort, the AL incidences were still significantly lower in the intracorporeal barbed suture reinforcement group (10.57% vs 2.44%, SD = 0.334).

Conclusions

Intracorporeal barbed suture reinforcement is associated with low AL incidences after laparoscopic LAR for rectal cancer, which is a potential procedure for reducing AL and worthy of application clinically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01782-x.

Efficacy of staple line reinforcement by barbed suture for preventing anastomotic leakage in laparoscopic rectal cancer surgery

BACKGROUND

Anastomotic leakage (AL) is a severe complication in rectal cancer surgery. Various methods, including intracorporeal reinforcing suturing, have been used to reduce the incidence of AL. However, little is known about the efficacy of staple-line reinforcement by barbed suture for preventing AL.

AIM

To evaluate the efficacy of staple-line reinforcement using barbed suture for preventing AL in laparoscopic surgery for rectal cancer.

METHODS

We retrospectively reviewed the clinical datum of 319 patients undergoing laparoscopic low anterior resection combined with double stapling technique between May 1, 2017 and January 31, 2021. All surgeries were performed by the same surgical team specializing in colorectal surgery. Patients were divided into two groups depending on whether they received reinforcing sutures. Patients’ baseline characteristics did not show any significant difference between the two groups. We analyzed patient-, tumor-, as well as surgery-related variables using univariate and multivariate logistic analyses.

RESULTS

There were 168 patients in the reinforcing suture group and 151 patients in the non-reinforcing suture group. AL occurred in 25 cases (7.8%). Its incidence was significantly higher in the non-reinforcing suture group than in the reinforcing suture group (4.8% vs 11.3%, P = 0.031). The multivariate analyses demonstrated that the tumor site, tumor size and presence of staple-line reinforcement were independent risk factors for AL. We divided these patients into two risk groups based on the combination of tumor site and tumor size. Patients without any risk factor were assigned to the low-risk group (n = 177), whereas those having one or two risk factors were assigned to the high-risk group (n = 142). In the high-risk group, the AL incidence considerably decreased in the reinforcing suture group compared with that in the non-reinforcing suture group (P = 0.038). Nonetheless, no significant difference was found in the low-risk group between the two groups.

CONCLUSION

Staple-line reinforcement by barbed suture may decrease the incidence of AL. A large-scale prospective randomized controlled trial is needed for evaluating the efficacy of staple-line reinforcement for preventing AL.

Effect of the transanal drainage tube on preventing anastomotic leakage after laparoscopic surgery for rectal cancer: a systematic review and meta-analysis

PURPOSE

Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, and transanal drainage tube (TDT) efficacy is still contentious. This study aimed to evaluate the TDT effect on AL prevention.

METHODS

All relevant papers were searched by using a predefined search strategy (two randomized controlled trials (RCTs), one prospective study, and four retrospective studies). Meta-analysis was conducted to estimate AL and re-operation pooled rates.

RESULTS

A total of 7 studies (1556 patients) were included: No significant statistic difference was found between two groups on AL rate (odds ratio (OR) 0.61, P = 0.11) and re-operation rate (OR 0.52, P = 0.10). For subgroup analysis, significant statistic difference was found between two groups on AL rate (OR 0.29, P = 0.002) and re-operation rate (OR 0.15, P = 0.04) in patients without neoadjuvant therapy. As for patients without diverting stoma, the AL rate (OR 0.35, P = 0.002) was significantly lower than that in patients without TDT.

CONCLUSIONS

TDT may reduce AL morbidity and re-operation rate for patients without high risk of AL, but may be useless for those in high-risk situations.

Is it safe to perform an anastomosis for rectal cancer after prostate cancer? A multicentre study of 126 patients from the GRECCAR group

AIM

To determine the safety of performing an anastomosis after rectal cancer (RC) resection in patients with a previously treated prostate cancer (PC).

METHODS

Patients with a previously treated PC who underwent rectal resection from 2008 to 2018 were retrospectively included. Outcomes were compared between patients who underwent rectal resection with anastomosis (restorative surgery, RS+ group) and those with a definitive stoma (RS- group). In the RS+ group, anastomotic leak (AL) rates were assessed according to the type of reconstruction.

