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Guerra F, Coletta D, Giuliani G, Turri G, Pedrazzani C, Coratti A. Association Between Cross-Stapling Technique in Mechanical Colorectal Anastomosis and Short-term Outcomes. Dis Colon Rectum 2024; 67:1258-1269. [PMID: 38924002 DOI: 10.1097/dcr.0000000000003382] [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: 06/28/2024]
Abstract
BACKGROUND The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered possible risk factors for anastomotic leakage. OBJECTIVE This study aimed to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis after minimally invasive surgery. DATA SOURCES A systematic review of the published literature was undertaken. PubMed/MEDLINE, Web of Science, and Embase databases were screened up to July 2023. STUDY SELECTION Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction compared with the conventional method of double-stapled anastomosis were included. INTERVENTIONS Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared. MAIN OUTCOME MEASURES The rate of anastomotic leak was the primary end point of interest. Perioperative details including postoperative morbidity were also appraised. RESULTS There were 2537 patients from 12 studies included for data extraction, with no significant differences in age, BMI, or proportion of high ASA score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure than for the conventional procedure (OR = 0.38 [95% CI, 0.26-0.56]). The incidences of overall postoperative morbidity (OR = 0.57 [95% CI, 0.45-0.73]) and major morbidity (OR = 0.48 [95% CI, 0.32-0.72]) following modified stapled anastomosis were significantly lower than following conventional double-stapled anastomosis. LIMITATIONS The retrospective nature of most included studies is a main limitation, essentially because of the lack of randomization and the risk of selection and detection bias. CONCLUSIONS The available evidence supports the modification of the conventional double-stapled technique with the elimination of 1 of both dog-ears as it is associated with a lower incidence of anastomotic-related morbidity.
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Affiliation(s)
- Francesco Guerra
- Division of General and Acute Care Surgery, AUSL Toscana Sud Est, Grosseto, Italy
| | - Diego Coletta
- Division of Hepatobiliary Surgery, IRCCS Regina Elena National Cancer Institute, Roma, Italy
- Division of General and Hepatobiliary Surgery, Sapienza University of Rome, Roma, Italy
| | - Giuseppe Giuliani
- Division of General and Acute Care Surgery, AUSL Toscana Sud Est, Grosseto, Italy
| | | | | | - Andrea Coratti
- Division of General and Acute Care Surgery, AUSL Toscana Sud Est, Grosseto, Italy
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Van Zande J, Magamadov K, Van Molhem Y. The bow tie technique for single stapled colorectal anastomosis: technical note. Acta Chir Belg 2024:1-5. [PMID: 39225321 DOI: 10.1080/00015458.2024.2400800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/30/2024] [Indexed: 09/04/2024]
Abstract
AIM In this technical note we describe a simplified totally transabdominal technique to perform a single stapled end-to-end colorectal anastomosis without the need for transanal transection, linear stapler line resection, purse string or dog-ear suturing. METHOD The rationale and the technique itself are first explained by using a schematic design. Next, step-by-step pictures of one of our cases show the feasibility and advantages of this technique. At the end, the limits of this technique are illustrated. RESULTS The technique was used for 20 colorectal anastomosis, 9 benign and 11 oncological cases. Median age was 68 years and average BMI was 28 kg/m2. Risk factors for anastomotic leakage were reported in 10 cases. The bow tie technique was performed in every case and the linear stapler line was entirely resected in all cases. No positive air leak test or anastomotic leakage was reported. CONCLUSIONS The bow tie technique is a feasible technique to perform an end-to-end single stapled colorectal anastomosis with promising results on anastomotic leakage. Further research with larger prospective data collection is necessary to validate this technique and show its potential benefit on anastomotic leakage.
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Affiliation(s)
- Jaro Van Zande
- Department of General Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
| | - Khozh Magamadov
- Department of General Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
| | - Yves Van Molhem
- Department of General Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
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Kotze PG, Avellaneda N, Moretti RDAM, Carvello M, Tomada EP, Campos FG, Spinelli A. Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques. Dis Colon Rectum 2024; 67:S26-S35. [PMID: 38710588 DOI: 10.1097/dcr.0000000000003292] [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: 05/08/2024]
Abstract
BACKGROUND Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION IPAA technique. MAIN OUTCOME MEASURES Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Nicolas Avellaneda
- General and Colorectal Surgery Department, CEMIC University Hospital, Buenos Aires, Argentina
| | | | - Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa Paoluzzi Tomada
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Bae J, Butt A, Labinoti R, Driver I, Malik A. Innovative intraoperative strategies for optimizing postoperative outcomes in robotic or laparoscopically assisted surgery - a video vignette. Colorectal Dis 2024; 26:1080-1081. [PMID: 38468131 DOI: 10.1111/codi.16934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/02/2023] [Indexed: 03/13/2024]
Affiliation(s)
- James Bae
- Ipswich Hospital, Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Alfred Butt
- Ipswich Hospital, Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Roland Labinoti
- Ipswich Hospital, Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Ian Driver
- Ipswich Hospital, Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Arshad Malik
- Ipswich Hospital, Colorectal Surgery, East Suffolk and North Essex NHS Foundation Trust, Essex, UK
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Stevanato Filho PR, Bezerra TS, Marques TMDM, Nahime RH, Takahashi RM, Nakagawa WT, Lopes A, Aguiar S. A precise approach to robotic intracorporeal rectal transection and hand-sewn purse-string anastomosis for low anterior resection. J Surg Oncol 2024; 129:939-944. [PMID: 38221657 DOI: 10.1002/jso.27583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/24/2023] [Accepted: 12/26/2023] [Indexed: 01/16/2024]
Abstract
This study presents a new technique for robotic-assisted intracorporeal rectal transection and hand-sewn anastomosis for low anterior resection that overcomes some limitations of conventional techniques. By integrating the advantages of the robotic platform, ensuring standardized exposure during rectal transection, and emphasizing the importance of avoiding complications associated with staple crossings, this innovation has the potential to significantly improve outcomes and reduce costs for patients with lower rectal tumors.
