Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Role of body mass index in anastomotic leakage after curative treatment for rectal cancer

BACKGROUND

Anastomotic leakage (AL) represents a severe complication after rectal surgery, leading to significant morbidity, mortality, and increased healthcare costs. Despite improvements in surgical methods and perioperative care, the challenge of AL persists.

OBJECTIVES

Explore the impact of body mass index (BMI) on the risk of AL following curative treatment for rectal cancer, providing insight into its predictive value.

DESIGN

Retrospective review.

SETTINGS

Data were collected from a single tertiary center, emphasizing the specialized postoperative outcomes in a high-care setting.

PATIENTS AND METHODS

The study population was comprised patients who underwent sphincter-saving surgery combined with neoadjuvant chemoradiation for rectal cancer from 2001 to 2011. Patients with anastomotic stenosis were excluded.

MAIN OUTCOME MEASURES

The primary outcome investigated was the occurrence of AL post-surgery. Secondary outcomes included the assessment of local cancer recurrence rates within the AL group.

SAMPLE SIZE

224; 13 excluded.

RESULTS

Of 237 patients who underwent surgery, 13 with anastomotic stenosis were excluded from this study. Of the remaining 224, 15 individuals (6.3%) developed AL. A potential association between higher BMI and increased AL risk was identified. Additionally, the study noted a higher incidence of local rectal cancer recurrence in the group that developed leakage.

CONCLUSION

The findings suggest BMI as a significant predictive factor for AL after curative rectal cancer treatment. This emphasizes the need for heightened awareness and possible preoperative counseling for obese patients regarding their increased risk of postoperative leakage.

LIMITATIONS

The study was retrospective with all the inherit biases of such studies. The sample size was small and this may have introduced a type 2 statistical error.

Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis

To prevent anastomotic leakage and other postoperative complications after laparoscopic rectal cancer surgery, a protective ileostomy is often used. However, the necessity of performing ileostomy after laparoscopic rectal cancer remains controversial. The aim of this meta-analysis was to assess the benefit of ileostomy on wound infection after laparoscopic rectal cancer. The Cochrane Library, EMBASE, Web of Science, and PubMed were used to retrieve all related documents up to September 2023. Completion of the trial literature was submitted once the eligibility and exclusion criteria were met and the literature quality assessment was evaluated. This study compared the post-operative post-operative complications of an ileostomy with that of non-ileostomy in a laparoscope. We used Reman 5.3 to analyse meta-data. Controlled studies were evaluated with ROBINS-I. The meta-analyses included 525 studies, and 5 publications were chosen to statistically analyse the data according to the classification criteria. There was no statistically significant difference in the rate of postoperative wound infections among ostomate and nonostomate (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.66, 4.84; p = 0.25). In 5 trials, the incidence of anastomotic leak was increased after surgery in nonostomate patients (OR, 0.26; 95% CI, 0.12, 0.57; p = 0.0009). Two studies reported no significant difference in the length of operation time when nonstomal compared to stomal operations in patients with rectal cancer (mean difference, 0.87; 95% CI, -2.99, 4.74; p = 0.66). No significant difference was found in the rate of wound infection and operation time after operation among the two groups, but the incidence of anastomosis leak increased after operation. Protective ileostomy after laparoscopic rectal cancer was effective in reducing the risk of anastomotic leakage in patients, and we found no additional risk of infection. We cautiously conclude that protective ileostomy is active and necessary for patients with a high risk of anastomotic leakage after surgery, which needs to be further confirmed by high-quality studies with larger samples.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tumour-specific mesorectal excision for rectal cancer: Systematic review and meta-analysis of oncological and functional outcomes

BACKGROUND

Tumour-specific mesorectal excision (TSME) practice for rectal cancer only relies on small retrospective studies. This study aimed to perform a systematic review and meta-analysis to assess the oncological and functional outcomes of TSME practice.

METHODS

A systematic review protocol was drawn to include all the studies that compared partial versus total mesorectal excision (PME vs TME) practised for rectal adenocarcinoma up to 16 cm from the anal verge. A systematic literature search was conducted on EMBASE-Medline, Pubmed and Cochrane Library. Reports were screened for the study's outcomes: oncological radicality, postoperative anastomotic leak risk and functional outcomes. Included studies were appraised for risk-of-bias and meta-analysed. Evidence was rated with the GRADE approach.

RESULTS

Twenty-seven studies were included, consisting of 12325 patients (PME n = 4460, 36.2%; TME n = 7865, 63.8%). PME was performed for tumours higher than 10 cm from the anal verge in 54.5% of patients. There was no difference between PME and TME in circumferential resection margin positivity (OR 1.31, 95%CI 0.43-3.95, p = 0.64; I2 = 38%), and local recurrence risk (HR 1.05, 95%CI 0.52-2.10, p = 0.90; I2 = 40%). The postoperative leak risk (OR 0.42, 95%CI 0.27-0.67, p < 0.001; I2 = 60%) and the major low anterior resection syndrome risk (OR 0.34, 95%CI 0.28-0.40, p < 0.001; I2 = 0%) were lower after PME surgery. No difference was found in urinary incontinence (OR 0.68, 95%CI 0.13-3.67, p = 0.66) and urinary retention after early catheter removal (OR 2.00, 95%CI 0.24-16.51, p = 0.52).

