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Jones M, Moran B, Heald RJ, Bunni J. Can the Heald anal stent help to reduce anastomotic or rectal stump leak in elective and emergency colorectal surgery? A single-center experience. Ann Coloproctol 2024; 40:82-85. [PMID: 38414124 PMCID: PMC10915531 DOI: 10.3393/ac.2023.00038.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 02/29/2024] Open
Abstract
Anastomotic and rectal stump leaks are feared complications of colorectal surgery. Diverting stomas are commonly used to protect low rectal anastomoses but can have adverse effects. Studies have reported favorable outcomes for transanal drainage devices instead of diverting stomas. We describe our use of the Heald anal stent and its potential impact in reducing anastomotic or rectal stump leak after elective or emergency colorectal surgery. We performed a single-center retrospective analysis of patients in whom a Heald anal stent had been used to "protect" a colorectal anastomosis or a rectal stump, in an elective or emergency context, for benign and malignant pathology. Intraoperative and postoperative outcomes were reviewed using clinical and radiological records. The Heald anal stent was used in 93 patients over 4 years. Forty-six cases (49%) had a colorectal anastomosis, and 47 (51%) had an end stoma with a rectal stump. No anastomotic or rectal stump leaks were recorded. We recommend the Heald anal stent as a simple and affordable adjunct that may decrease anastomotic and rectal stump leak by reducing intraluminal pressure through drainage of fluid and gas.
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Affiliation(s)
- Michael Jones
- Department of Colorectal Surgery, Royal United Hospital, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Brendan Moran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Richard John Heald
- Pelican Cancer Foundation, Basingstoke, UK
- Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal
| | - John Bunni
- Department of Colorectal Surgery, Royal United Hospital, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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Sueda T, Tei M, Mori S, Nishida K, Yasuyama A, Nomura M, Yoshikawa Y, Tsujie M. Clinical Impact of Transanal Drainage Tube on Anastomosis Leakage Following Minimally Invasive Resection Without Diverting Stoma in Patients With Rectal Cancer: A Propensity Score-matched Analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:608-616. [PMID: 37852234 DOI: 10.1097/sle.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/09/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES As one of the most serious complications of rectal cancer (RC) surgery, preventing anastomotic leakage (AL) is crucial. Several studies have suggested a positive role of the transanal drainage tube (TaDT) in AL prevention. However, whether TaDT is beneficial for AL in patients with RC remains controversial. The present study aimed to evaluate the clinical impact of TaDT on AL following minimally invasive resection without diverting stoma (DS) in patients with RC. MATERIALS AND METHODS We retrospectively analyzed 392 consecutive patients with RC who had undergone minimally invasive resection without DS between 2010 and 2021. Propensity score matching (PSM) was performed to reduce selection bias. AL was classified as grade A, B, or C. RESULTS A TaDT was used in 214 patients overall. After PSM, we enrolled 316 patients (n=158 in each group). Before PSM, significant group-dependent differences were observed in terms of age, American Society of Anesthesiologists physical status, and the use of antiplatelet/anticoagulant agents. The frequency of AL was 7.3% in the overall cohort and was significantly lower in the TaDT group (3.7%) than in the non-TaDT group (11.8%). The rate of grade B AL was significantly lower in the TaDT group than in the non-TaDT group (before PSM, P <0.01; after PSM, P =0.02). However, no significant differences between groups were found for grade C AL. Moreover, multivariate analysis identified the lack of a TaDT as an independent risk factor for AL in the overall and matched cohorts [before PSM, odds ratio, 3.64, P <0.01; after PSM, odds ratio, 2.91, P =0.02]. CONCLUSION These results indicated that TaDT may play a beneficial role in preventing AL, particularly of grade B, for patients with RC undergoing minimally invasive resection without DS. However, further randomized controlled trials, including patient-reported outcomes, are still needed to understand better the role of TaDT in preventing ALs in patients with RC undergoing minimally invasive resection without DS.
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Xia S, Wu W, Ma L, Luo L, Yu L, Li Y. Transanal drainage tube for the prevention of anastomotic leakage after rectal cancer surgery: a meta-analysis of randomized controlled trials. Front Oncol 2023; 13:1198549. [PMID: 37274258 PMCID: PMC10235681 DOI: 10.3389/fonc.2023.1198549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
Background Anastomotic leakage (AL) is a serious complication of anterior resection for rectal cancer. The use of transanal drainage tubes (TDT) during surgery to prevent AL remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of TDT in reducing AL. Methods Relevant data and studies published from inception until November 1, 2022, were retrieved from PubMed, Embase, and Cochrane Library databases to compare the incidence of AL after anterior resection for rectal cancer with and without TDT. Results This meta-analysis included 5 RCTs comprising 1385 patients. The results showed that the intraoperative use of TDT could not reduce the incidence of AL after rectal cancer surgery (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.52-1.59; p = 0.75). A subgroup analysis of different degrees of AL revealed that TDT did not reduce the incidence of postoperative grade B AL (RR, 1.18; 95% CI, 0.67-2.09; p = 0.56) but decreased the incidence of grade C AL (RR, 0.28; 95% CI: 0.12-0.64; p = 0.003). Further, TDT did not reduce the incidence of AL in patients with rectal cancer and a stoma (RR, 2.40; 95% CI, 1.01-5.71; p = 0.05). Conclusion TDT were ineffective in reducing the overall incidence of AL, but they might be beneficial in reducing the incidence of grade C AL in patients who underwent anterior resection. However, additional multicenter RCTs with larger sample sizes based on unified control standards and TDT indications are warranted to validate these findings.