RESULTS

A total of 126 patients underwent rectal surgery for mid-low RC after a previous PC treated by radiotherapy (RT) and/or radical prostatectomy. Overall, 80 patients (63%) underwent a RS and 46 patients (37%) underwent rectal surgery with a definitive stoma. There was no statistical difference between the two groups in terms of intraoperative data, except for the type of resection with more multivisceral resection in the RS- group (p < 0.01). In the RS+group, a diverting stoma was performed in 74% of cases. No difference between the two groups in terms of overall morbidity was found. In the RS+group (n = 80), 17 patients (21%) experienced AL. Of these, none was observed when delayed coloanal anastomosis was performed (p = 0.16). Long-term permanent stoma in the RS+ group was 16% (n = 13).

CONCLUSION

Restorative surgery after resection for RC in patients with a previous history of RT and/or radical prostatectomy for PC is safe without additional morbidity. In selected patients for restorative surgery, performing delayed coloanal anastomosis may represent a promising option.

Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer

AIM

After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter-saving surgery are to perform a side-to-end manual coloanal anastomosis (CAA) (or with J-pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull-through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer.

METHOD

From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n = 190) versus DCAA without stoma (n = 33).

RESULTS

Overall 3-month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p = 0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant).

CONCLUSION

Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).

Nonmetastatic ypt0 rectal cancer after neoadjuvant treatment and total mesorectal excision: Lessons from a retrospective multicentric cohort of 383 patients

BACKGROUND

A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision.

METHODS

All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored.

RESULTS

Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124).

CONCLUSION

The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.

Associations between matrix metalloproteinase, tissue inhibitor of metalloproteinase and collagen expression levels in the adjacent rectal tissue of colorectal carcinoma patients

As the commonest type of cancer in Europe and the third most common type of cancer worldwide, colorectal carcinoma (CRC) poses a challenge for numerous scientific studies. At present, the cause of this disease is remains to be elucidated, but early diagnosis is only one solution to prevent serious health complications. As a structural scaffold, the extracellular matrix (ECM) is in direct contact with tumour cells and significantly interferes with tumour progression. During the process of tumorigenesis, the ECM undergoes structural changes in which collagens serve an important role. Their life cycle is regulated by proteolytic enzymes called matrix metalloproteinases (MMPs), which are controlled by tissue inhibitors of metalloproteinases (TIMPs). The present study analysed the gene expression of MMPs (MMP1-2-8-10-13), TIMPs (TIMP1-2-4) and collagens (COL1A1 and COL3A1) and the correlation with biochemical parameters in the adjacent rectal tissue (ART) of patients with CRC. The patients who underwent standard neoadjuvant pre-therapy showed increased concentrations of collagen in the normal ART. The mRNA levels of COL3A1, TIMP1 and TIMP2 were significantly higher in the ART of CRC patients (with or without pre-therapy) when compared with the control group. This finding suggested that TIMPs served an important role in the regulation of MMPs and in the modification of collagen content in the ECM. Despite the small data set, the present study provided insights into the transcriptomic relationships between the individual genes that are an integral part of the ECM.

Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer

AIM

To investigate the conflicting consequences of faecal diversion on stoma outcomes and anastomotic leakage in anterior resection for rectal cancer, including interaction effects determined by the extent of mesorectal excision.

METHOD

Anterior resections between 2007 and 2016 were identified using the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine stoma outcome 2 years after surgery. Tumour distance from the anal verge constituted a proxy for extent of mesorectal excision [total mesorectal excision (TME): ≤10 cm; partial mesorectal excision (PME): 13-15 cm]. With confounder-adjusted probit regression, the total effect of defunctioning stoma on permanent stoma, and the interaction effect of extent of mesorectal excision, were estimated together with the indirect effect through anastomotic leakage. Baseline risks, risk differences (RDs) and relative risks (RRs) were reported.