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Affiliation(s)
| | - Tiago S Bezerra
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Tomas M D M Marques
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Rebeca H Nahime
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Renata M Takahashi
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Wilson T Nakagawa
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Ademar Lopes
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Samuel Aguiar
- Colorectal Cancer Reference Center, A.C. Camargo Cancer Center, São Paulo, Brazil
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Spinelli A, Foppa C, Maroli A, Sacchi M, Armuzzi A, Danese S, Bemelman W, Carvello M. Transanal transection and single-stapling techniques are associated with shorter rectal cuff and lower urgency rate after pouch surgery compared with the double-stapled approach. Surgery 2023; 174:808-812. [PMID: 37517895 DOI: 10.1016/j.surg.2023.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis is most commonly performed by double-stapling technique after rectal transection with a linear stapler. Double-stapling is increasingly criticized for the uneven longer cuffs and potential weak points. A transanal rectal transection and single-stapled anastomosis may potentially overcome the limitations of double-stapling. A single-stapled anastomosis may be accomplished through a transanal rectal transection followed by bottom-up dissection (transanal-ileal pouch-anal anastomosis) or through an abdominal, rectal dissection and subsequent transanal transection and single-stapled anastomosis. The purpose of this study is to compare short-term and functional outcomes of double-stapling versus single-stapled techniques for ileal pouch-anal anastomosis. METHODS This is a single-institution, ambidirectional study. Patients with ulcerative colitis undergoing ileal pouch-anal anastomosis between 2014 and 2021 were included in the study and allocated into 2 groups: group 1, including double stapled ileal pouch anal anastomosis, and group 2, including single-stapled-ileal pouch-anal anastomosis. The primary endpoint was the difference in functional parameters. RESULTS A total of 130 patients were included, 46 undergoing double-stapling-ileal pouch-anal anastomosis and 84 receiving single-stapled ileal pouch-anal anastomosis. Rectal-cuff length (defined as the distance between the dentate line and ileal pouch-anal anastomosis) was shorter after single-stapled compared with double-stapling ileal pouch-anal anastomosis (1.98 ± 0.21 vs 2.20 ± 0.53 cm, P = .01). Anastomotic leak rate was comparable between group 1 and group 2 (6% vs 5%, P = .69). Functional parameters were comparable except for urgency, which was lower for single-stapled compared with double-stapling ileal pouch-anal anastomosis (8%, vs 30%, P = .002). CONCLUSION Single-stapled ileal pouch-anal anastomosis was associated with a shorter rectal cuff and lower urgency than double-stapling ileal pouch-anal anastomosis. In our opinion, these results warrant a prospective multicentric trial to scrutinize and confirm these benefits on a larger scale.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy.
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Annalisa Maroli
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Matteo Sacchi
- Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Willem Bemelman
- Department of Gastroenterology, Inflammatory Bowel Disease Unit (IBD Unit), San Raffaele Hospital, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, Institute for Treatment and Research (IRCCS) Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan, Italy
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Azevedo C, Costa Pereira C, Vilela Pinto N, Antunes A, Marques I, Costa Pereira J. Laparoscopic staple line invagination in low colorectal anastomosis - A Video Vignette. Colorectal Dis 2023; 25:1552-1553. [PMID: 37029612 DOI: 10.1111/codi.16570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Constança Azevedo
- Centro Hospitalar Universitário Cova da Beira, EPE, Alameda Pêro da Covilhã, 6200-251, Covilhã, Portugal
| | | | - Nuno Vilela Pinto
- Hospital de Braga, R. das Comunidades Lusíadas, 133, Braga, Portugal
| | - Alexandra Antunes
- Hospital de Braga, R. das Comunidades Lusíadas, 133, Braga, Portugal
| | - Isabel Marques
- Hospital de Braga, R. das Comunidades Lusíadas, 133, Braga, Portugal
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Foppa C, Carvello M, Maroli A, Sacchi M, Gramellini M, Montorsi M, Spinelli A. Single-stapled anastomosis is associated with a lower anastomotic leak rate than double-stapled technique after minimally invasive total mesorectal excision for MRI-defined low rectal cancer. Surgery 2023; 173:1367-1373. [PMID: 36967334 DOI: 10.1016/j.surg.2023.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/13/2023] [Accepted: 02/11/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND After total mesorectal excision, distal rectal transection and anastomosis are critical for short-term, oncological, and functional outcomes, including anastomotic leak. A double-pursestring, single-stapled anastomosis avoids cross-stapling, overcoming the potential drawbacks of transabdominal rectal transection and double-stapled anastomosis. This study aims to compare the anastomotic leak rate in double-stapled and single-stapled anastomoses after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer. METHODS Adult patients (>18 years old) undergoing minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer with a stapled low anastomosis (below 5 centimeters from the anal verge) between January 2010 and January 2022 at a single institution were allocated to 2 groups according to the anastomosis: double-stapled (abdominal stapled transection and double-stapled anastomosis) or single-stapled (transanal rectal transection and double-pursestring single-stapled anastomosis). The exclusion criteria were nonrestorative procedures or any type of manual anastomosis. The primary endpoint was the rate of 90-day clinical and radiologic anastomotic leak. RESULTS In total, 185 single-stapled and 458 double-stapled were included. Clinical and tumor characteristics were comparable between the groups. The 90-day anastomotic leak rate was significantly lower in the single-stapled group (6.48% vs 15.28%; P = .002), with similar rates of grade and timing. Thirty- and 90-day complication rates were higher in the double-stapled group (P = .0001; P = .02), with comparable Clavien-Dindo grades. At multivariable analysis, double-stapled anastomosis (P = .01), active smoking (P = .03), and the presence of comorbidities (P = .01) resulted as independent risk factors for an anastomotic leak. CONCLUSION Transanal transection and double-pursestring, single-stapled anastomosis were associated with a lower anastomotic leak rate after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer.
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Affiliation(s)
- Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Annalisa Maroli
- IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Matteo Sacchi
- IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Marco Gramellini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy.
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Yamauchi S, Kanda S, Yoshimoto Y, Kubota A, Tsuda K, Yube Y, Kaji S, Oka S, Orita H, Brock MV, Mine S, Fukunaga T. Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial. Surg Endosc 2023:10.1007/s00464-023-10068-z. [PMID: 37076615 DOI: 10.1007/s00464-023-10068-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/01/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance. METHODS A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications. RESULTS Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8 min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different. CONCLUSIONS No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.
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Affiliation(s)
- Suguru Yamauchi
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan.
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Satoshi Kanda
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Yutaro Yoshimoto
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Akira Kubota
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Kenki Tsuda
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Yukinori Yube
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Sanae Kaji
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Shinichi Oka
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Hajime Orita
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Malcolm V Brock
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shinji Mine
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
| | - Tetsu Fukunaga
- Department of Esophageal and Gastroenterological Surgery, Faculty of Medicine, Juntendo University, 3-1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan
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Adachi T, Kitaguchi D, Teramura K, Hasegawa H, Ikeda K, Tsukada Y, Nishizawa Y, Sasaki T, Ito M. Single-center comparative study of short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. Surg Endosc 2023:10.1007/s00464-023-09948-1. [PMID: 36890411 DOI: 10.1007/s00464-023-09948-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers. METHODS This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10 cm) or low (< 5 cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1 mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared. RESULTS Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%. CONCLUSIONS Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.
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Affiliation(s)
- Toshiyuki Adachi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koichi Teramura
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Deputy M, Pitman F, Sahnan K, Miskovic D, Faiz O. An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at a tertiary referral centre. Colorectal Dis 2023. [PMID: 36806873 DOI: 10.1111/codi.16528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023]
Abstract
AIM A robotic approach to ileal pouch-anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic. METHOD A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch-anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected. RESULTS Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16-52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m2 (range 18.1-34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5-49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems. DISCUSSION RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.