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Affiliation(s)
- Shijun Xia
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Wenjiang Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Lijuan Ma
- Shenzhen Traditional Chinese Medicine Anorectal Hospital, Futian, Shenzhen, China
| | - Lidan Luo
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Linchong Yu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Yue Li
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
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Rondelli F, Avenia S, De Rosa M, Rozzi A, Rozzi S, Chillitupa CIZ, Bugiantella W. Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis. Surg Today 2023; 53:163-173. [PMID: 34997332 DOI: 10.1007/s00595-021-02423-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/13/2021] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Fabio Rondelli
- Department of Surgical and Biomedical Sciences, School of Medicine, University of Perugia, Perugia, Italy. .,General and Specialized Surgery Unit, "Santa Maria" Hospital, Via T. Di Joannuccio, 1, 05100, Terni, Italy.
| | - Stefano Avenia
- Department of Surgical and Biomedical Sciences, School of Medicine, University of Perugia, Perugia, Italy
| | - Michele De Rosa
- General Surgery Unit, "San Giovanni Battista" Hospital, Usl Umbria 2, Via M. Arcamone, 1, 06034, Foligno, Italy
| | - Angelo Rozzi
- General and Specialized Surgery Unit, "Santa Maria" Hospital, Via T. Di Joannuccio, 1, 05100, Terni, Italy
| | - Settimio Rozzi
- General and Specialized Surgery Unit, "Santa Maria" Hospital, Via T. Di Joannuccio, 1, 05100, Terni, Italy
| | | | - Walter Bugiantella
- General Surgery Unit, "San Giovanni Battista" Hospital, Usl Umbria 2, Via M. Arcamone, 1, 06034, Foligno, Italy
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Ammendola M, Ammerata G, Filice F, Filippo R, Ruggiero M, Romano R, Memeo R, Pessaux P, Navarra G, Montemurro S, Currò G. Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube. Surg Innov 2023; 30:20-27. [PMID: 35582732 DOI: 10.1177/15533506221090995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic. METHODS Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment. RESULTS Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur. CONCLUSION In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Francesco Filice
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Bari, Italy
| | - Patrick Pessaux
- Department of General, Digestive and Endocrine Surgery,IHU-Strasbourg, Institute of Image-Guided Surgery, IRCAD, Research Institute Against Cancer of the Digestive System, University Hospital of Strasbourg, Strasbourg, France
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, General Surgery Unit, University "Magna Graecia" Medical School, Catanzaro, Italy
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Ammendola M, Filice F, Battaglia C, Romano R, Manti F, Minici R, de'Angelis N, Memeo R, Laganà D, Navarra G, Montemurro S, Currò G. Left hemicolectomy and low anterior resection in colorectal cancer patients: Knight-griffen vs. transanal purse-string suture anastomosis with no-coil placement. Front Surg 2023; 10:1093347. [PMID: 37139187 PMCID: PMC10149919 DOI: 10.3389/fsurg.2023.1093347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
Background Colorectal cancer (CRC) is considered one of the most frequent neoplasms of the digestive tract with a high mortality rate. Left hemicolectomy (LC) and low anterior resection (LAR) with minimally invasive laparoscopic and robotic approaches or with the open technique are the gold standard curative treatment. Materials and methods Seventy-seven patients diagnosed with CRC were recruited between September 2017 and September 2021. All patients underwent a preoperative staging with a full-body CT scan. The goal of this study was to compare both types of surgeries, LC-LAR LS with Knight-Griffen colorectal anastomosis and LC-LAR open with Trans-Anal Purse-String Suture Anastomosis (the TAPSSA group), by positioning a No-Coil transanal tube (SapiMed Spa, Alessandria, Italy), in terms of postoperative complications such as prolonged postoperative ileus (PPOI), anastomotic leak (AL), postoperative ileus (POI), and hospital stay. Results The patients were divided into two groups: the first with 39 patients who underwent LC and LAR in LS with Knight-Griffen anastomosis (Knight-Griffen group) and the second with 38 patients who underwent LC and LAR by the open technique with the TAPSSA group. Only one patient who underwent the open technique suffered AL. POI was 3.76 ± 1.7 days in the TAPSSA group and 3.07 ± 1.3 days in the Knight-Griffen group. There were no statistically significant differences in terms of AL and POI between the two different groups. Conclusion The important point that preliminarily emerged from this retrospective study was that the two different techniques showed similarities in terms of AL and POI, and therefore, all the advantages reported in the previous studies pertaining to No-Coil also hold good in this study regardless of the surgical technique used. However, randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, University “Magna Graecia” Medical School, Catanzaro, Italy
- Correspondence: Michele Ammendola
| | - Francesco Filice
- Science of Health Department, Digestive Surgery Unit, University “Magna Graecia” Medical School, Catanzaro, Italy
| | - Caterina Battaglia
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, University “Magna Graecia” Medical School, Catanzaro, Italy
| | - Francesco Manti
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Roberto Minici
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital (AP-HP), University Paris Cité, Clichy, France
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, “F. Miulli” Hospital, Acquaviva Delle Fonti, Bari, Italy
| | - Domenico Laganà
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, “Magna Graecia” University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, “G. Martino” Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, University “Magna Graecia” Medical School, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, General Surgery Unit, University “Magna Graecia” Medical School, Catanzaro, Italy
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Sciuto A, Peltrini R, Andreoli F, Di Santo Albini AG, Di Nuzzo MM, Pirozzi N, Filotico M, Lauria F, Boccia G, D’Ambra M, Lionetti R, De Werra C, Pirozzi F, Corcione F. Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases. J Clin Med 2022; 11:jcm11092632. [PMID: 35566757 PMCID: PMC9104879 DOI: 10.3390/jcm11092632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.