RESULTS

The main study cohort included 4529 patients. Defunctioning stomas influenced the absolute permanent stoma risk (TME: RD 0.11 [95% CI 0.09-0.13]; PME: RD 0.15 [95% CI 0.13-0.16]). The baseline risk was higher in TME, with a resulting greater RR in PME (2.23 [95% CI 1.43-3.02] vs 4.36 [95% CI 3.05-5.68]). The indirect reduction in permanent stoma rates, due to the alleviating effect of faecal diversion on anastomotic leakage, was small (TME: 0.89 [95% CI 0.81-0.96]; PME: 0.96 [95% CI 0.91-1.00]).

CONCLUSION

In anterior resection for rectal cancer, defunctioning stomas may reduce chances of a stoma-free outcome. Considering leakage reduction benefits, consequences of routine diversion in TME might be fairly balanced, while this seems questionable in PME.

Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial

AIM

The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy.

METHODS

This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group).

RESULTS

Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17).

CONCLUSION

Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).

Can end-to-end anastomosis reduce the risks of anastomotic leak compared to side-to-end anastomosis? A comparative study of 518 consecutive patients undergoing laparoscopic total mesorectal excision for low- or mid-rectal cancer

BACKGROUND

After laparoscopic total mesorectal excision (TME) for low or mid-rectal cancer, we observed several cases of anastomotic leakage (AL) in patients with side-to-end anastomosis (STE). Thus, from December 2018, we routinely performed end-to-end anastomosis (ETE). The aim of this study was to assess if this new strategy changed AL and chronic pelvic sepsis rates in our department.

METHODS

A retrospective study was conducted on all the patients who underwent a laparoscopic rectal resection with TME and sphincter-saving surgery for mid- and low-rectal adenocarcinoma from January 2006 to December 2019. A comparative study between STE and routine ETE was performed. The primary outcome was the assessment of postoperative AL rate. The secondary outcomes were: (a) overall morbidity rate; (c) severe morbidity rate defined by a Clavien-Dindo score > 3; (c) chronic leak rate.

RESULTS

Five hundred eighteen patients underwent TME: STE was performed in 394 cases (76%) and ETE in 124 but for the first 66 cases only if STE was impossible (i.e., too short colon, obese patients). AL rates for STE were 57/204 (23%) after stapled colorectal anastomosis (CRA) and 34/190 (18%) after manual coloanal anastomosis (CAA). Since December 2018, routine ETE was performed in 58 cases. The AL rate for routine ETE was 3/24 (12%) for CRA, and 2/34 (6%) for CAA: thus, The AL rate dropped from 23% (91/394) after STE to 9% (5/58) after routine ETE (p = 0.0005). After a mean follow-up of 43 months (6-156), incidence of chronic AL was 68/394 (17%) after STE and 15/117 (13%) after ETE (p = 0.32). In the group of ETE with chronic AL, 11 patients (73%) spontaneously healed and stoma reversal was possible, whereas this happened in only 20 patients (29%) after STE (p = 0.0025).

CONCLUSIONS

ETE seems to be associated with a significantly lower rate of AL and higher rate of spontaneous healing after chronic AL than STE.

Mucosa plication reinforced colorectal anastomosis and trans-anal vacuum drainage: a pilot study with preliminary results

Dehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019–October 2020. The mean age of patients was 61 years (lower–upper quartiles 54–69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower–upper quartiles 3.00–4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien–Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation.

Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.

The assessment of risk factors for long-term survival outcome in ypN0 patients with rectal cancer after neoadjuvant therapy and radical anterior resection

BACKGROUND

The main negative prognostic factors in patients with rectal cancer after radical treatment include regional lymph node involvement, lymphovascular invasion, and perineural invasion. However, some patients still develop cancer recurrence despite the absence of the above risk factors. The aim of the study was to assess clinicopathological factors influencing long-term oncologic outcomes in ypN0M0 rectal cancer patients after neoadjuvant therapy and radical anterior resection.

METHODS

A retrospective survival analysis was performed on a group of 195 patients. We assessed clinicopathological factors which included tumor regression grade, number of lymph nodes in the specimen, Charlson comorbidity index (CCI), and colorectal anastomotic leakage (AL).