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Affiliation(s)
- Mohammed Deputy
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Francesca Pitman
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Leicester University Medical School, George Davies Centre, Leicester, UK
| | - Kapil Sahnan
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Danilo Miskovic
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - Omar Faiz
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Harrow, UK.,Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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12
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Zhang L, Xie Z, Gong L, Lv X. 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. Front Surg 2023; 9:1038873. [PMID: 36684252 PMCID: PMC9852756 DOI: 10.3389/fsurg.2022.1038873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/10/2022] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - L. Gong
- Correspondence: X. Lv L. Gong
| | - X. Lv
- Correspondence: X. Lv L. Gong
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13
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Yang Y, Ding F, Xu T, Pan Z, Zhuang J, Liu X, Guan G. Double-stapled anastomosis without "dog-ears" reduces the anastomotic leakage in laparoscopic anterior resection of rectal cancer: A prospective, randomized, controlled study. Front Surg 2023; 9:1003854. [PMID: 36684218 PMCID: PMC9852307 DOI: 10.3389/fsurg.2022.1003854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/31/2022] [Indexed: 01/09/2023] Open
Abstract
Background Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate whether the resection of "dog-ears" in laparoscopic anterior resection of rectal cancer (called modified double-stapling technique, MDST) could reduce the rate of AL in patients with middle and high rectal cancer, as compared with the conventional double-stapling technique (DST). Methods The clinical data of 232 patients with middle and high rectal cancer were prospectively collected from September 2015 to October 2018. They were randomly divided into the MDST group (n = 116) and the DST group (n = 116) and the data were prospectively analyzed. Morbidity and AL rate were compared between the two groups. Results Patient demographics, tumor size, and time of first flatus were similar between the two groups. No difference was observed in the operation time between the two groups. The AL rate was significantly lower in the MDST group than in the DST group (3.4 vs. 11.2%, p = 0.032). The age and anastomotic technique were the factors associated with AL according to the multivariate analysis. The location of the AL in the DST group was further investigated, revealing that AL was in the same place as the "dog-ears" (11/13, 84.6%). Conclusions Our prospective comparative study demonstrated that MDST have a better short-term outcome in reducing AL compared with DST. Therefore, this technique could be an alternative approach to maximize the benefit of laparoscopic anterior resection on patients with middle and high rectal cancer. The "dog-ears" create stapled corners potentially ischemic, since they represent the area with high incidence of AL.(NCT:02770911).
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Affiliation(s)
- Yuanfeng Yang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Feng Ding
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tianbao Xu
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhen Pan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinfu Zhuang
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xing Liu
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China,Correspondence: Guoxian Guan Xing Liu
| | - Guoxian Guan
- Department of Colorectal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Correspondence: Guoxian Guan Xing Liu
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14
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Gaidarski III AA, Ferrara M. The Colorectal Anastomosis: A Timeless Challenge. Clin Colon Rectal Surg 2022; 36:11-28. [PMID: 36619283 PMCID: PMC9815911 DOI: 10.1055/s-0042-1756510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.
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Affiliation(s)
| | - Marco Ferrara
- Colon and Rectal Clinic of Orlando, Orlando, Florida,Address for correspondence Marco Ferrara, MD Colon and Rectal Clinic of Orlando110 West Underwood ST, Suite A, Orlando, FL 32806
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15
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Feng Q, Yuan W, Li T, Tang B, Jia B, Zhou Y, Zhang W, Zhao R, Zhang C, Cheng L, Zhang X, Liang F, He G, Wei Y, Xu J, Feng Q, Wei Y, He G, Liang F, Yuan W, Sun Z, Li T, Tang B, Tang B, Gao L, Jia B, Li P, Zhou Y, Liu X, Zhang W, Lou Z, Zhao R, Zhang T, Zhang C, Li D, Cheng L, Chi Z, Zhang X, Yang G. Robotic versus laparoscopic surgery for middle and low rectal cancer (REAL): short-term outcomes of a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7:991-1004. [PMID: 36087608 DOI: 10.1016/s2468-1253(22)00248-5] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/15/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Robotic surgery for rectal cancer is gaining popularity, but evidence on long-term oncological outcomes is scarce. We aimed to compare surgical quality and long-term oncological outcomes of robotic and conventional laparoscopic surgery in patients with middle and low rectal cancer. Here we report the short-term outcomes of this trial. METHODS This multicentre, randomised, controlled, superiority trial was done at 11 hospitals in eight provinces of China. Eligible patients were aged 18-80 years with middle (>5 to 10 cm from the anal verge) or low (≤5 cm from the anal verge) rectal adenocarcinoma, cT1-T3 N0-N1 or ycT1-T3 Nx, and no evidence of distant metastasis. Central randomisation was done by use of an online system and was stratified according to participating centre, sex, BMI, tumour location, and preoperative chemoradiotherapy. Patients were randomly assigned at a 1:1 ratio to receive robotic or conventional laparoscopic surgery. All surgical procedures complied with the principles of total mesorectal excision or partial mesorectal excision (for tumours located higher in the rectum). Lymph nodes at the origin of the inferior mesenteric artery were dissected. In the robotic group, the excision procedures and dissection of lymph nodes were done by use of robotic techniques. Neither investigators nor patients were masked to the treatment allocation but the assessment of pathological outcomes was masked to the treatment allocation. The primary endpoint was 3-year locoregional recurrence rate, but the data for this endpoint are not yet mature. Secondary short-term endpoints are reported in this article, including two key secondary endpoints: circumferential resection margin positivity and 30-day postoperative complications (Clavien-Dindo classification grade II or higher). The outcomes were analysed according in a modified intention-to-treat population (according to the original assigned groups and excluding patients who did not undergo surgery or no longer met inclusion criteria after randomisation). This trial was registered with ClinicalTrials.gov, number NCT02817126. Study recruitment has completed, and the follow-up is ongoing. FINDINGS Between July 17, 2016, and Dec 21, 2020, 1742 patients were assessed for eligibility. 502 patients were excluded, and 1240 patients were enrolled and randomly assigned to receive either robotic surgery (620 patients) or laparoscopic surgery (620 patients). 69 patients were excluded (34 in the robotic surgery group and 35 in the laparoscopic surgery group). 1171 patients were included in the modified intention-to-treat analysis (586 in the robotic group and 585 in the laparoscopic group). Six patients in the robotic surgery group received laparoscopic surgery and seven patients in the laparoscopic surgery group received robotic surgery. 22 (4·0%) of 547 patients in the robotic group had a positive circumferential resection margin as did 39 (7·2%) of 543 patients in the laparoscopic group (difference -3·2 percentage points [95% CI -6·0 to -0·4]; p=0·023). 95 (16·2%) of patients in the robotic group had at least one postoperative complication (Clavien-Dindo grade II or higher) within 30 days after surgery, as did 135 (23·1%) of 585 patients in the laparoscopic group (difference -6·9 percentage points [-11·4 to -2·3]; p=0·003). More patients in the robotic group had a macroscopic complete resection than in the laparoscopic group (559 [95·4%] of 586 patients vs 537 [91·8%] of 585 patients, difference 3·6 percentage points [0·8 to 6·5]). Patients in the robotic group had better postoperative gastrointestinal recovery, shorter postoperative hospital stay (median 7·0 days [IQR 7·0 to 11·0] vs 8·0 days [7·0 to 12·0], difference -1·0 [95% CI -1·0 to 0·0]; p=0·0001), fewer abdominoperineal resections (99 [16·9%] of 586 patients vs 133 [22·7%] of 585 patients, difference -5·8 percentage points [-10·4 to -1·3]), fewer conversions to open surgery (10 [1·7%] of 586 patients vs 23 [3·9%] of 585 patients, difference -2·2 percentage points [-4·3 to -0·4]; p=0·021), less estimated blood loss (median 40·0 mL [IQR 30·0 to 100·0] vs 50·0 mL [40·0 to 100·0], difference -10·0 [-20·0 to -10·0]; p<0·0001), and fewer intraoperative complications (32 [5·5%] of 586 patients vs 51 [8·7%] of 585 patients; difference -3·3 percentage points [-6·3 to -0·3]; p=0·030) than patients in the laparoscopic group. INTERPRETATION Secondary short-term outcomes suggest that for middle and low rectal cancer, robotic surgery resulted in better oncological quality of resection than conventional laparoscopic surgery, with less surgical trauma, and better postoperative recovery. FUNDING Shenkang Hospital Development Center, Shanghai Municipal Health Commission (Shanghai, China), and Zhongshan Hospital Fudan University (Shanghai, China).