CONCLUSIONS

Evidence from this meta-analysis shows that TSME for rectal cancer has good oncological results and leads to the best-fitted functional results possible for the patient's condition.

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

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

Proteína C reactiva y su progresión en el tiempo para la detección de las fugas anastomóticas

Introducción. Las fugas anastomóticas son una complicación común y crítica en cirugía gastrointestinal, por lo que su identificación y tratamiento temprano son necesarios para evitar resultados adversos. El uso convencional con un valor límite de la proteína C reactiva ha demostrado una utilidad limitada. El objetivo de este estudio fue determinar la utilidad de la medición seriada de la proteína C reactiva en la detección de fugas anastomóticas. Métodos. Revisión prospectiva de base de datos retrospectiva de pacientes sometidos a cirugía abdominal mayor con al menos una anastomosis intestinal. Se midió la proteína C reactiva al tercer y quinto día posoperatorio. Las complicaciones se categorizaron según la clasificación de Clavien-Dindo. La precisión diagnóstica fue evaluada por el área bajo la curva. Resultados. Se incluyeron 157 pacientes, el 52 % mujeres. La edad promedio fue de 63,7 años. El mayor número de cirugías correspondió a gastrectomía (36,3 %), resección anterior de recto (15,3 %) y hemicolectomía derecha (13,4 %). El 25,5 % tuvieron alguna complicación postoperatoria y el 32,5 % (n=13) presentaron fuga en la anastomosis. El aumento de la proteína C reactiva tuvo un área bajo la curva de 0,918 con un punto de corte de aumento en 1,3 mg/L, sensibilidad de 92,3 % (IC95% 78 – 100) y una especificidad de 92,4 % (IC95% 88 – 96). Conclusiones. El aumento de 1,3 mg/L en la proteína C reactiva entre el día de la cirugía y el quinto día fue un predictor preciso de fugas anastomóticas en pacientes con cirugía abdominal mayor.

Short- and long-term outcomes of laparoscopic low anterior resection with "dog ear" invagination anastomosis for mid and distal rectal cancer a propensity score matched analysis

Background

The lateral intersecting margin (dog-ear) was a weak spot of the double stapled technique (DST), We designed "dog-ear" invagination anastomosis (DAIA), which could eliminate the "dog-ear" in laparoscopic anterior resection.

Patients and methods

A total of 202 patients underwent elective curative LLAR + DST (n = 143) or LLAR + DAIA (n = 59) were enrolled in the study. Propensity score matching (PSM) was used to minimize the adverse effects. The clinical data between LLAR + DST and LLAR + DAIA was compared, and the effect of factors on overall survival (OS) and disease-free survival (DFS) was analyzed.

Results

After PSM, 53 pairs of the LLRA + DST and LLRA + DAIA patients were enrolled in the study. The LLRA + DAIA group has a higher level (3.50 ± 1.03 vs. 2.87 ± 1.10, P = 0.01) of the anastomosis than that of the LLRA + DST group. Patients in LLAR + DAIA group have a lower incidence of protecting loop ileostomy compared to LLAR + DST group (20.75% vs. 5.66%, P < 0.05). The LLRA + DAIA patients presented better rates of LARS compare to LLRA + DST patients at 6 months (major LARS 37.74% (n = 20) vs. 67.93% (n = 36); P = 0.007) and 12 months (major LARS 13.21% (n = 7) vs. 20.37% (n = 11); P = 0.03) after surgery. The OS and DFS rates were similar (P > 0.05).

Conclusion

Laparoscopic low anterior resection with "dog-ear" invagination anastomosis technique are well-established procedures for patients with low rectal cancer. "Dog-ear" invagination anastomosis technique may reduce the incidence of protecting loop ileostomy and significantly affect LARS score, and demonstrate a positive impact on the quality of life after surgery.

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.

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.

Application of the Bioabsorbable Polyglycolic Acid Sheet in Colorectal Anastomosis in Animal Models

Objectives

Anastomotic complications after colorectal surgery are one of the most serious outcomes. To address this issue, this study used the newly developed bioabsorbable polyglycolic acid (PGA) sheet to assess its usefulness and safety using two approaches of double stapling technique (DST) after laparoscopic anterior resection (AR) in pig models.

Methods

Rectal intratissue pressure was assessed after DST anastomosis in two groups, i.e., with (PGA group) or without PGA sheet (nonPGA group), which was sandwiched between the anastomosis in the first approach. In the second approach, after laparoscopic DST anastomosis with PGA sheet attached at anvil side, the clinical short-term outcomes within 1 week and histological findings at 1 week after the surgery were evaluated.