RESULTS

In the univariate analysis, AL and CCI > 3 had a significant negative impact on disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). After the division of ALs into early and late ALs, it was found that only patients with late ALs had a significantly worse survival. The multivariate Cox regression analysis showed that CCI > 3 was a significant adverse risk factor for DFS (HR 5.78, 95% CI 2.15-15.51, p < 0.001), DSS (HR 7.25, 95% CI 2.25-23.39, p < 0.001), and OS (HR 3.9, 95% CI 1.72-8.85, p = 0.001). Similarly, late ALs had a significant negative impact on the risk of DFS (HR 5.05, 95% CI 1.97-12.93, p < 0.001), DSS (HR 10.84, 95% CI 3.44-34.18, p < 0.001), and OS (HR 4.3, 95% CI 1.94-9.53, p < 0.001).

CONCLUSIONS

Late AL and CCI > 3 are the factors that may have an impact on long-term oncologic outcomes. The impact of lymph node yield on understaging was not demonstrated.

Monitoring of C-reactive protein decreases length of stay after laparoscopic total mesorectal excision for cancer: a prospective case-matched study in 236 patients

AIM

The aim of this study was to evaluate a discharge strategy driven by monitoring of C-reactive protein (CRP) in a homogeneous group of patients undergoing laparoscopic total mesorectal excision with sphincter-saving surgery for rectal cancer (TME).

METHOD

One hundred and thirteen patients who underwent a TME had CRP monitoring on postoperative day (POD) 5. Patients were discharged on POD 6 if the CRP level was ≤100 mg/L. Patients were matched (according to age, gender, body mass index, neoadjuvant pelvic irradiation and type of anastomosis) to 123 control patients who underwent the same operation with the same postoperative care but without CRP monitoring.

RESULTS

Postoperative 3-month overall [CRP group 62/113 (55%) vs controls 73/123 (59%); p = 0.487] and severe (i.e. Clavien-Dindo grade 3 and above) [CRP group 17/113 (15%) vs controls 19/123 (15%); p = 0.931] morbidity rates were similar between groups. Mean length of hospital stay (LHS) was significantly shorter in the CRP group (CRP group 9.7 ± 14 days vs controls 11.6 ± 7 days; p < 0.001). Discharge occurred on POD 6 in 55/113 (49%) patients from the CRP group vs 7/123 (6%) from the control group (p < 0.001). The rehospitalization rate [CRP group 19/113 (17%) vs controls 13/123 (11%); p = 0.177] was similar between groups. The CRP level on POD 5 had a diagnostic property to assess an anastomotic leakage with an area under the curve of 0.81.

CONCLUSION

In patients who underwent TME, a discharge strategy based on CRP monitoring significantly decreased LHS without increasing morbidity, mortality or rehospitalization rates.

Treatment of anastomotic leakage after rectal cancer resection: The TENTACLE-Rectum study

AIM

Anastomotic leakage is a severe complication after low anterior resection (LAR) for rectal cancer and occurs in up to 20% of patients. Most research focuses on reducing its incidence and finding predictive factors for anastomotic leakage. There are no robust data on severity and treatment strategies with associated outcomes. The aims of this work were (1) to investigate the factors that contribute to severity of anastomotic leakage and to compose an anastomotic leakage severity score and (2) to evaluate the effects of different treatment approaches on prespecified outcome parameters, stratified for severity score and other leakage characteristics.

METHOD

TENTACLE-Rectum is an international multicentre retrospective cohort study. Patients with anastomotic leakage after LAR for primary rectal cancer between 1 January 2014 and 31 December 2018 will be included by each centre. We aim to include 1246 patients in this study. The primary outcome is 1-year stoma-free survival (i.e. patients alive at 1 year without a stoma). Secondary outcomes include number of reinterventions and unplanned readmissions within 1 year, total length of hospital stay, total time with a stoma, the type of stoma present at 1 year (defunctioning, permanent), complications related to secondary leakage and mortality. For aim (1) regression models will be used to create an anastomotic leakage severity score. For aim (2) the effectiveness of different treatment strategies for leakage will be tested after correction for severity score and leakage characteristics, in addition to other potential related confounders.