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Affiliation(s)
- Qingyang Feng
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Weitang Yuan
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Taiyuan Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Bo Tang
- Department of General Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Baoqing Jia
- Department of General Surgery, The First Medical Center, PLA General Hospital, Beijing, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cheng Zhang
- Department of General Surgery, Northern Theater Command General Hospital, Shenyang, Liaoning Province, China
| | - Longwei Cheng
- Second Department of Gastrointestinal Surgery, Jilin Cancer Hospital, Changchun, Jilin Province, China
| | - Xiaoqiao Zhang
- Department of General Surgery, The 960th Hospital of the PLA Joint Logistic Support Force, Jinan, Shandong Province, China; Department of General Surgery, Shandong Provincial Hospital affiliated to the Shandong First Medical University, Jinan, Shandong Province, China
| | - Fei Liang
- Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China
| | - Guodong He
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Ye Wei
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China
| | - Jianmin Xu
- Department of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Engineering Research Center of Colorectal Cancer Minimally Invasive Technology, Shanghai, China.
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16
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Yi X, Liao W, Feng X, Li H, Chen Z, Wang J, Lu X, Wan J, Lin J, Hong X, Diao D. An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area. Updates Surg 2022; 74:1645-1656. [PMID: 35596113 DOI: 10.1007/s13304-022-01282-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/20/2022] [Indexed: 12/24/2022]
Abstract
Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.
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Affiliation(s)
- Xiaojiang Yi
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Weilin Liao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaochuang Feng
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Hongming Li
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Zhaoyu Chen
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiahao Wang
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xinquan Lu
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jin Wan
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiaxin Lin
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaoyan Hong
- Department of Anesthesiology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Dechang Diao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China.
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17
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Liu C, Wang Y, Zhao AR, Hu FA, Fan Q, Han G, Ding G, Fu T, Geng L, Yin H. An alternative asymmetric figure-of-eight single-layer suture technique for bowel anastomosis in an in vitro porcine model. Front Surg 2022; 9:896542. [PMID: 36248362 PMCID: PMC9554239 DOI: 10.3389/fsurg.2022.896542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Anastomotic techniques are of vital importance in restoring gastrointestinal continuity after resection. An alternative asymmetric figure-of-eight single-layer suture anastomotic technique was introduced and its effects were evaluated in an in vitro porcine model. Twelve 15-cm grossly healthy small intestine segments from a porcine cadaver were harvested and randomly divided into asymmetric figure-of-eight single-layer suture (figure-of-eight suture) and single-layer interrupted suture technique (interrupted suture) groups (n = 6 in each group). The anastomosed bowel was infused with methylene blue solution to test anastomotic leakage. Anastomosis construction time, leakage, and suture material cost were recorded and analyzed statistically using Fisher's exact test and Student's t-test. One anastomotic leakage occurred (16.67%) in the figure-of-eight suture group, and two (33.33%) in the interrupted suture group (p > 0.9999). The anastomosis construction time was relatively short in the figure-of-eight suture group, but the difference did not reach a statistically significant level between the two groups. The mean number of suture knots and the cost of suture material in the figure-of-eight suture group were significantly decreased in comparison to the interrupted suture group (15.67 ± 3.30 vs. 22.17 ± 2.03, 167.11 ± 35.20 vs. 236.45 ± 21.70 CNY, p < 0.01, respectively). Our results suggested that the alternative asymmetric figure-of-eight suture technique was safe and economic for intestinal anastomosis. An in vivo experiment is required to elucidate the effects of this suture technique on the physiological anastomotic healing process.
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Affiliation(s)
- Chen Liu
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
- The Department of Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yewen Wang
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Ai-rong Zhao
- The Department of Pharmacy, Binzhou Medical University Hospital, Binzhou, China
| | - Feng-ai Hu
- The Clinical Laboratory, Binzhou Medical University Hospital, Binzhou, China
| | - Qizhong Fan
- The Department of Pharmacy, Binzhou Medical University Hospital, Binzhou, China
| | - Guoxiu Han
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Guojian Ding
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Tingliang Fu
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
| | - Lei Geng
- The Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China
- Correspondence: Lei Geng Hongshan Yin
| | - Hongshan Yin
- The Department of Urology, Binzhou Medical University Hospital, Binzhou, China
- Correspondence: Lei Geng Hongshan Yin
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18
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Ban B, Shang A, Shi J. Efficacy of staple line reinforcement by barbed suture for preventing anastomotic leakage in laparoscopic rectal cancer surgery. World J Gastrointest Surg 2022; 14:821-832. [PMID: 36157360 PMCID: PMC9453327 DOI: 10.4240/wjgs.v14.i8.821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/28/2022] [Accepted: 07/26/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a severe complication in rectal cancer surgery. Various methods, including intracorporeal reinforcing suturing, have been used to reduce the incidence of AL. However, little is known about the efficacy of staple-line reinforcement by barbed suture for preventing AL.