Results

Assessment of rectal intratissue pressure showed a mean pressure of 9.28 kPa in the PGA group versus 5.78 kPa in the nonPGA group (p = 0.39). The results of clinical short-term outcomes revealed that there were no anastomotic complications. The results of histological findings in anastomotic bowel tissues with PGA sheet were not significantly different from those of the control case.

Conclusions

The bioabsorbable PGA sheet can be used for colorectal DST anastomosis in animal models and may be a valuable tool for this procedure.

Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study

BACKGROUND

Anastomotic leak after gastrointestinal anastomosis is a serious complication. Anastomotic failure depends on various parameters. The aim of our study was to evaluate the pressure resistance of a new device, EEA™ circular stapler with Tri-Staple™ technology 28 mm Medium/Thick (Triple-rows circular stapler; TCS) compared with EEA™ circular stapler with DST series™ technology 28 mm, 4.8 mm staples (double-rows circular stapler; DCS).

PATIENTS AND METHODS

We performed 30 anastomoses (DSC: 15, TCS: 15) of DST with porcine colon model in vitro. We performed following 3 comparative experiences; Experiment 1: observation of staple shape with a colonoscopy, Experiment 2: comparison of the pressure resistance, Experiment 3: comparison of leakage points.

RESULTS

There was no hypoplasia of staples and the shapes were well-formed by colonoscopy. The leakage pressure of DCS was 19.6 ± 4.4 mm Hg (mean ± standard deviation) and that of TCS was 38.6 ± 10.2 mm Hg (mean ± standard deviation). There was a significantly difference between 2 groups (P < .001). 12 cases of DCS (80%) and 10 cases of TCS (66.7%) had leakages from Circular stapler point. 2 cases of DCS (13.3%) and 5 cases of TCS (33.3%) had leakages from Crossing points. Only 1 case of DCS had leakages from Dog ear point (6.7%). There was no significantly difference in leakage site between 2 groups (P = .195).

CONCLUSIONS

TSC showed high pressure resistance during DST compared with that of DCS. It was suggested that TCS may contribute to the reduction of anastomotic leakage rate.

Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score-matched study

Anastomotic leakage (AL) after colorectal surgery is a serious complication. This study aimed to evaluate the effectiveness of the EEA™ circular stapler, a new triple-row circular stapler (TCS), relative to a conventional, double-row circular stapler (DCS). A total of 285 patients who underwent anastomosis with the double stapling technique at the Tokyo Medical University Hospital between 2017 and 2021 were included in this nonrandomized clinical trial with historical controls using a propensity score (PS) analysis. The primary endpoint was the risk of AL. We performed a 1:2 PS matching analysis. Before case matching, AL occurred in 15 (7.4%) and 2 (2.4%) patients in the DCS and TCS groups, respectively, with no significant difference (P = .17). After case matching, AL occurred in 13 patients (11.6%) and 1 patient (1.8%) in the DCS and TCS groups, respectively, revealing a significant difference (P = .04). Cox models were created by applying PS to adjust for group differences via regression adjustment. Odds ratios for AL in the DCS group versus the TCS group were 0.31 (95% confidence interval [CI]: 0.07-1.38) in the entire cohort, 0.15 (95% CI: 0.02-0.64) in the regression adjustment cohort, and 0.14 (95% CI: 0.02-1.09) in the 1:2 PS-matched cohort. PS analysis of clinical data suggested that the use of TCS contributes to a reduced risk of AL after colorectal anastomosis CTwith the double stapling technique.

Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience

Background

Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk.

Methods

A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL.

Results

The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m², preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis.

Conclusions

AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11686-y.

Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis.

RESULTS

Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality.

CONCLUSION

J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

Outcomes of side-to-end versus end-to-end colorectal anastomosis in non-emergent sigmoid and rectal cancers: randomized controlled clinical trial

Purpose

The outcomes of open colorectal anastomosis of side-to-end vs. end-to-end in non-emergent sigmoid and rectal cancer surgery in adults were compared.

Methods

A randomized controlled trial on individuals with sigmoid and rectal cancers was conducted between September 2016 and September 2018.

Results

The mean age was 62.58±12.3 years in the side-to-end anastomotic (SEA) group and 61.03±13.98 years in the end-to-end anastomotic (EEA) group. Except for the operative time, intraoperative data revealed no significant differences between the studied groups, and the SEA group revealed that the mean anastomotic time was significantly shorter. Perioperative blood loss, length of stay, reoperation, inpatient death, infection, and bleeding were significantly associated with leakage. There is a statistically significant change regarding the range of bowel frequency in the EEA group only (P=0.04). There is a statistically significant difference regarding incontinence for flatus in the SEA group only (P≤0.001). A statistically significant change in both groups regards incontinence for liquid stools (P≤0.001) and clustering of stools (P≤0.001 and P=0.043). The quality of life in the SEA group significantly dropped at 6 months and then returned to baseline as regards to physical well-being (PWB), functional well-being (FWB), and colorectal cancer symptoms (CCS) with no difference as regards SWB and EWB, while in the EEA group, the exact change happened only as regard PWB and FWB, but SWB and CCS percentage did not return to baseline.