CONCLUSION

TENTACLE-Rectum will be an important step towards drawing up evidence-based recommendations and improving outcomes for patients who experience severe treatment-related morbidity.

High ligation of the inferior mesenteric artery and anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta-analysis of randomized controlled trial studies

AIM

Surgeons have concerns whether high ligation (HL) of the inferior mesenteric artery (IMA) increases the incidence of anastomotic leakage (AL). This meta-analysis aimed to evaluate the influence of HL of the IMA on AL compared with low ligation (LL).

METHODS

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched. Randomized controlled trial studies that compared HL with LL of the IMA in anterior resection for rectal cancer and reported AL outcomes were eligible for inclusion. The odds ratios and mean differences were analysed by a random-effects model. Trial sequential analysis was performed to minimize the risk of random errors. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence for outcomes.

RESULTS

Of the 531 records screened, five randomized controlled trials with 779 patients were selected for analysis. The pooled incidence of AL was 12.1% (95% Cl 7.77-18.26) in the HL group and 9.7% (95% Cl 5.79-15.82) in the LL group (OR 1.20, 95% CI 0.77-1.87, P = 0.42). In trial sequential analysis, the cumulative Z-score curve exceeded the futility boundary, although the required information size of 1060 had not been reached. The quality of evidence was judged to be high according to the GRADE approach.

CONCLUSIONS

This meta-analysis shows that HL of the IMA does not increase the incidence of AL in anterior resection for rectal cancer.

Impact of early biochemical diagnosis of anastomotic leakage after rectal cancer surgery: long-term results from GRECCAR 5 trial

Elevated C-reactive protein, should be used to prompt early detection of AL prior to the development of clinical symptoms. Early biochemical diagnosis and intervention of AL mitigates the negative impact of AL on oncological outcomes in patients with rectal cancer.

Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer-a nationwide register-based cohort study

PURPOSE

A defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer.

METHODS

Data from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects.

RESULTS

During a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67-0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma.

CONCLUSION

A defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.

Drainage smell and peritonitis are efficient indicators of anastomotic leakage after laparoscopic rectal cancer resection

Objective

Anastomotic leakage (AL) is a frequent complication after laparoscopic rectal cancer resection (LRCR). The main objective of the present study was to identify accurate indicators of AL after LRCR.

Methods

A retrospective case-control study was performed of 185 patients who underwent laparoscopic surgery for rectal cancer between March 2012 and February 2017 at Beijing Friendship Hospital. Potential indicators of AL were examined via univariate and multivariate analyses. The performance of multivariate analysis was evaluated using receiver operating characteristic (ROC) curves.

Results

The overall AL rate was 17.84%. Multivariate analysis identified drainage smell (odds ratio [OR = 35.318, 95% confidence interval [CI] = 7.114 to 175.338) and peritonitis [OR = 17.475, 95% CI = 1.540 to 198.318) as independent indicators of AL. The area under the ROC curve was 0.720 (95% CI = 0.606 to 0.835).

Conclusion

Drainage smell and peritonitis could be reliable and accurate indicators of AL after LRCR.

Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: A retrospective case-control study

BACKGROUND

The purpose of the study was to evaluate the association between microfibrillar collagen hemostat and anastomotic leakage after anterior resection.

METHOD

Between March 2015 and December 2019, a total of 203 consecutive rectal cancer patients who underwent elective anterior resection were included. Patient parameters were analyzed. The relevant risk factors were identified by univariate and multivariate analysis. Propensity score matching was performed to reduce the selection bias.

RESULTS

In total, 26 (12.8%) of the 203 study patients developed clinical anastomotic leakage. The length of hospital stay was significantly prolonged by anastomotic leakage. In univariate analysis and multivariate analysis, male sex, low tumor location, and intraoperative application of microfibrillar collagen hemostat significantly increased the risk of anastomotic leakage. Furthermore, analysis after propensity score matching confirmed the independent role of microfibrillar collagen hemostat in anastomotic leakage. In addition, the median time of anastomotic leakage occurrence from the initial operation in patients with microfibrillar collagen hemostat was 9.00 days, which was significantly later than that in patients without microfibrillar collagen hemostat.