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Affiliation(s)
- Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
- Department of Electrical Engineering and Information Technology, University of Naples Federico II, 80125 Naples, Italy
- Correspondence:
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Andreoli
- Department of Minimally Invasive Surgery, Cristo Re Hospital, 00167 Rome, Italy;
| | - Andrea Gianmario Di Santo Albini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Nello Pirozzi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Giuseppe Boccia
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
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OUP accepted manuscript. Br J Surg 2022; 109:900-903. [DOI: 10.1093/bjs/znac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/10/2022] [Accepted: 05/01/2022] [Indexed: 11/14/2022]
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Choy KT, Yang TWW, Heriot A, Warrier SK, Kong JC. Does rectal tube/transanal stent placement after an anterior resection for rectal cancer reduce anastomotic leak? A systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1123-1132. [PMID: 33515307 DOI: 10.1007/s00384-021-03851-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is increasing evidence that either a transanal stent (TAS) or rectal tube (RT) can decrease the risk of anastomotic leakage (AL) after anterior resection for rectal cancer, in which a diverting stoma may not be required. OBJECTIVES The aim of this review was to investigate the efficacy and safety of RT/TAS in preventing AL after anterior resections. DATA SOURCES An up-to-date systematic review was performed on the available literature between 2000 and 2020 on PubMed, EMBASE, Medline and Cochrane Library databases. STUDY SELECTION All studies reporting on anterior resections in adults, comparing transanal tube/stent versus non-tube/stent, were analysed. MAIN OUTCOME MEASURE The primary outcome was rates of AL, whereas secondary outcomes compared associated unplanned re-operation for AL and hospital length of stay (LOS). RESULTS Two randomized controlled trials and 13 observational studies were included, with 1714 patients receiving RT/TAS and 1741 patients without. There were 119 (7%) patients with AL in the RT/TAS group compared to 216 (12.3%) patients in the non-RT/TAS group (OR: 0.48, 95% CI: 0.38-0.62, p < 0.001). There were 47 (2.9%) patients with AL complications requiring surgery in the RT/TAS group compared to 132 (8%) patients in the non-RT/TAS group (OR: 0.29, 95% CI: 0.20-0.42, p < 0.001) and no significant difference identified with the standardized mean difference (SMD) favouring the RT/TAS group for hospital LOS (SMD: -0.23, 95% CI: -0.51 to 0.06, p = 0.115). CONCLUSION The use of RT/TAS post restorative anterior resection for rectal cancer should be considered, given the benefits shown from this meta-analysis.
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Affiliation(s)
- Kay T Choy
- Department of Surgery, Austin Hospital, 145 Studley Rd, Heidelberg, VIC, 3084, Australia.
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Bunni J. Use of a Heald anal stent to treat colonic pseudo-obstruction ('Ogilvie's syndrome'). ANZ J Surg 2021; 91:215-216. [PMID: 33590631 DOI: 10.1111/ans.16404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022]
Affiliation(s)
- John Bunni
- Department of Colorectal Surgery, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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Ammendola M, Ruggiero M, Talarico C, Memeo R, Ammerata G, Capomolla A, Filippo R, Romano R, Pallio S, Navarra G, Montemurro S, Currò G. No Coil® placement in patients undergoing left hemicolectomy and low anterior resection for colorectal cancer. World J Surg Oncol 2020; 18:327. [PMID: 33302970 PMCID: PMC7731543 DOI: 10.1186/s12957-020-02096-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the most common tumor of the gastrointestinal tract. Anastomotic leak (AL) and prolonged postoperative ileus (PPOI) are two important complications of colorectal surgery. In this observational retrospective study, we evaluated the positive effects of transanal tube No Coil® in patients with CRC undergoing low anterior resection (LAR) and left hemicolectomy (LC). METHODS Thirty-eight cases and forty controls resulted eligible for the final sample. No Coil® placement (SapiMed Spa, Alessandria, Italy) was considered an inclusion criteria for the case group. No Coil® was placed immediately after the end of surgical treatment. RESULTS PPOI was significantly more frequent in the control group. AL was evident in 1 patient (2.6%) of cases and 3 patients (7.5%) of controls. No statistical difference was found in AL occurrence between groups. POI days and AL resulted associated with hospital stay. POI days were negatively associated with No Coil placement and positively with AL. CONCLUSION With our preliminary data, we suggest that No Coil® placement can be considered as a valuable procedure assisting colorectal surgery, but further studies are required to confirm and enlarge actual evidence.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Carlo Talarico
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Antonella Capomolla
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Socrate Pallio
- Department of Clinical and Experimental Medicine, Digestive Diseases Endoscopy Unit, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, Digestive Surgery Unit, "Mater Domini" Hospital, University "Magna Graecia" Medical School, Viale Europa, Germaneto, 88100, Catanzaro, Italy.,Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
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12
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Dumble C, Morgan T, Wells CI, Bissett I, O'Grady G. The impact of transanal tube design for preventing anastomotic leak in anterior resection: a systematic review and meta-analysis. Tech Coloproctol 2020; 25:59-68. [PMID: 33125604 DOI: 10.1007/s10151-020-02354-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Placement of a transanal tube (TAT) into the rectum is a strategy used to attempt to prevent anastomotic leak (AL) in anterior resection surgery. There is a wide variation in materials and tube design in devices used as TATs and previous meta-analyses have not considered TAT design in their analyses. This study reviews the impact that design of TAT has on AL rates. METHODS A systematic review of the literature was performed with the aim of identifying studies evaluating the use of TATs for preventing AL and then defining the design of TATs. Studies were then compared in groups based on TAT design in a meta-analysis to evaluate whether design is an important variable in outcomes. RESULTS Thirty-three studies were included. There was a wide variety of tubes used as TATs. On meta-analysis, catheter-type TATs were associated with a substantially lower rate of AL (OR: 0.46; 95% CI 0.30, 0.68). By contrast, stent-type TATs were not associated with any reduction in the incidence of AL (OR: 1.06, 95% CI 0.50, 2.22). Catheter-type TATs were also associated with substantial reductions in the rate of reoperation (OR: 0.32; 95% CI 0.20, 0.50), whereas stent-type TATs showed no benefit in the rate of reoperation (OR: 0.79; 95% CI 0.37, 1.65). CONCLUSIONS Off-the-shelf catheter-type transanal tubes appeared effective in preventing AL, whereas custom-designed stent-type TATs were not demonstrated to be effective; although high quality evidence is limited. TAT design should be an important consideration in further research of the use of TATs in anterior resection surgery.
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Affiliation(s)
- C Dumble
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - T Morgan
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand.
| | - C I Wells
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - I Bissett
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
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Ye W, Zhu Z, Liu G, Chen B, Zeng J, Gao J, Wang S, Cai H, Xu G, Huang Z. Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study. Medicine (Baltimore) 2019; 98:e15939. [PMID: 31169715 PMCID: PMC6571267 DOI: 10.1097/md.0000000000015939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.