Conclusion

The SEA group offers a safe alternative approach to the EEA group.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

[Mobilization of splenic flexure - routine or selective (results of a single-center randomized study)]

OBJECTIVE

To evaluate safety and effectiveness of routine splenic flexure mobilization (SFM) in surgical treatment of rectal cancer (RC).

MATERIAL AND METHODS

A single-center randomized study was performed between 2016 and 2019. Patients were randomized into 2 groups (SFM (+), n=156, SFM(-), n=67). Standard anterior and low anterior rectal resection was used. We used a combination of medial, lateral, and anterior approaches for SFM. Intraoperative, early and late postoperative complications, histological data, local recurrence, overall 3-year, relapse-free and cancer-specific survival were analyzed.

RESULTS

Surgery time was 253.2±72.8 and 252.0±78.0 min in the SFM(+) and SFM(-) groups, respectively (p=0.98). Blood loss was 53.3±53.6 and 67.0±108.8 ml, respectively (p=0.85), length of specimen - 28.6 (95% CI 27.2-29.9) and 24.0 cm (95% CI 22.2-25.7) (p<0.0001). Length of residual fragment of sigmoid colon was 5.0 (95% CI 3.9-6.1) and 9.1 cm (95% CI 7.2-11.1) (p<0.0001), respectively. The number of examined lymph nodes was 15.5 (95% CI 14.2-16.8) and 16.1 (95% CI 14.2-18.1) (p=0.52), number of affected lymph nodes - 1.5 (95% CI 0.9-2.1) and 1.5 (95% CI 0.9-2.2), respectively (p=0.38). Spleen damage was more common in the SFM (-) group (4.5% vs. 1.3%, p=0.12). Logistic regression analysis indicates that SFM does not affect the incidence of spleen damage. Severity of postoperative complications was similar (p=0.63). Anastomotic leak (AL) was more common in the SFM group (-) (17.9% vs. 9.6%, p=0.04). AL grade B was more common in the SFM(-) group (p=0.0001). Logistic regression analysis revealed the following predictors of anastomotic leakage: length of specimen and length of residual sigmoid colon. There was no significant relationship between SFM and incidence of local and systemic recurrences. Overall, cancer-specific and relapse-free 3-year survival was similar.

CONCLUSION

SFM is a safe procedure with various advantages. However, this approach does not improve intraoperative, early and long-term postoperative outcomes that does not allow us to recommend this approach for routine application.

Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains

Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.

Defining Anastomotic Leak and the Clinical Relevance of Leaks

Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.

A multicentre confirmatory single-arm trial of the safety and efficacy of a transanal drain for prevention of anastomotic leakage after surgery for rectal cancer

AIM

Recent reports have described the use and efficacy of several types of transanal tube (TAT) for preventing anastomotic leakage by reducing intraluminal pressure. The aim of this study was to evaluate the safety and efficacy of a newly developed TAT for the prevention of anastomotic leakage after low anterior resection (LAR) for rectal cancer.

METHOD

A multicentre confirmatory single-arm trial was designed to evaluate the safety and efficacy of a new TAT after LAR for rectal cancer. A total of 115 patients were registered in the trial at several cancer centres and other hospitals. All patients initially received reconstruction with a stapled anastomosis, but 18 then underwent creation of a diverting stoma. Of the remaining 97 patients, the first 96 were included in the protocol-defined primary analysis set. The primary outcome was the incidence of symptomatic leakage and the secondary endpoint was the incidence of complications associated with use of the TAT. The TAT was placed during LAR without creating a covering stoma and the drain was removed 4 or 5 days postoperatively.

RESULTS

The rate of symptomatic leakage was 5.2% (95% confidence interval 1.7-11.7), which was significantly lower than the predetermined threshold value of 15.8% (one-sided p-value 0.0013). Only one patient had Grade 3 rectal bleeding that might have been related to use of the TAT.

CONCLUSION

This nonrandomized study shows that the TAT appears to be safe and results in lower rates of anastomotic leakage in LAR compared with previous studies.

Contrast-enhanced abdominal computed tomography to evaluate anastomotic integrity before ileostomy closure in postoperative colorectal cancer patients

PURPOSE

To investigate the usefulness of contrast-enhanced abdominal computed tomography (CECT) to predict clinically significant anastomotic leakage (CSAL) in patients who received colorectal cancer surgery with diverting ileostomy.

METHODS

In this retrospective cohort study, patients who underwent colorectal cancer surgery with diverting ileostomy from January 2014 to May 2018 and postoperative CECT were included. The performance of significant CECT features, identified using multivariable logistic regression, to predict CSAL was calculated. In subgroup analysis, the areas under the receiver operating characteristic curve (AUROCs) were compared between CECT and water-soluble contrast enema (WSCE) using DeLong's method.