CONCLUSION

In addition to male sex and low tumor location, intraoperative application of microfibrillar collagen hemostat was demonstrated to be a significant risk factor for anastomotic leakage. This finding suggested that surgeons should be fully aware of this potential risk in anterior resection. Because of the limitation of retrospective study, however, randomized controlled trials are needed to confirm this association in the future.

Delayed coloanal anastomosis: an alternative option for restorative rectal cancer surgery after high-dose pelvic radiotherapy for prostate cancer

AIM

Restorative total mesorectal excision (TME) for rectal cancer after high-dose pelvic radiotherapy for prostate cancer has been reported to provide an unacceptable rate of pelvic sepsis. In a previous publication we proposed that delayed coloanal anastomosis (DCAA) should be performed in this situation. The present study aimed to assess the feasibility and outcomes of this strategy.

METHOD

Between 2000 and 2018, 1094 men were operated on for rectal cancer in our institution. All men with T2/T3 mid and low rectal cancer with preoperative radiotherapy and restorative TME were considered for this study (n = 416). Patients with external-beam high-dose radiotherapy (EBHRT) for prostate cancer (70-78 Gy) were identified and compared with patients with conventional long-course chemoradiotherapy (CRT) followed by TME. We compared our already published historical cohort (2000-2012), including arm A (CRT + TME; n = 236) and arm B (EBHRT + TME; n = 12), with our early cohort (2013-2018), including arm C (CRT + TME; n = 158) and arm D (EBHRT + TME-DCAA; n = 10). The end-points were morbidity, pelvic sepsis, reoperation rate and quality of the specimen.

RESULTS

Overall morbidity was not significantly different between groups. Pelvic sepsis decreased from 50% (arm B) to 10% (arm D) with the use of DCAA (P = 0.074), and was similar between arms A, C and D. Quality of the specimen was not significantly different between the four groups.

CONCLUSION

Our results suggest that TME with DCAA in patients with previous EBHRT is feasible, with the same postoperative pelvic sepsis rate as conventional CRT.

Intra-operative fluorescence angiography is reproducible and reduces the rate of anastomotic leak after colorectal resection for cancer: a prospective case-matched study

AIM

Intra-operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left-sided colonic or low anterior resection with anastomosis for colorectal cancer.

METHODS

All patients with left-sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA-). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end-point.

RESULTS

In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra-operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788-0.998, P < 0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA- group compared to the IOFA+ group (16.7% vs 2.4%, P = 0.026) involving significantly more anastomotic dehiscence which required re-intervention (19% vs 2.4%, P = 0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA- group compared with the IOFA+ group (9.5% vs 0%, P = 0.040).

CONCLUSION

In this prospective case-matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible.

Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation

Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.

The impact of anastomotic leakage on oncology after curative anterior resection for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Anastomotic leakage (AL) is a serious clinical complication after anterior resection for rectal cancer and will lead to an increase in postoperative mortality. However, the effect on long-term oncology outcomes remains controversial.

METHODS

We searched the PubMed, Embase, and Cochrane library databases for related articles. The included studies assessed local recurrence, distant recurrence, overall survival, cancer-specific survival and disease-free survival. The systematic reviews and meta-analyses was conducted in accordance with the PRISMA guidelines. The combined RRs with 95% CI were then calculated using a fixed effects model or a randomized effect model.

RESULTS

A total of 18 cohort studies included 34,487 patients who met the inclusion criteria. The meta-analysis demonstrated that AL was associated with increased local recurrence (RR 1.47, 95% CI 1.14-1.90, I = 57.8%). Anastomotic leakage decreased overall survival (RR 0.92, 95% CI 0.88-0.96, I = 58.1%), cancer-specific survival (RR 0.96, 95% CI 0.92-1.00, I = 30.4%), and disease-free survival (RR 0.85, 95% CI 0.77-0.94, I = 80.4%). Distant recurrence may had no significant effects of AL (RR 1.16, 95% CI 0.91-1.46, I = 58.4%).