AIM To evaluate the efficacy of staple-line reinforcement using barbed suture for preventing AL in laparoscopic surgery for rectal cancer.
METHODS We retrospectively reviewed the clinical datum of 319 patients undergoing laparoscopic low anterior resection combined with double stapling technique between May 1, 2017 and January 31, 2021. All surgeries were performed by the same surgical team specializing in colorectal surgery. Patients were divided into two groups depending on whether they received reinforcing sutures. Patients’ baseline characteristics did not show any significant difference between the two groups. We analyzed patient-, tumor-, as well as surgery-related variables using univariate and multivariate logistic analyses.
RESULTS There were 168 patients in the reinforcing suture group and 151 patients in the non-reinforcing suture group. AL occurred in 25 cases (7.8%). Its incidence was significantly higher in the non-reinforcing suture group than in the reinforcing suture group (4.8% vs 11.3%, P = 0.031). The multivariate analyses demonstrated that the tumor site, tumor size and presence of staple-line reinforcement were independent risk factors for AL. We divided these patients into two risk groups based on the combination of tumor site and tumor size. Patients without any risk factor were assigned to the low-risk group (n = 177), whereas those having one or two risk factors were assigned to the high-risk group (n = 142). In the high-risk group, the AL incidence considerably decreased in the reinforcing suture group compared with that in the non-reinforcing suture group (P = 0.038). Nonetheless, no significant difference was found in the low-risk group between the two groups.
CONCLUSION Staple-line reinforcement by barbed suture may decrease the incidence of AL. A large-scale prospective randomized controlled trial is needed for evaluating the efficacy of staple-line reinforcement for preventing AL.
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Affiliation(s)
- Bo Ban
- Department of General Surgery, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
| | - An Shang
- Department of General Surgery, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
| | - Jian Shi
- Department of General Surgery, The Second Hospital of Jilin University, Changchun 130041, Jilin Province, China
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19
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Waqas A, Mykoniatis I, Sidiqi N, Ahmed A, Stefan S, Naqvi S, Harper M, Khan J. Early Experience of Undertaking Robotic Assisted Total Mesorectal Excision in Rectal Resections, Avoiding a Diverting Stoma: Key eHancement of the Anastomosis for No Stoma Technique - A Case Series. Surg Innov 2022:15533506221108833. [PMID: 35855510 DOI: 10.1177/15533506221108833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.
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Affiliation(s)
- Ahmad Waqas
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Ioanis Mykoniatis
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Najaf Sidiqi
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Anwar Ahmed
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Samuel Stefan
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Syed Naqvi
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Mick Harper
- Faculty of Science, 66971University of Portsmouth, Portsmouth, UK
| | - Jim Khan
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK.,2369Anglia Ruskin University Chelmsford, Chelmsford, UK
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Mazaki J, Katsumata K, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Ishizaki T, Nagakawa Y, Tsuchida A. Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study. Medicine (Baltimore) 2022; 101:e29600. [PMID: 35839009 PMCID: PMC11132375 DOI: 10.1097/md.0000000000029600] [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] [Received: 11/11/2021] [Accepted: 05/01/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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Mazaki J, Katsumata K, Ishizaki T, Fukushima N, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Nagakawa Y, Tsuchida A. Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score-matched study. Medicine (Baltimore) 2022; 101:e29325. [PMID: 35801763 PMCID: PMC9259104 DOI: 10.1097/md.0000000000029325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
- *Correspondence: Junichi Mazaki, Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: )
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Noritoshi Fukushima
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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22
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A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised? J Gastrointest Surg 2022; 26:1070-1076. [PMID: 34993896 DOI: 10.1007/s11605-021-05236-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/19/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Most ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. METHODS Single-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. RESULTS The study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. CONCLUSION Transanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.
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23
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Comprehensive literature review of the outcome, modifications, and alternatives to double-stapled low pelvic colorectal anastomosis. Surgery 2022; 172:512-521. [DOI: 10.1016/j.surg.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/16/2022] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
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24
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Habeeb TAAM, Mohammad H, Wasefy T, Mansour MI. Outcomes of side-to-end versus end-to-end colorectal anastomosis in non-emergent sigmoid and rectal cancers: randomized controlled clinical trial. Ann Coloproctol 2022:ac.2021.00906.0129. [PMID: 35272448 DOI: 10.3393/ac.2021.00906.0129] [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: 10/14/2021] [Accepted: 12/17/2021] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Tamer A A M Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hatem Mohammad
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Tamer Wasefy
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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25
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Yuen A, Brar MS, de Buck van Overstraeten A. Indications and Surgical Technique for Transanal Proctectomy and Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease. Clin Colon Rectal Surg 2022; 35:135-140. [PMID: 35237109 PMCID: PMC8885156 DOI: 10.1055/s-0041-1742114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical management of inflammatory bowel disease has advanced significantly over the years. One particular focus of its evolution has been to minimize invasiveness. Transanal surgery has given the contemporary surgeon an alternate approach to access the low rectum situated in the confines of the deep pelvis. In benign disease, combining transanal surgery with laparoscopy has allowed for the development of novel techniques to create ileal pouch-anal anastomoses, perform intersphincteric Crohn's proctectomies, manage complications from pelvic surgery, and facilitate redo pelvic surgery. We aim to review the indications for transanal surgery in benign disease, describe an approach to transanal pouch surgery in detail, and discuss the potential benefits, pitfalls, and contentious issues surrounding this approach.