RESULTS

Of 325 patients (median age, 58 years; 213 men), CECT was routinely performed to evaluate cancer status in 307 (94.5%), and CSAL was observed in 28 (8.6%). After multivariable adjustment, anastomotic mural defect (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.77-15.51; p = 0.003), perianastomotic air (OR 7.28; 95% CI 1.82-29.17; p = 0.007) and ischemic colitis (OR 3.30; 95% CI 1.13-9.61; p = 0.029) were significantly associated with CSAL. The sensitivity, specificity, accuracy, and positive and negative predictive values of significant CECT features were 60.7%, 88.2%, 85.9%, 32.7%, and 96.0%, respectively. In subgroup analysis of 144 patients, the AUROC using significant CECT features (optimal sensitivity/specificity, 50.0%/90.4%) was comparable to that using WSCE (optimal sensitivity/specificity, 12.5%/97.8%) to predict CSAL (0.704 vs. 0.552, p = 0.085).

CONCLUSION

CECT performed after colorectal cancer surgery may be useful to assess anastomotic integrity before ileostomy closure, especially to negatively predict CSAL. In the presence of anastomotic mural defect, perianastomotic air, or ischemic colitis, WSCE may be recommended to exclude CSAL.

Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients

BACKGROUND

Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice.

METHODS

Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge.

RESULTS

Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar.

CONCLUSIONS

Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.

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).

Urinary dysfunction in women following total mesorectal excision versus partial mesorectal excision for treatment of rectal cancer

Background

Colorectal cancer is a condition which is associated with substantial morbidity and mortality. The aim of this study was to assess urinary dysfunction and its effect on quality of life in women who underwent total mesorectal excision compared to women treated by partial mesorectal excision for treatment of rectal cancer.

Methods

We performed a retrospective cohort study at a tertiary university hospital between January 2014 and December 2019. A comparison was performed between women who underwent total mesorectal excision as opposed to partial mesorectal excision for treatment of rectal cancer. Pre-operative, intra-operative and post-operative data were compared between groups. Data regarding radiation therapy was recorded and compared as well. Urinary dysfunction and its impact on quality of life were assessed using UDI-6 and USIQ questionnaires. Further univariate and multivariate analyses were performed in the attempt of assessing risk factors for urinary dysfunction.

Results

A total of 107 women were included in the study, 73 women underwent partial mesorectal excision as opposed to 34 women who were treated by total mesorectal excision. Twenty-five women in the TME group underwent radiation therapy prior to surgery as opposed to none in the PME group (p < 0.001). Urinary dysfunction following surgery as assessed using the UDI-6 questionnaire did not differ between groups. Similar findings were recorded with regard to the impact of urinary dysfunction on quality of life as assessed using the USIQ questionnaire. Following multivariate analysis longer hospital stay was associated with increased risk of some degree of urinary dysfunction.

Conclusions

Women undergoing total mesorectal excision have comparable results to partial mesorectal excision with regard to urinary dysfunction.

Is prophylactic lateral lymph node dissection needed for lower rectal cancer? A single-center retrospective study

Background

The effectiveness of prophylactic lateral lymph node dissection (LLND) in treating patients with lower rectal cancer remains controversial and has not been clearly established. Therefore, we aimed to retrospectively analyze the survival impact of prophylactic LLND in patients with lower rectal cancer.

Methods

Data of 301 patients with lower rectal cancer (tumor’s lower edge on the anal side of the peritoneal reflexion) with clinical T3 disease and negative preoperative lateral lymph node metastasis, who underwent radical resection (R0) at our hospital between April 2007 and March 2017, were included in this study. Patients who received preoperative chemotherapy or radiotherapy were excluded. The relapse-free survival (RFS) and overall survival (OS) rates were compared between the dissection (prophylactic LLND, n = 37) and non-dissection (no prophylactic LLND, n = 264) groups.

Results

Significantly fewer men and younger patients were noted in the dissection group than in the non-dissection group. Post-surgery 3- and 5-year RFS rates were 69.6% and 66.8% in the dissection group and 75.1% and 72.5% in the non-dissection group, respectively (5-year post-surgery RFS, p = 0.58). In the dissection and non-dissection groups, the 5-year OS rates were 86.5% and 79.7%, respectively (p = 0.29), and the 5-year cancer-specific survival rates were 88.9% and 86.0%, respectively (p = 0.29), with no significant differences. Lateral lymph node recurrence was observed in one (2.7%) and 10 patients (3.8%) in the dissection and non-dissection groups, respectively, and there was no significant difference between the groups.

Conclusions

In this study, the effectiveness of prophylactic LLND was limited in patients with > T3 lower rectal cancer with no evidence of preoperative lymph node metastasis. Prophylactic LLND may not be necessary if there is no preoperative lymph node metastasis, even if the invasion depth is T3 or higher.

A meta-analysis of the role of diverting ileostomy after rectal cancer surgery

PURPOSE

Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication.

METHODS

The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints.

RESULTS

A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively).

CONCLUSION

A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.