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Affiliation(s)
- Weipeng Ye
- Department of Clinical Medicine, Fujian Medical University, Fuzhou
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Zhipeng Zhu
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Gang Liu
- Department of Breast Surgery, The Third Hospital of Nanchang City, Key Laboratory of Breast Diseases, Nanchang, Jiangxi
| | - Borong Chen
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Junjie Zeng
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Jin Gao
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Shengjie Wang
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Hejie Cai
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Guoxing Xu
- Endoscopy Center, The First Affiliated Hospital of Xiamen University, Xiamen, P.R. China
| | - Zhengjie Huang
- Department of Clinical Medicine, Fujian Medical University, Fuzhou
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
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Fecal diverting device for the substitution of defunctioning stoma: preliminary clinical study. Surg Endosc 2019; 33:333-340. [PMID: 30109482 PMCID: PMC6336740 DOI: 10.1007/s00464-018-6389-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND A novel fecal diverting device (FDD) made for the prevention of sepsis resulting from anastomotic leakage (AL) was tested successfully in an animal study. This study was undertaken to evaluate the clinical safety and effectiveness of the FDD. METHODS A prospective observation trial was implemented in a tertiary referral university hospital. The study enrolled patients who needed a defunctioning stoma to preserve low-lying rectal anastomosis. The FDD was fixed to the proximal colon 15 cm from the anastomosis and scheduled to divert feces for 3 weeks. The duration could be extended for more than 3 weeks if AL was noted. Postoperative evaluations of AL were performed by obtaining a computed tomography (CT) scan after 1 week and a contrast study after 3 weeks. The outcomes were FDD-related complications, and the capacity of the FDD to preserve the anastomosis. The median follow-up period was 10 (range 5-40) months. RESULTS Thirty-one patients, including 5 benign cases, were evaluated. There was no case of stoma conversion or surgical re-intervention. Evidence of AL was identified in 10 (32%) patients using the CT scan at 1 week after surgery. However, in the contrast study at 3 weeks after surgery, only 5 cases of AL sinus were noted. Conservative treatments including 1-3 weeks prolongation of FDD maintenance were enough to preserve the anastomosis. There were 3 cases of partial colonic wall erosions at the FDD attachment area. All of these patients showed improvement with conservative treatment. The limitations were that the study was performed in a single institute and without a control group. CONCLUSIONS The FDD showed a sufficient capacity of fecal diversion and maintenance duration that prevented aggravation of sepsis in the case of AL without significant complications.
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Montemurro S, De Luca R, Caliandro C, Ruggieri E, Rucci A, Sciscio V, Ranaldo N, Federici A. Transanal Tube NO COIL® after Rectal Cancer Proctectomy. The “G. Paolo II” Cancer Centre Experience. TUMORI JOURNAL 2018; 98:607-14. [DOI: 10.1177/030089161209800511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study. Methods From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL®, 60–80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventhpostoperative day if no signs of leakage occurred. Results The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%. Conclusions The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.
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Affiliation(s)
- Severino Montemurro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Cosimo Caliandro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Eustachio Ruggieri
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Antonello Rucci
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Vito Sciscio
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Nunzio Ranaldo
- Institute of Gastroenterology, University Medical School, Bari, Italy
| | - Antonio Federici
- Department of Physiology, University Medical School, Bari, Italy
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16
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Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
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17
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Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis: A case controlled study. Ann Med Surg (Lond) 2016; 6:12-6. [PMID: 27158483 PMCID: PMC4843097 DOI: 10.1016/j.amsu.2016.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/08/2016] [Accepted: 01/10/2016] [Indexed: 12/22/2022] Open
Abstract
Background and aims The aim of this study was to investigate the clinical usefulness of the placement of a transanal drainage tube to prevent anastomotic leakage in colorectal anastomoses. Material and methods This single-center retrospective trial included all patients treated with surgery for benign or malign colorectal disease between January 2009 and December 2012. The transanal drainage tube was immediately placed after colorectal anastomosis until day five and was routinely used since 2010. Patients treated with a transanal drainage tube were compared with the control group. Statistical analysis was performed using Fisher's exact or Chi-square tests for group comparison and a linear regression model for multivariate analysis. Results This study included 242 patients (46% female; median age 63 years; range 18–93); 34% of the patients underwent a laparoscopic procedure, and 57% of the patients received a placement of a transanal drainage tube. Anastomotic leakage occurred in 19 patients (7.9%). Univariate analysis showed a higher rate of anastomotic leakage in patients with an ASA score 4 (p = 0.02) and a lower rate in patients with transanal drainage placement (3.6% vs. 13.6%; p = 0.007). The grading of the complication of anastomotic leakage was reduced with transanal drainage (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006), and the hospital stay was shortened (17.6 ± 12.5 vs. 22.1 ± 17.6 days; p = 0.02). Multivariate analysis revealed that transanal drainage was the only significant factor (HR = −2.90; −0.168 to −0.032; p = 0.007) affecting anastomotic leakage. Conclusions Placement of a transanal drainage tube in patients with colorectal anastomoses is a safe and simple technique to perform and reduces anastomotic leakage, the severity of the complication and hospital stay. A transanal drainage tube as a mechanism to reduce anastomotic leakage is proposed. Transanal drainage tube reduces anastomotic leakage 3.6% vs. 13.6% (p = 0.007). Transanal drainage reduced the grade of complication (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006).
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Blumetti J, Abcarian H. Management of low colorectal anastomotic leak: Preserving the anastomosis. World J Gastrointest Surg 2015; 7:378-383. [PMID: 26730283 PMCID: PMC4691718 DOI: 10.4240/wjgs.v7.i12.378] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
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Ha GW, Kim HJ, Lee MR. Transanal tube placement for prevention of anastomotic leakage following low anterior resection for rectal cancer: a systematic review and meta-analysis. Ann Surg Treat Res 2015; 89:313-8. [PMID: 26665126 PMCID: PMC4672095 DOI: 10.4174/astr.2015.89.6.313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/22/2015] [Accepted: 07/24/2015] [Indexed: 12/30/2022] Open
Abstract
Purpose Anastomotic leakage following low anterior resection (LAR) for rectal cancer is a serious complication that increases morbidity and mortality rates. Transanal tube placement may reduce postoperative anastomotic leakage rate by reducing intraluminal pressure and preventing fecal extrusion through the staple line. This meta-analysis evaluated the effectiveness of transanal tube placement to prevent anastomotic leakage after LAR for rectal cancer using a stapling technique. Methods A systematic review of the literature was consistent with the recommendations of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement. Multiple comprehensive databases, including PubMed, Embase, Cochrane Library and KoreaMed, were searched. The main study outcomes were anastomotic leakage. Results Two randomized clinical trials and 4 nonrandomized studies involving 1,118 patients were included. Subgroup analyses of randomized clinical trials found that transanal tube placement had no effect on study outcomes. Meta-analysis of nonrandomized studies showed that transanal tube placement was associated with a lower incidence of anastomotic leakage (relative risk, 0.32; 95% CI, 0.15-0.67; I2 = 0%). Conclusion Transanal tube placement may be effective in preventing or reducing the occurrence of anastomotic leakage after LAR for rectal cancer using a stapling technique. Randomized clinical trials with sufficient power are needed to confirm the benefit of transanal tube placement.