CONCLUSION

AL has a negative effect on local recurrence and long-term survival (including overall survival, cancer-specific survival, and disease-free survival) after anterior resection for rectal cancer, but not related to distant recurrence.

Long term outcome of anastomotic leakage in patients undergoing low anterior resection for rectal cancer

Background

The influence of anastomotic leakage (AL) on local recurrence rates and survival in rectal cancer remains controversial. The aim of this study was to analyze the effect of asymptomatic anastomotic leakage (AAL) and symptomatic anastomotic leakage (SAL) on short- and long-term outcome after curative rectal cancer resection.

Methods

All patients who underwent surgical resection of non-metastatic rectal cancer with curative intent from January 2005 to December 2017 were retrospectively analyzed. Short-term morbidity, long-term functional and oncological outcomes were compared between patients with SAL, AAL and without AL (WAL).

Results

Overall, 200 patients were included and AL was observed in 39 (19.5%) patients (10 AAL and 29 SAL) with a median follow-up of 38.5 months. Rectal cancer location and preoperative neoadjuvant treatment was similar between the three groups. Postoperative 30-day mortality rate was nil. The permanent stoma rate was higher in patients with SAL or AAL compared to WAL patients (44.8 and 30% vs 9.3%, p < 0.001). The mean wexner continence grading scale was significantly different between AAL (11,4 ± 3,8), SAL (10,3 ± 0,6) and WAL (6,4 ± 4,7) groups (p = 0.049). The 3 and 5-year overall and disease-free survival rates were similar between the 3 groups (86.6% /84% vs 100%/100% vs 76%/70 and 82.9%/77% vs 100%/100% vs 94.7%/88.3% for patients with SAL, AAL, and WAL, p = 0.480 and p = 0.527).

Conclusion

The permanent stoma rate was significant higher in patients with SAL or AAL compared to WAL patients. AL did not impair long-term oncological outcome.

Colorectal anastomosis dehiscence: a call for more detailed morphological classification

Introduction

A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology.

Aim

To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications.

Material and methods

This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7^th and 10^th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist.

Results

Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference.

Conclusions

Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Does a transanal drainage tube reduce anastomotic leakage? A matched cohort study in 144 patients undergoing laparoscopic sphincter-saving surgery for rectal cancer

BACKGROUND

The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS).

METHODS

A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL.

RESULTS

A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0-5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04-8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36-23.53]) were associated with AL.

CONCLUSIONS

Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer.

The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage.

METHODS

The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I² , and bias was evaluated by funnel plot and Begg's test.

RESULTS

A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12).

CONCLUSIONS

The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.

How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting

AIMS

Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage.

METHODS

A three-step Delphi-method was used to find consensus recommendations.

RESULTS

Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis.

CONCLUSION

Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.

Anastomotic leak in colorectal cancer patients: New insights and perspectives

Anastomotic leak (AL) remains a potentially life-threatening sequela of colorectal surgery impacting on mortality, short- and long-term morbidity, quality of life, local recurrence (LR) and disease-free survival. Despite technical improvements and the identification of several surgery- and patient-related factors associated to the risk of AL, its incidence has not significantly changed over time. In this context, the clarification of the mechanisms underlying anastomotic healing remains an important unmet need, crucial for improving patients' outcomes. This review concentrates on novel key findings in the etiopathogenesis of AL, how they can contribute in determining LR, and measures which may contribute to reducing its incidence. AL results from a complex, dynamic interplay of several factors and biological processes, including host genetics, gut microbiome, inflammation and the immune system. Many of these factors seem to act in concert to drive both AL and LR, even if the exact mechanisms remain to be elucidated. The next generation sequencing technology, including the microbial metagenomics, could lead to tailored bowel preparations targeting only those pathogens that can cause AL. Significant progress is being made in each of the reviewed areas, moving toward translational and targeted therapeutic strategies to prevent the difficult complication of AL.