Colorectal anastomosis during cytoreductive radical surgery in patients with peritoneal surface malignancies. Validation of a new technique (without stoma) to prevent anastomosis leakage in more than 1000 procedures

OBJECTIVE

To describe a novel end-to-end "true" reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer.

METHODS

Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were: (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) "cleaning" the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed.

RESULTS

According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis. Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%.

CONCLUSIONS

A technical modification to create a "true" end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.

Less is more-the best test for anastomotic leaks in rectal cancer patients prior to ileostomy reversal

PURPOSE

No clear consensus exists on how to routinely assess the integrity of the colorectal anastomosis prior to ileostomy reversal. The objective of this study was to evaluate the accuracy of contrast enema, endoscopic procedures, and digital rectal examination in rectal cancer patients in this setting.

METHODS

A systematic literature search was performed. Studies assessing at least one index test for which a 2 × 2 table was calculable were included. Hierarchical summary receiver operating characteristic curves were calculated and used for test comparison. Paired data were used where parameters could not be calculated. Methodological quality was assessed with the QUADAS-2 tool.

RESULTS

Two prospective and 11 retrospective studies comprising 1903 patients were eligible for inclusion. Paired data analysis showed equal or better results for sensitivity and specificity of both endoscopic procedures and digital rectal examination compared to contrast enema. Subgroup analysis of contrast enema according to methodological quality revealed that studies with higher methodological quality reported poorer sensitivity for equal specificity and vice versa. No case was described where a contrast enema revealed an anastomotic leak that was overseen in digital rectal examination or endoscopic procedures.

CONCLUSIONS

Endoscopy and digital rectal examination appear to be the best diagnostic tests to assess the integrity of the colorectal anastomosis prior to ileostomy reversal. Accuracy measures of contrast enema are overestimated by studies with lower methodological quality. Synopsis of existing evidence and risk-benefit considerations justifies omission of contrast enema in favor of endoscopic and clinical assessment.

TRIAL REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019107771.

Inflammatory markers for the early detection of post-operative infection: The same threshold for rectal and colic surgery?

INTRODUCTION

Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal?

PATIENTS AND METHOD

This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve.

RESULTS

An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P=0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC=0.87) corresponds to CRP on D4 for a threshold of 100mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100mg/L (AUC=0.71): sensitivity 63.6%, NPV 93.9%.

CONCLUSION

Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP>100mg/L at D4.

Does the timing of protective ileostomy closure post-low anterior resection have an impact on the outcome? A retrospective study

BACKGROUND

The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair.

METHOD

From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, RESULT: The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002).

CONCLUSION

The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

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.

Standard versus eversion-modified double-staple technique for low colorectal anastomoses after resection of rectal cancer

Purpose

The double-staple technique, performed as either the standard procedure or after eversion of the rectal stump, is a well-established method of performing low colorectal anastomoses following the resection of rectal cancer. Eversion of the tumor-bearing ano-rectal stump was proposed to allow the linear stapler to be fired at a safe distance of clearance from the tumor. We conducted this study to compare the results of the standard versus the eversion-modified double-staple technique.

Methods

The subjects of this retrospective study were 753 consecutive patients who underwent low stapled colorectal anastomosis after resection of rectal cancer. The patients were divided into two groups according to the method of anastomosis used: Group A comprised 165 patients (22%) treated with the modified eversion technique and group B comprised 588 patients (78%) treated with the standard technique. The primary endpoints of the study were postoperative mortality, surgery-related morbidity, the number of sampled lymph nodes in the mesorectum, and late disease-related survival.

Results

Postoperative mortality was 1.2% in group A and 1.7% in group B (p = 0.66). Postoperative morbidity was 12% in group A and 11% in group B (p = 0.75). The mean number of sampled lymph nodes in the mesorectum was 23 (range 17–27) in group A and 24 (range 19–29) in group B (p = 0.06). The 5-year disease-related survival was 73% in group A and 74% in group B (p = 0.75).

Conclusion

The standard and eversion-modified double-staple techniques yield comparable results.

Intraoperative fluorescence angiography with indocyanine green: retrospective evaluation and detailed analysis of our single-center 5-year experience focused on colorectal surgery

Objectives

Assessing bowel perfusion with indocyanine green fluorescence angiography (ICG-FA) shows positive effects on anastomotic healing in colorectal surgery.

Methods

A retrospective evaluation of 296 colorectal resections where we performed ICG-FA was undertaken from January 2014 until December 2018. Perfusion of the bowel ends measured with ICG-FA was compared to the visual assessment before and after performing the anastomosis. According to the observations, the operative strategy was confirmed or changed. Sixty-seven low anterior rectal resections (LARs) and 76 right hemicolectomies were evaluated statistically, as ICG-FA was logistically not available for every patient in our service and thus a control group for comparison resulted.