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Affiliation(s)
- Gi Won Ha
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Hyun Jung Kim
- Institute for Evidence-Based Medicine, Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Min Ro Lee
- Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
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Adamova Z. Transanal Tube as a Means of Prevention of Anastomotic Leakage after Rectal Cancer Surgery. VISZERALMEDIZIN 2015; 30:422-6. [PMID: 26288609 PMCID: PMC4513832 DOI: 10.1159/000369569] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anastomotic leaks after low anterior resection for rectal cancer remain the most feared complication. The aim of our study was to investigate whether the use of a transanal tube could reduce the leakage rate after this surgical procedure. METHODS This is a retrospective analysis of a single-institution experience. The study includes 66 patients who underwent low anterior resection for rectal cancer without stoma creation between January 2008 and June 2013. Patients were divided into two groups, i.e. those with a transanal drainage tube (TT; n = 9) and those without tube (NTT; n = 57), and evaluated for clinically evident anastomotic leakage and postoperative complications. RESULTS The postoperative anastomotic leakage appeared in 5 patients (9%) in the NTT group while no single case was observed within the TT group. Despite the disadvantageous background in the TT group (a transanal stent was used in the most high-risk patients), these patients had no postoperative complications. In the NTT group, 23% had some kind of postoperative complications, and 5% died. The difference between the two groups is not significant. CONCLUSIONS Our study showed that the use of a transanal tube in low anterior resection for rectal cancer could potentially be a simple and effective method of reducing anastomotic leakage. In order to prove our observations, larger prospective randomized studies should be performed.
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Affiliation(s)
- Zuzana Adamova
- Department of Surgery, Vsetin Hospital, Vsetin, Czech Republic
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21
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Yang Q, Tang C, Qi X, Yi G, Xu L. Mitigating the Consequences of Anastomotic Leakage After Laparoscopic Rectal Cancer Resection. Surg Innov 2014; 22:348-54. [PMID: 24902687 DOI: 10.1177/1553350614537561] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background. With regard to laparoscopic low anterior resection, anastomotic leakage still remains a challenge and continues to account for approximately 30% of postoperative deaths. This study was designed to evaluate whether the intracolonic and perineal drainage is associated with a decreased risk for anastomotic leakage after laparoscopic rectal cancer surgery without stool diversion. Patients and Methods. Prospective data were collected from 337 patients with rectal cancer who underwent laparoscopic resection without defunctioning stoma. Results. A total of 157 patients underwent laparoscopic rectal resection, followed by the placement of intracolonic and perineal drainage, while 180 underwent laparoscopic surgery routinely. No difference in clinically significant leakage was observed between the intracolonic and perineal drainage and the control groups (3.8% vs 8.3%, P = .0874). However, reoperation was underwent at a significantly lower rate after the placement of intracolonic and perineal drainage (intracolonic and perineal drainage: 1 of 6 [16.7%] vs control: 14 of 15 [93.3%]; P < .01). In multivariate analysis, extraperitoneal tumor location and operation duration ≥180 minutes were independently associated with anastomotic leakage. Conclusions. Significant risk factors of anastomotic leakage include extraperitoneal tumor location and operation duration ≥180 minutes. The placement of intracolonic and perineal drainage was not found to be significantly associated with anastomotic leakage, but this method could mitigate the clinical consequences of leakage and decrease the rate of reoperation and transverse colostomy after laparoscopic anterior resection for rectal cancer.
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Affiliation(s)
- Qingqiang Yang
- Affiliated Hospital of Luzhou Medical College, Luzhou, People’s Republic of China
| | - Chunyan Tang
- Affiliated Hospital of Luzhou Medical College, Luzhou, People’s Republic of China
| | - Xiaolong Qi
- Affiliated Hospital of Luzhou Medical College, Luzhou, People’s Republic of China
| | - Guoping Yi
- Affiliated Hospital of Luzhou Medical College, Luzhou, People’s Republic of China
| | - Liang Xu
- Affiliated Hospital of Luzhou Medical College, Luzhou, People’s Republic of China
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Chen J, Zhang Y, Jiang C, Yu H, Zhang K, Zhang M, Zhang GQ, Zhou SJ. Temporary ileostomy versus colostomy for colorectal anastomosis: evidence from 12 studies. Scand J Gastroenterol 2013; 48:556-62. [PMID: 23514091 DOI: 10.3109/00365521.2013.779019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the safety and efficacy of temporary ileostomy and temporary colostomy after a low anterior resection for rectal cancer by comparing the postoperative complications, then investigate which type of stoma is better. MATERIAL AND METHODS Studies comparing temporary ileostomy with colostomy for colorectal anastomosis were searched. The rates of complications (i.e., clinical anastomotic leak or fistula, stoma prolapse, parastomal hernia, wound infection related to stoma closure, obstruction following stoma closure, and skin trouble) were pooled and compared using a meta-analysis. The risk ratios (RRs) were calculated with 95% confidence intervals (CIs). RESULTS The study included five randomized controlled trials (RCTs) and seven non-randomized studies involving 1687 patients. The meta-analysis of the RCTs demonstrated a lower risk of stoma prolapse (RR 0.15; 95% CI: 0.04-0.48) in the temporary ileostomy group. Meta-analysis of the non-randomized studies showed a lower risk of stoma prolapse and wound infection after stoma closure in the temporary ileostomy group (both p < 0.05). CONCLUSIONS Temporary ileostomy has a minor impact on patients; we endorse temporary ileostomy over colostomy after a low anterior resection for rectal cancer.