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Affiliation(s)
- Andrew Yuen
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mantaj S. Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony de Buck van Overstraeten
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada,Address for correspondence Anthony de Buck van Overstraeten, MD, MSc 600 University Avenue Rm 455, Toronto, ON M5G1X5Canada
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26
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Anastomosis-Related Complications After Stapled Anastomosis With Reinforced Sutures in Transanal Total Mesorectal Excision for Low Rectal Cancer: A Retrospective Single-Center Study. Dis Colon Rectum 2022; 65:246-253. [PMID: 34657080 DOI: 10.1097/dcr.0000000000002016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The International Transanal Total Mesorectal Excision Registry group showed that transanal total mesorectal excision included clinical issues regarding anastomosis-related complications. OBJECTIVE This study evaluated anastomotic complications in patients whose anastomoses were created with the stapler plus reinforced sutures procedure after transanal total mesorectal excision for low rectal cancer. DESIGN This was a retrospective single-center study. SETTING The study was conducted at the National Cancer Center Hospital East, Japan. PATIENTS Between June 2016 and December 2019, 150 patients underwent transanal total mesorectal excision for low rectal cancer. Stapled anastomosis was performed for 55 patients, and coloanal handsewn anastomosis was performed for 95 patients. Blood perfusion of the colon was routinely evaluated with intraoperative indocyanine green fluorescence angiography. All patients who underwent stapled anastomosis received additional handsewn sutures on all rounds of the stapled line. Patients who underwent intersphincteric resection were excluded. MAIN OUTCOME MEASURES The anastomosis-related complications were compared between the groups. RESULTS Early anastomotic leakage was found in one (1.8%) and eight (8.4%) patients in the stapled group and handsewn group. Overall anastomosis-related complications, pelvic abscess, and anastomotic stenosis were significantly less frequent in the stapled group (p < 0.001, p < 0.048, and p < 0.032). Incomplete donuts after the stapled anastomosis were observed in 9 patients (16.4%); however, we reinforced all around the stapled line in these patients, and this reduced the subsequent occurrence of anastomotic leakage. LIMITATIONS First, this was a retrospective single-center study that was not randomized or controlled. Second, there were chronological differences regarding the anastomotic method between the two groups. Third, our study included a relatively small number of patients who received preoperative chemoradiotherapy. CONCLUSIONS Stapled anastomosis with reinforced handsewn sutures resulted in fewer anastomosis-related complications than did coloanal handsewn anastomosis after transanal total mesorectal excision for low rectal cancer; thus, the former may be superior and should be the preferred method, when technically possible. See Video Abstract at http://links.lww.com/DCR/B749.COMPLICACIONES RELACIONADAS CON LAS ANASTOMOSIS ENGRAMPADAS Y REFORZADAS CON SUTURAS EN LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER DE RECTO BAJO: ESTUDIO RETROSPECTIVO UNICÉNTRICO. ANTECEDENTES El grupo del Registro Internacional de Excisión Total del Mesorrecto por vía Transanal mostró que la excisión total mesorrectal transanal incluía problemas clínicos relacionados a las complicaciones involucradas con la anastomosis. OBJETIVO Se evaluaron las complicaciones anastomóticas en pacientes cuyas anastomosis se realizaron con engrampadora reforzada de suturas después de la excisión total de l mesorrecto por vía transanal en casos de cáncer de recto bajo. DISEO Estudio retrospectivo unicéntrico. AJUSTE El Hospital del Centro Nacional del Cáncer del Este, Japón. PACIENTES Entre junio de 2016 y diciembre de 2019, 150 pacientes se sometieron a excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo. Se realizó anastomosis con engrampadora en 55 y anastomosis coloanal suturada a mano en 95 pacientes. La perfusión tisular sanguínea del colon operado se evaluó de forma rutinaria con angiografía de fluorescencia con verde de indocianina intraoperatoria. Todos los pacientes que se sometieron a anastomosis con grapas recibieron suturas realizadas a mano adicionales sobre la totalidad de la línea de grapas. Se excluyeron los pacientes sometidos a resección interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO Las complicaciones relacionadas con la anastomosis se compararon entre los grupos. RESULTADOS Se encontró fuga anastomótica temprana en 1 (1.8%) y 8 (8.4%) pacientes en el grupo de engrampado y en el grupo suturado a mano, respectivamente. En general, las complicaciones relacionadas con la anastomosis, el absceso pélvico y la estenosis anastomótica fueron significativamente menos frecuentes en el grupo con grapas (p < 0.001, p < 0.048, p < 0.032, respectivamente). Se observaron donas incompletas después de la anastomosis grapada en 9 pacientes (16,4%); sin embargo, reforzamos todo alrededor de la línea de grapas en estos pacientes, y esto redujo la aparición posterior de fugas anastomóticas. LIMITACIONES Inicialmente, este fue un estudio retrospectivo de un solo centro que no fue aleatorizado ni controlado. En segundo lugar, hubo diferencias cronológicas con respecto al método anastomótico entre los dos grupos. En tercer lugar, nuestro estudio incluyó un número relativamente pequeño de pacientes que recibieron quimiorradioterapia preoperatoria. CONCLUSIONES La anastomosis engrapada reforzada con suturas realizadas a mano dio como resultado menos complicaciones relacionadas con la anastomosis que la anastomosis coloanal suturada a mano después de la excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo; por tanto, el primero puede ser superior y debería ser el método preferido, cuando sea técnicamente posible. Consulte Video Resumen en http://links.lww.com/DCR/B749. (Traducción-Dr. Xavier Delgadillo).
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Brunner M, Zu'bi A, Weber K, Denz A, Langheinrich M, Kersting S, Weber GF, Grützmann R, Krautz C. The use of single-stapling techniques reduces anastomotic complications in minimal-invasive rectal surgery. Int J Colorectal Dis 2022; 37:1601-1609. [PMID: 35704092 PMCID: PMC9262801 DOI: 10.1007/s00384-022-04197-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Leakage of rectal anastomoses is one of the most important and feared complications in colorectal surgery. Apart from patient-specific risk factors, technical aspects may influence the occurrence of anastomotic complications. This study investigated whether using single-stapling techniques (SST) instead of the double-stapling technique (DST) for minimal-invasive rectal anastomosis is associated with a lower rate of anastomotic complications. METHODS A retrospective review of 272 patients who received a minimally invasive stapled rectal anastomosis (3-16 cm from the anal verge) at our institution from 2015 to 2020 was performed. In 131 patients, rectal anastomosis was created by SST (SST group), while 141 patients received a rectal anastomosis with crossing stapler lines (DST group). The impact of the anastomotic technique on patient outcomes was determined by uni- and multivariate analyses. RESULTS Overall anastomotic leakage rate was 6%. Patients with SST anastomoses had a lower leakage rate than patients with DST anastomoses (3% vs. 9% in the DST group, p = 0.045). The rate of anastomotic stenosis was lower in the SST group than in the DST group (1% vs. 6%, p = 0.037). Overall morbidity and mortality did not differ between the two groups. Multivariate analysis showed that single-stapling techniques significantly reduce the risk of anastomotic leakage (OR 3.5 [1.0-11.5], p = 0.043). CONCLUSION The use of SST for rectal anastomosis may help to reduce anastomotic complications. This finding should be confirmed by a randomized controlled trial.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany.
| | - Alaa Zu'bi
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany
| | - Klaus Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany
| | - Melanie Langheinrich
- Department of General, Thoracic and Vascular Surgery, Greifswald University, Ferdinand-Sauerbruch-Straße, VisceralGreifswald, Germany
| | - Stephan Kersting
- Department of General, Thoracic and Vascular Surgery, Greifswald University, Ferdinand-Sauerbruch-Straße, VisceralGreifswald, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, 91054, Germany.
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Campos FG, Pandini RV, Bustamante-Lopez LA, Nahas SC. Surgical Technique and Considerations about Transanal Transection and Single-Stapled (TTSS) Anastomosis: The Search for a Perfect Anastomosis. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractThe evaluation of preventive measures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review the most recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed.