Results

The operative strategy based on the ICG-FA results was changed in 48 patients (16.2%), from which only one developed an anastomotic leakage (AL) (2.1%). The overall AL rate was calculated as 5.4%. Within the 67 patients with LAR, the strategy was changed in 11 patients (16.4%). No leakage was seen in those. In total three AL happened (4.5%), which was three times lower than the AL rate of 13.6% in the control group but statistically not significant. From the 76 right hemicolectomies a strategy change was undertaken in 10 patients (13.2%), from which only one developed an AL. This was the only AL reported in the whole group (1.3%), which was six times lower than the leakage rate of the control group (8.1%). This difference was statistically significant (p=0.032).

Conclusions

Based on the positive impact by ICG-FA on the AL rate, we established the ICG-FA into our clinical routine. Although randomized studies are still missing, ICG-FA can raise patient safety, with only about 10 min longer operating time and almost no additional risk for the patients.

A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial

AIM

Our aim was to evaluate the efficacy of indocyanine green (ICG) fluorescence angiography (FA) in reducing the incidence of anastomotic leakage (AL) following colorectal anastomosis.

METHOD

A single-centre randomized trial was undertaken between 2018 and 2019. Those patients who underwent a stapled colorectal anastomosis were randomized 1:1 for ICG FA versus visual clinical assessment of blood perfusion of the anastomosed colon and rectal stump (non-ICG FA group). The primary end-point was to assess whether ICG FA was associated with a reduction in the incidence of AL. Secondary outcomes were the rate of postoperative complications and change in the level of bowel resection.

RESULTS

A total of 380 patients undergoing sigmoid and rectal resection were enrolled. After randomization, three patients were excluded. The results of 377 cases were available for analysis; 187 had ICG FA and 190 were in the non-ICG FA group. ICG FA identified impaired blood perfusion of the colon in 36 (19%) cases. An AL (grade A, B or C) developed in 48 patients: 17 (9.1%) in the ICG FA group and 31 (16.3%) in the non-ICG FA group (P = 0.04). ICG FA did not decrease the rate of AL of high anastomoses (9-15 cm from the anal verge), at 1.3% vs 4.6% in the non-ICG FA group (P = 0.37). In contrast, a decrease in AL rate was found for low (4-8 cm) colorectal anastomoses (14.4% in ICG FA vs 25.7% in the non-ICG FA group; P = 0.04).

CONCLUSION

ICG FA is associated with a reduction in AL following low anterior resection.

Total mesorectal excision - 40 years of standard of rectal cancer surgery

Total mesorectal excision (TME) was first described 40 years ago by Richard Heald. The purpose of this article is to point out importance of this surgical procedure. Starting from first attempts to surgically cure rectal carcinoma in the nineteenth century through Miles' operation at the beginning of the twentieth century results were not satisfactory due to high number of local recurrences after resections for rectal cancer. Progress in surgical technique and knowledge of anatomy and embryology of the rectum led to development of TME. Principle of TME is surprisingly simple: removal of the rectum with complete embryonic space containing lymph nodes which are site of primary dissemination of the disease. Main advantages and drawbacks of TME as well as focus on newer procedures developed from the concept of TME are presented in the form of a review.

The use of Endo-SPONGE® in rectal anastomotic leaks: a systematic review

BACKGROUND

The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE^®) in the treatment of rectal anastomotic leaks.

METHODS

All studies looking at endoluminal vacuum therapy with Endo-SPONGE^® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity.

CONCLUSIONS

Endo-SPONGE^® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.

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.

Anastomotic Leak Does Not Impact Oncologic Outcomes After Preoperative Chemoradiotherapy and Resection for Rectal Cancer

OBJECTIVE

The aim of this study was to evaluate the relationship of anastomotic leakage, local recurrence, and overall survival in rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection.

BACKGROUND

Little is known about the association between anastomotic leakage and oncologic outcomes after preoperative CRT.

METHODS

A total of 698 consecutive primary rectal cancer patients after preoperative CRT between April 19, 2000, and December 27, 2013, were retrospectively reviewed. Forty-seven patients who had anastomotic leakage were compared with 651 patients who had no anastomotic leakage.

RESULTS

Of 698 patients, 47 (6.7%) patients had anastomotic leakage. Among these 47 patients, 39 (83.0%) had grade C leak that required urgent operation, while 8 (17.0%) had grade B leak that was managed expectantly or by percutaneous drainage. The median follow-up period was 47.6 months (range, 27.1 to 68.9 months). One hundred twenty (17.2%) recurrences were identified among all patients. The median overall disease-free survival was 43 months (range, 22.4 to 66.7 months). Five-year disease-free survival did not differ significantly between the 2 groups (80.5% vs 80.4%, P = 0.839). Five-year local recurrence-free survival did not differ significantly either between the 2 groups (93.7% vs 94.9%, P = 0.653). Five-year overall survival rates of patients with or without leakage were 90.9% and 86.3%, respectively (P = 0.242). Five-year cancer-specific survival rates of patients with or without leakage were 92.2% and 86.3%, respectively (P = 0.248).

CONCLUSION

After preoperative CRT, an anastomotic leak is not associated with a significant increase in local recurrence or long-term survival in rectal cancer.