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Affiliation(s)
- Jie Chen
- Department of General Surgery, Yixing People's Hospital (The Affiliated Hospital of Jiangsu University), Yixing, China
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23
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Affiliation(s)
- E J Cook
- Poole General Hospital NHS Foundation Trust, UK
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24
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Goudie S, Dreyer S, Siddiqi R. Modified mattress suture. Ann R Coll Surg Engl 2012; 94:366. [DOI: 10.1308/rcsann.2012.94.5.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Granville-Chapman J, Elliott DS. Use a ball-ended anterior cruciate ligament reamer to protect patella tendon during minimal access tibial nailing. Ann R Coll Surg Engl 2012; 94:371. [DOI: 10.1308/rcsann.2012.94.5.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - DS Elliott
- Ashford and St Peter’s Hospitals NHS Foundation Trust,UK
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26
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Kazi HA, Thomas TG. Use of a sharps bin to provide lower limb traction. Ann R Coll Surg Engl 2012; 94:360. [DOI: 10.1308/rcsann.2012.94.5.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- HA Kazi
- Wirral University Teaching Hospital NHS Foundation Trust,UK
| | - TG Thomas
- Wirral University Teaching Hospital NHS Foundation Trust,UK
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MacDonald ER, Renwick AA, Molloy RG. Laparoscopic hepatic flexure mobilisation. Ann R Coll Surg Engl 2012; 94:360. [DOI: 10.1308/rcsann.2012.94.5.360a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - RG Molloy
- Gartnavel General Hospital, Glasgow,UK
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28
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Cheung A. Soft tissue protection from exposed K-wires. Ann R Coll Surg Engl 2012; 94:372. [DOI: 10.1308/rcsann.2012.94.5.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- A Cheung
- West Hertfordshire Hospitals NHS Trust,UK
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29
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Leong E, Lemon M. A knot quicker and easier than Whip stitching in anterior cruciate ligament reconstruction. Ann R Coll Surg Engl 2012. [DOI: 10.1308/rcsann.2012.94.5.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- E Leong
- Royal Surrey County Hospital nHS foundation Trust,UK
| | - M Lemon
- Royal Surrey County Hospital nHS foundation Trust,UK
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Affiliation(s)
- J Krysa
- Guy’s and St Thomas’ NHS Foundation Trust,UK
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31
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Cook EJ, Moran BJ, Heald RJ, Nash GF. Pelvic collection drainage by Heald anal stent. Ann R Coll Surg Engl 2012; 94:361. [DOI: 10.1308/rcsann.2012.94.5.361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- EJ Cook
- Department of General Surgery,Poole General Hospital, Poole,UK
| | - BJ Moran
- Department of General Surgery,North Hampshire Hospital, Basingstoke,UK
| | - RJ Heald
- Department of General Surgery,North Hampshire Hospital, Basingstoke,UK
| | - GF Nash
- Department of General Surgery,Poole General Hospital, Poole,UK
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32
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Affiliation(s)
- RP Walter
- South Devon Healthcare NHS Foundation Trust,UK
| | - S James
- South Devon Healthcare NHS Foundation Trust,UK
| | - JR Davis
- South Devon Healthcare NHS Foundation Trust,UK
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33
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Storey RL, Gouda MR, Smith AM. A simple exercise to encourage precise suture placement. Ann R Coll Surg Engl 2012; 94:370. [DOI: 10.1308/rcsann.2012.94.5.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- RL Storey
- Leeds Teaching Hospitals NHS Trust,UK
| | - MR Gouda
- Leeds Teaching Hospitals NHS Trust,UK
| | - AM Smith
- Leeds Teaching Hospitals NHS Trust,UK
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34
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Travers H, Mansfield S. A technique to maintain pneumoperitoneum and allow easy inspection of the abdomen after specimen delivery in laparoscopic colorectal surgery. Ann R Coll Surg Engl 2012; 94:362. [DOI: 10.1308/rcsann.2012.94.5.362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- H Travers
- Royal Devon and Exeter NHS Foundation Trust,UK
| | - S Mansfield
- Royal Devon and Exeter NHS Foundation Trust,UK
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35
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Weddell C, McMurtrie A, Hamad AK. A simple aid to fracture reduction in the digit. Ann R Coll Surg Engl 2012; 94:369-70. [DOI: 10.1308/rcsann.2012.94.5.369a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- C Weddell
- Shrewsbury and Telford Hospital NHS Trust,UK
| | - A McMurtrie
- Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust,UK
| | - AK Hamad
- Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust,UK
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36
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Middleton PR, Ng L, Humphrey A. A technique to aid the insertion of distal locking screws. Ann R Coll Surg Engl 2012; 94:364-5. [DOI: 10.1308/rcsann.2012.94.5.364a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- PR Middleton
- County Durham and Darlington NHS Foundation Trust,UK
| | - L Ng
- Newcastle upon Tyne Hospitals NHS Foundation Trust,UK
| | - A Humphrey
- County Durham and Darlington NHS Foundation Trust,UK
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Ellis G, Pridgeon S, Graham S. A technique for optimal manipulation of rotation of the flexible ureterorenoscope. Ann R Coll Surg Engl 2012; 94:365-6. [DOI: 10.1308/rcsann.2012.94.5.365a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - S Graham
- Whipps Cross University Hospital NHS TrustUK
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38
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Godfrey DA, Nash GF. Double decompression of presacral collection by heald anal stent and foley catheter combination. SURGICAL TECHNIQUES DEVELOPMENT 2011. [DOI: 10.4081/std.2011.e28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The authors demonstrate the effective drainage of presacral sepsis following low anterior resection surgery using the novel approach of both the Heald anal stent and a Foley catheter combined. The Heald stent was placed trans-anally without the need for anaesthetic and an 18Fr Foley was placed through this. A presacral collection was drained through the stent, allowing the patient to be discharged after a week without the need to return to the operating theatre. The Heald stent may be used to successfully drain a presacral collection by double decompression of the rectum and the presacral space.