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Affiliation(s)
- Fábio Guilherme Campos
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rafael Vaz Pandini
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Sérgio Carlos Nahas
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Spinelli A, Foppa C, Carvello M, Sacchi M, De Lucia F, Clerico G, Carrano FM, Maroli A, Montorsi M, Heald RJ. Transanal Transection and Single-Stapled Anastomosis (TTSS): A comparison of anastomotic leak rates with the double-stapled technique and with transanal total mesorectal excision (TaTME) for rectal cancer. Eur J Surg Oncol 2021; 47:3123-3129. [PMID: 34384655 DOI: 10.1016/j.ejso.2021.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/04/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND in the literature on rectal cancer (RC) surgery many studies have focused on the quality of total mesorectal excision (TME) dissection, while there is a scarcity of comparative data on transection and anastomosis. No anastomosis has so far proved to be superior to any other. The aim of this study was to compare anastomotic leak (AL) rates between conventional laparoscopic double-stapled (DS), transanal total mesorectal excision (TaTME) and Transanal Transection and Single-Stapled anastomosis (TTSS) techniques. METHODS consecutive mid-low RC patients undergoing elective laparoscopic TME with stapled anastomosis and protective stoma, by either DS, TaTME or TTSS techniques were retrieved from a prospectively collected database. RESULTS 127 DS; 100 TaTME and 50 TTSS were included. Demographics, distance of the tumor from anal verge and neoadjuvant therapy were comparable. Operative time was longer in TaTME over DS and TTSS (p < 0.0001). More 90-days complications occurred in DS group vs TTSS (p = 0.029). The AL rate was 17.5% in DS, 6% in TaTME and 2% in TTSS group (p = 0.005). AL grade was: one B (2%) in TTSS; 2 grade B (2%) and 4 grade C (4%) in TaTME; 6 grade A (4.7%), 7 grade B (5.5%) and 9 grade C (7.1%) in DS group. Reintervention rate after AL was higher in DS group over TTSS (12.6% vs 2%; p = 0.003). The rate of stoma closure, pathology data and margin positivity did not differ. CONCLUSIONS TTSS strategy is feasible, safe and leads to very low AL rates after TME for RC.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Matteo Sacchi
- IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesca De Lucia
- IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Giuseppe Clerico
- IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Maria Carrano
- IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Annalisa Maroli
- IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Division of General and Digestive Surgery, via Manzoni 56, 20089, Rozzano, Milan, Italy
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Park L, Zaghiyan KN, Fleshner PR. Transanal Ileal Pouch: Is It Better? J Laparoendosc Adv Surg Tech A 2021; 31:898-904. [PMID: 34129407 DOI: 10.1089/lap.2021.0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with ulcerative colitis and select patients with Crohn's disease. Minimally invasive techniques have been increasingly adopted including the transanal approach. However there remains a dearth of comparative data assessing the technical advantages and outcomes of a transanal approach to the IPAA against other minimally invasive techniques. Methods: In this review, we describe our learned approach with the transanal IPAA (ta-IPAA) and highlight key technical steps for a successful surgery in addition to evaluating the current literature on surgical and functional outcomes of this relatively novel procedure. Results: The ta-IPAA affords better visualization and access during a pelvic dissection translating to lower conversion rates. Lower odds of postoperative morbidity have been reported, but there was no difference in severity of complications when present. Though this technique has the advantages of a more accurate rectal transection obviating the need for multiple staple firings, the risk of anastomotic leak was similar between the two groups. Functional outcomes were found to be overall similar, though data is limited. Conclusions: The technical aspects of the IPAA have continued to evolve to mitigate the challenges posed by a deep pelvic dissection. While the ta-IPAA has been shown to be a safe and feasible procedure, the true advantages and functional benefits of this technique have yet to be elucidated with large-scale, quality data.
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Affiliation(s)
- Lisa Park
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen N Zaghiyan
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Phillip R Fleshner
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Jiang TY, Zang L, Dong F, Feng B, Zong YP, Sun J, Liu HS, Zheng MH, Ma JJ. Effect of different reinforcement methods on anastomotic leakage prevention after laparoscopic double anastomosis. J Surg Oncol 2021; 123 Suppl 1:S81-S87. [PMID: 33740257 DOI: 10.1002/jso.26333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES To investigate the effects of different suture reinforcement methods for anastomotic leakage and other postoperative complications after the use of a laparoscopic double stapling technique (DST). METHODS We collected the data of 124 patients who underwent laparoscopic radical resection of colorectal cancer from July 2017 to September 2018 at our institution. Patients were divided into three groups according to the suture reinforcement methods: intermittent, continuous suture reinforcement, and non-reinforcement (n = 41, 41, and 42, respectively). One-way analysis of variance, χ2 , Fisher's exact, and nonparametric tests were used for statistical analysis. RESULTS Among the 124 patients, there were no statistically significant differences in operation times, intraoperative blood loss, postoperative hospital stays and recovery of bowel movement. Nine patients were diagnosed with anastomotic leakage (AL). The incidences of serious AL in the intermittent and continuous suture reinforcement groups were lower than that in the control group, with lower reoperation rate, shorter average lengths of stay and lower treatment costs of two experimental groups. CONCLUSION Intermittent and continuous sutures after laparoscopic DST is effective, safe, and feasible on anastomotic leakage prevention. These procedures could be popularized in rectal surgery on patients with high risk of AL.