[Splenic flexure mobilization in surgery for rectal cancer]

Nowadays, the issue of splenic flexure mobilization (SFM) in anterior and low anterior rectal resection for rectal cancer is still debatable. This stage is important because dissection results tension-free anastomosis and excision of specimen of enough length with adequate number of harvested lymph nodes. However, literature review confirmed the absence of agreement regarding reduced incidence of colorectal anastomotic leakage and improved long-term oncologic outcomes after SFM. Opinion about selective approach to this procedure is becoming more common. Therefore, randomized trials are necessary to determine a need for routine SFM or indications for selective approach to SFM in anterior rectal resection for rectal cancer.

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.

Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer: systematic review and meta-analysis of randomized controlled trials

Background

There is a relatively high risk of anastomotic leak in low anterior resection (LAR), associated with significant morbidity and mortality. This systematic review and meta-analysis aims to compare diverting stoma vs. no stoma for LAR in terms of leak rates, reoperations, mortality rates and complication rates.

Methods

We systematically performed electronic searches of databases Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club and DARE from inception to present. Only randomized controlled trials comparing LAR for rectal cancer with versus without stoma diversion were included for analysis. Main outcomes were anastomotic leak, reoperation rate and mortality. Secondary outcomes included other operative and stoma-related complications.

Results

Eight randomized controlled trials were included in the study for qualitative and quantitative analyses. A significantly longer operative duration for patients with stoma diversion was seen (WMD 19.50 min; 95% CI: 7.38, 31.63; I²=0%, P=0.002). The pooled rate for anastomotic leak was significantly lower for those with stoma diversion (6.3% vs. 18.3%; RR 0.36; 95% CI: 0.24, 0.54; I²=0%; P<0.00001). There was lower reoperation rate for patients with stoma diversion compared to no stoma (5.9% vs. 16.7%; RR 0.40; 95% CI: 0.26, 0.60; I²=0%; P<0.00001). No significant difference was found in terms of leak-related mortality between stoma vs. no-stoma cohorts (0.47% vs. 1.0%; P=0.51).

Conclusions

The present meta-analysis suggests a diverting or defunctioning stoma following LAR for rectal cancers can reduce anastomotic leak and reoperation rates, without increased risk of mortality or other complications.

Single-incision laparoscopic ileostomy is a safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection

Purpose

Currently, many operations are performed using the single-incision laparoscopic method. Although there have been recent reports on single-incision laparoscopic ileostomy, none have compared this method to conventional laparoscopic ileostomy. This study aimed to assess the safety and feasibility of single-incision laparoscopic ileostomy for anastomotic leakage following laparoscopic low anterior resections.

Methods

From April 2012 to April 2017, 38 patients underwent laparoscopic ileostomy (single-incision; 19 patients referred to as group A, conventional laparoscopy; 19 patients referred to as group B) for anastomotic leakage following laparoscopic low anterior resection. We analyzed surgical and clinical outcomes between the 2 groups. Patients in whom a protective ileostomy was carried out during the initial laparoscopic low anterior resection were excluded from this study.

Results

No significant differences were observed between the 2 groups in terms of patient demographics and initial operation details. Incisional surgical site infections occurred less in group A than in group B (2 of 19 vs. 9 of 19, P = 0.029). The median ileostomy operation time, amount of intraoperative bleeding, parastomal hernia ratio, hospital stay duration after ileostomy, postoperative pain score were not significantly different between the 2 groups.

Conclusion

Single-incision laparoscopic ileostomy is safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection.

Splenic flexure mobilization in rectal cancer surgery: do we always need it?

Splenic flexure (SFM) in rectal cancer surgery is a crucial step which may increase the difficulty of the operation. The aim of this retrospective single-center study is to demonstrate if the selective omission of SFM during anterior rectal resection can reduce the complexity of the operation, without affecting post-operative and oncologic outcomes. Data of 112 consecutive rectal resections for cancer from March 2010 to March 2017 were analyzed and divided into two groups: SFM and No-SFM. A sub-analysis was then performed for laparoscopy and traditional cases. Post-operative and oncologic outcomes, including overall (OS) and cancer-related survival (CRS), were analyzed and compared. SFM was performed in 42% of cases and laparoscopy was used in 73.2%. Operative time resulted significantly lower in the No-SFM group (190 vs. 225 min, p = 0.01). In laparoscopy in the No-SFM group, operative time and post-operative stay were significantly lower (205.5 vs. 222.5 min, p = 0.04; 9 vs. 10 days, p = 0.01). Most of the open resections were performed without SFM (35.4% vs. 14.9%, p = 0.02). No statistical significant differences were found in OS and CRS in the two groups. We support the hypothesis that every surgeon should carry out an accurate intra-operative evaluation to perform a selective SFM. When possible, SFM can be safely avoided with no additional risks in terms of post-operative and oncologic outcomes.

Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost

BACKGROUND

Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal.

METHODS

A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

RESULTS

Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00).

CONCLUSION

Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.