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39
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Morks AN, Havenga K, Ploeg RJ. Can intraluminal devices prevent or reduce colorectal anastomotic leakage: A review. World J Gastroenterol 2011; 17:4461-9. [PMID: 22110276 PMCID: PMC3218136 DOI: 10.3748/wjg.v17.i40.4461] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 02/18/2011] [Accepted: 02/25/2011] [Indexed: 02/06/2023] Open
Abstract
Colorectal anastomotic leakage is a serious complication of colorectal surgery, leading to high morbidity and mortality rates. In recent decades, many strategies aimed at lowering the incidence of anastomotic leakage have been examined. The focus of this review will be on mechanical aids protecting the colonic anastomosis against leakage. A literature search was performed using MEDLINE, EMBASE, and The Cochrane Collaborative library for all papers related to prevention of anastomotic leakage by placement of a device in the colon. Devices were categorised as decompression devices, intracolonic devices, and biodegradable devices. A decompression device functions by keeping the anal sphincter open, thereby lowering the intraluminal pressure and lowering the pressure on the anastomosis. Intracolonic devices do not prevent the formation of dehiscence. However, they prevent the faecal load from contacting the anastomotic site, thereby preventing leakage of faeces into the peritoneal cavity. Many attempts have been made to find a device that decreases the incidence of AL; however, to date, none of the devices have been widely accepted.
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Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study. World J Surg 2011; 35:1367-77. [PMID: 21437746 DOI: 10.1007/s00268-011-1053-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage is the most significant complication after low anterior resection (LAR) for rectal carcinoma, and it is the major cause of postoperative mortality and morbidity. The objective of the present study was to investigate whether the use of a transanal tube as an alternative endoluminal diversion technique for rectal carcinoma can reduce the 30-day leakage rate after LAR. METHODS From June 2003 to December 2009, a total of 398 patients were randomized to a transanal tube or not after LAR. Inclusion criteria for randomization were biopsy-proven carcinoma of the rectum located ≤15 cm above the anal verge, measured with a rigid rectoscope; age≥18 years; informed consent; ability to understand the study information; estimated survival of >6 months; anterior resection for the lesion; final negative air leakage test; intact anastomotic stapler rings; and the absence of major intraoperative adverse events. RESULTS Patient demographics, tumor size and location, Duke's stage, preoperative co-morbidity, and operative details were comparable between the two groups in general analysis and subgroup analysis (double-staple technique and handsewn technique). The overall rate of symptomatic leakage was 6.78% (27 of 398 patients). Patients randomized to a transanal tube (n=200) had leakage in 4.0% (8 of 200 patients) and those without a tube (n=198) in 9.6% (19 of 198 patients) (p=0.026). With regard to the double-staple technique subgroup, 3.7% (7 of 188) patients with a tube presented with a symptomatic anastomotic leakage, compared with 9.3% (17 of 182) of those without a tube (p=0.028). Of the patients with anastomotic leakage in the double-staple technique subgroup, the need for urgent abdominal reoperation was 28.6% (two of seven patients) in those randomized to a transanal tube and 82.4% (14 of 17) in those without (p=0.021). The 30-day mortality after LAR was nil. In the double-staple technique subgroup, a quicker resumption of gastrointestinal motility manifested by a smaller ratio of patients with flatus>postoperative day (POD) 3 (p=0.019) and a smaller ratio of poor gastrointestinal electromyogram on POD 3 (p<0.001) was associated with use of a transanal tube. Additionally, patients with a tube appeared to have a lower rectal resting pressure by POD 3 (4.0±2.2 vs. 5.0±2.2 kPa; p<0.001) or POD 5 (4.3±2.3 vs. 5.6±2.3 kPa; p<0.001), compared to the resting pressures patients without the device, respectively. A shorter length of hospital stay was associated with use of a transanal tube both in the double-staple technique subgroup (p<0.001) and the handsewn technique subgroup (p=0.011). Multivariate logistic regression analysis revealed that body mass index>25 kg/m2 and a poor gastrointestinal electromyogram on POD 3 were found to be independent risk factors for anastomotic leakage in the low anastomosis subgroup. CONCLUSIONS The presence of a transanal tube is effective and safe in decreasing the rate of clinically significant anastomotic leaks and in mitigating the clinical consequences of leakage after anterior resection for rectal cancer with the technique of total mesorectal excision and double-staple anastomosis. The potential benefits of transanal tube placement are multifactorial, including drainage, reduction of endoluminal pressure, and promotion of gastrointestinal motility. Obesity and poor gastrointestinal electromyogram on POD 3 are independent risk factors for anastomotic leakage in patients with low anastomosis.
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Predicting the risk and diminishing the consequences of anastomotic leakage after anterior resection for rectal cancer. ACTA ACUST UNITED AC 2010; 57:47-50. [PMID: 21066983 DOI: 10.2298/aci1003047m] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Anastomotic leakage is one of the most serious early complications of any intestinal anastomosis. The morbidity and mortality are high and patients may be at increased risk of cancer recurrence. In colorectal surgery the risks are particularly high following low anterior resection. Factors which increase and decrease the risks are discussed. METHODS A review of the main published risk factors for anastomotic leakage after anterior resection for rectal cancer together with the authors personal experience is reported. A review of a recent large randomized trial of a defunctioning stoma versus no stoma is outlined. RESULTS The main factor influencing anastomotic leakage is the height of the anastomosis above the anal verge with the lower the anastomosis the higher the risk. All anastomoses within 7 cm of the anal verge are at increased risk which includes all patients who have had a total mesorectal excision. Neoadjuvant therapy (in particular long course radiotherapy or chemoradiotherapy) increases the risk. Male sex, older age, smoking, alcohol in excess, short course radiotherapy, obesity, general fitness, immunosuppression have been reported in some series as increasing the risk. A temporary diverting stoma decreases the consequences of leakage and reduces the need for emergency re-operation. Anastomotic leakage is associated with an increased postoperative death rate, reoperative rates, need for a permanent stoma and possibly an increase in local recurrence and decreased cancer specific and overall survival. CONCLUSION Anastomotic leakage is a serious early complication following surgery for rectal cancer. The height of the anastomosis and neoadjuvant therapy are the main predictors of an increased risk. A diverting stoma diminishes the consequences of risk and reduces the need for emergency re-operation.
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Abstract
The Heald Silastic Anal Stent (HSAS) was designed to protect a newly constructed low colorectal anastomosis by keeping the anus open for up to 10 days postoperatively, and has also been used in combination with percutaneous drainage to treat a leak from a low rectal anastomosis. We describe a technique in two patients where the HSAS alone allowed adequate drainage of a leaking low colorectal anastomosis.
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Affiliation(s)
- A Kamocka
- Department of General Surgery, Bedford Hospital, Bedford, UK
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43
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Influencing factors of symptomatic anastomotic leakage after anterior resection of the rectum for cancer. World J Surg 2009; 33:1292-7. [PMID: 19363687 DOI: 10.1007/s00268-009-0008-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the present study was to analyze the factors associated with anastomotic leakage after anterior resection for rectal cancer. METHODS Retrospectively collected consecutive data of 738 rectal cancer patients who underwent anterior resection in our hospital between 2005 and 2008 were reviewed. The associations between 15 patient-related and surgery-related variables and anastomotic leakage were studied with both the univariate chi-square test and multivariate logistic regression analysis. RESULTS Univariate analysis showed that risk factors associated with anastomotic leakage were low rectal cancer (located 5 cm or less above the dentate line) (5.9% vs. 0.9%; P = 0.003), non-specialized surgeon (3.9% vs. 11.3%; P = 0.031), and defunctioning transanal catheter placement (14.5% vs. 3.6%; P < 0.001). It should be noted that the mean surgeon case volumes of anterior resection of colorectal surgeons and non-specialized general surgeons were 43 per year and 2 per year, respectively (P < 0.001). In addition, there was a tendency for colorectal surgeons to operate on a greater proportion of low rectal cancers (72.1% vs. 52.8%; P = 0.003). In the multivariate analysis, besides low rectal cancer, non-specialized surgeon, and transanal catheter placement, three other factors were associated with anastomotic leakage: diabetes mellitus (P = 0.027), free distal margins less than 1 cm (P = 0.009), and a defunctioning stoma (P = 0.031). In a further analysis of 522 patients with low rectal cancer, the leakage rate in patients with a defunctioning stoma was significantly lower (2.9% vs. 8.5%; P = 0.007). By contrast, the leakage rate in the transanal catheter placement group was higher (15.1% vs. 4.9%; P = 0.008), because of its poor protective effect as well as the selection bias. CONCLUSIONS From the findings of this study, we believe that low rectal cancer, non-specialized surgeons, and diabetes mellitus are risk factors for anastomotic leakage after rectal surgery, and that a defunctioning stoma could significantly reduce the incidence of leakage in low rectal cancer patients.
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Tilney HS, Sains PS, Lovegrove RE, Reese GE, Heriot AG, Tekkis PP. Comparison of outcomes following ileostomy versus colostomy for defunctioning colorectal anastomoses. World J Surg 2007; 31:1142-51. [PMID: 17354030 DOI: 10.1007/s00268-006-0218-y] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The present study evaluated outcomes of patients undergoing proximal diversion using either a loop ileostomy or loop colostomy following distal colorectal resection for malignant and non-malignant disease. METHODS A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1966 and 2006, comparing loop ileostomy and loop colostomy to protect a distal colorectal anastomosis. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since 2000, higher quality papers, those reporting on 70 or more patients, and those reporting outcomes following colorectal cancer resections. RESULTS Seven studies, including three randomised controlled trials, satisfied the inclusion criteria. Outcomes of a total of 1,204 patients were analysed, of whom 719 (59.7%) underwent defunctioning loop ileostomy. High stoma output was more common following ileostomy formation (OR = 5.39, 95% CI: 1.11, 26.12, P = 0.04), but wound infections following their reversal were significantly fewer (OR = 0.21, 95% CI: 0.07, 0.62, P = 0.004). Overall complications were less frequent for ileostomy patients in the subgroup of high quality studies (OR = 0.22, 95% CI: 0.08, 0.59, P = 0.003). CONCLUSION The results of this meta-analysis suggest that ileostomy may be preferable to colostomy when used to defunction a distal colorectal anastomosis. Wound infections following stoma reversal were reduced, as were overall stoma-related complications and incisional hernia following stoma reversal for ileostomy patients in high quality studies.
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Affiliation(s)
- Henry S Tilney
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
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45
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Affiliation(s)
- A Brent
- North Hampshire Hospital, Basingstoke, Hampshire RG24 9NA, UK
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46
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Abstract
OBJECTIVE A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither. PATIENTS AND METHODS Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37-90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent. RESULTS A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without (P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without (P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons. CONCLUSION Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection.
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Affiliation(s)
- S Bülow
- Department of Surgical Gastroenterology, H:S Hvidovre Hospital, Hvidovre, Copenhagen, Denmark.
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Lawes D, Taylor I. Recent randomised trials in colorectal disease. Colorectal Dis 2005; 7:8-17. [PMID: 15606578 DOI: 10.1111/j.1463-1318.2004.00681.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Randomised trials represent the 'gold standard' for surgical research and have an important impact on clinical management. We provide an overview of the randomised trials, specifically related to the practice of colorectal surgery that were published between January and December 2003.
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Affiliation(s)
- D Lawes
- Department of Surgery, Royal Free and University College Medical School, University College, London, UK
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Law WL. Temporary Ileostomy Versus Temporary Colostomy: A Meta-analysis of Complications. Asian J Surg 2004. [DOI: 10.1016/s1015-9584(09)60034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Meade B, Moran B. Reducing the incidence and managing the consequences of anastomotic leakage after rectal resection. ACTA ACUST UNITED AC 2004; 51:19-23. [PMID: 16018361 DOI: 10.2298/aci0403019m] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Anastomotic dehiscence is a serious, life-threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as reported in the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of the anastomosis from the anal verge and the leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning by a loop stoma mitigates the consequences of leakage and probably reduces, but does not abolish, the risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre-operative chemotherapy or chemo-radiotherapy. A high index of suspicion is required in detecting the early non-specific signs of a leak and urgent surgical intervention is usually required to avert a life-threatening situation. Faecal diversion should be regarded as the optimal safety measure to reduce the consequences of leakage and to mange leakage of an unprotected anastomosis.
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Affiliation(s)
- B Meade
- Colorectal Research Unit, North Hampshire Hospital, Basingstoke, UK
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50
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Affiliation(s)
- Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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