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Affiliation(s)
- Tian-Yu Jiang
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Lu Zang
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Dong
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Feng
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Ya-Ping Zong
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Sun
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Hai-Shan Liu
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Min-Hua Zheng
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
| | - Jun-Jun Ma
- Department of General Surgery, Shanghai Jiao Tong University, Shanghai, 200025, China.,Shanghai Minimally Invasive Surgery Center, Shanghai Jiao Tong University, Shanghai, China
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Chen J, Zhang Z, Chang W, Yi T, Feng Q, Zhu D, He G, Wei Y. Short-Term and Long-Term Outcomes in Mid and Low Rectal Cancer With Robotic Surgery. Front Oncol 2021; 11:603073. [PMID: 33767981 PMCID: PMC7985529 DOI: 10.3389/fonc.2021.603073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate the risk factors for postoperative complications and anastomotic leakage after robotic surgery for mid and low rectal cancer and their influence on long-term outcomes. Methods A total of 641 patients who underwent radical mid and low rectal cancer robotic surgery at Zhongshan Hospital Fudan University from January 2014 to December 2018 were enrolled in this study. The clinicopathological factors of the patients were collected. The risk factors for short-term outcomes of complications and anastomotic leakage were analyzed, and their influences on recurrence and overall survival were studied. Results Of the 641 patients, 516 (80.5%) underwent AR or LAR procedures, while 125 (19.5%) underwent the NOSES procedure. Only fifteen (2.3%) patients had stoma diversion. One hundred and seventeen patients (17.6%) experienced surgical complications. Anastomotic leakage occurred in 44 patients (6.9%). Eleven patients (1.7%) underwent reoperation within 90 days after surgery. Preoperative radiotherapy did not significantly increase anastomotic leakage in our study (7.4% vs. 6.8%, P = 0.869). The mean postoperative hospital stay was much longer with complication (10.4 vs. 7.1 days, P<0.05) and leakage (12.9 vs. 7.4 days, P < 0.05). Multivariate analysis showed that male sex (OR = 1.855, 95% CI: 1.175–2.923, P < 0.05), tumor distance 5 cm from the anus (OR = 1.563, 95% CI: 1.016–2.404, P < 0.05), and operation time length (OR = 1.563, 95% CI: 1.009–2.421, P < 0.05) were independent risk factors for complications in mid and low rectal cancer patients. The same results for anastomotic leakage: male sex (OR = 2.247, 95% CI: 1.126–4.902, P < 0.05), tumor distance 5 cm from the anus (OR = 2.242, 95% CI: 1.197–4.202, P < 0.05), and operation time length (OR = 2.114, 95% CI: 1.127–3.968, P < 0.05). The 3-year DFS and OS were 82.4% and 92.6% with complication, 88.4% and 94.0% without complication, 88.6% and 93.1% with leakage, and 87.0% and 93.8% without leakage, respectively. The complication and anastomotic leakage showed no significant influences on long-term outcomes. Conclusion Being male, having a lower tumor location, and having a prolonged operation time were independent risk factors for complications and anastomotic leakage in mid and low rectal cancer. Complications and anastomotic leakage might have no long-term impact on oncological outcomes for mid and low rectal cancer with robotic surgery.
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Affiliation(s)
- Jingwen Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenju Chang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tuo Yi
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qingyang Feng
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dexiang Zhu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guodong He
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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McKechnie T, Sharma S, Daniel R, Eskicioglu C. End-to-end versus end-to-side anastomosis for low anterior resection: A systematic review and meta-analysis of randomized controlled trials. Surgery 2021; 170:397-404. [PMID: 33541747 DOI: 10.1016/j.surg.2020.12.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Numerous randomized controlled trials comparing end-to-end and end-to-side anastomoses after low anterior resection have been performed. Rates of anastomotic leakage and overall postoperative morbidity, as well as reported quality of postoperative bowel function, vary across individual studies. As such, this study meta-analyzes pooled data comparing end-to-end and end-to-side anastomosis after low anterior resection in terms of anastomotic leak rate and postoperative bowel function. METHODS A search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials was performed. Articles were included if they were randomized controlled trials that compared end-to-end and end-to-side anastomosis after low anterior resection for benign or malignant disease. The primary outcome was anastomotic leak rate. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS From 1,452 citations, 6 randomized controlled trials with 270 patients undergoing end-to-end anastomosis (45.9% female, mean age: 63.5 years) and 268 patients undergoing end-to-side anastomosis (52.4% female, mean age: 64.0 years) met inclusion criteria. Patients undergoing end-to-side anastomosis had a significantly lower rate of anastomotic leak (RR 0.37, 95% CI 0.15-0.93, P = .04, I2=0%). There were no differences in rate of anastomotic stenosis (RR 1.03, 95% CI 0.21-5.19, P = .97) or overall postoperative morbidity (RR 0.60, 95% CI 0.33-1.07, P = .08). Narrative review of postoperative bowel function demonstrated evidence of improved Wexner scores for 6 months postoperatively in patients undergoing end-to-side anastomosis. CONCLUSION End-to-side anastomosis significantly reduces the risk of anastomotic leak after low anterior resection. Additional prospective trials are warranted to confirm the findings of this review and to contribute to the growing evidence-base aimed at optimization of bowel function after low anterior resection.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. https://twitter.com/tylermckechnie
| | - Sahil Sharma
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. https://twitter.com/SharmaS_14
| | - Ryan Daniel
- University of Toronto, Temerty Faculty of Medicine, Toronto, ON, Canada. https://twitter.com/ryandaniel82
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
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Capolupo GT, Carannante F, Mascianà G, Lauricella S, Mazzotta E, Caricato M. Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre. BMC Surg 2021; 21:17. [PMID: 33407354 PMCID: PMC7789388 DOI: 10.1186/s12893-020-01007-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/08/2020] [Indexed: 12/18/2022] Open
Abstract
Background Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes. Methods Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed. Results Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data. Conclusions In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.
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Affiliation(s)
- G T Capolupo
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - F Carannante
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy.
| | - G Mascianà
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - S Lauricella
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - E Mazzotta
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - M Caricato
- Department of Colorectal Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy
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Sasaki K, Omoto I, Uchikado Y, Okumura H, Noda M, Tsuruda Y, Kita Y, Arigami T, Mori S, Kurahara H, Nakajyo A, Koriyama C, Natsugoe S, Ohtsuka T. Comparison of greater curvature and lesser curvature circular-stapled esophagogastrostomy after esophagectomy in patients with esophageal cancer: a prospective randomized controlled trial. Surg Today 2020; 51:575-581. [PMID: 32974752 DOI: 10.1007/s00595-020-02147-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Using a circular stapler to create an anastomosis for esophagogastrostomy after esophagectomy is well accepted; however, it remains uncertain if the greater curvature (GC) or lesser curvature (LC) of the gastric conduit is better for the anastomosis. We conducted this prospective study to compare the integrity of esophagogastrostomy between the esophagus and the GC or LC side of the gastric conduit. METHODS The subjects of this study were 70 patients who underwent esophagectomy and were randomized to a "GC" group and an "LC" group (n = 35 each). The primary and secondary end points were anastomotic leakage (AL) and anastomotic stricture (AS), respectively. RESULTS The overall AL rate was 22.1%, without a significant difference between the groups. Stump leakage developed in eight of nine patients in the GC group, whereas leakage developed at the esophagogastric anastomosis in five of six patients in the LC group. The rate of stump leakage was significantly higher than that of esophagogastric AL in the GC group. The overall AS rate was 4.4%, with a significant difference between the groups (0% in the GC group vs. 9.1% in the LC group). CONCLUSIONS AL rates were comparable in the two groups, but the sites of leakage were significantly different.
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Affiliation(s)
- Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
| | - Itaru Omoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Hiroshi Okumura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Masahiro Noda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yusuke Tsuruda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Akihiro Nakajyo
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
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A comparative cost analysis of transanal and laparoscopic total mesorectal excision for rectal cancer. Updates Surg 2020; 73:85-91. [PMID: 32929690 DOI: 10.1007/s13304-020-00879-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Despite proven clinical benefits in the short term, technical difficulties limit utilization of laparoscopy in rectal cancer surgery (RCS). Transanal Total Mesorectal Excision (taTME) overcomes many technical limitations of laparoscopic RCS. However, the costs of this procedure have not been addressed yet. Our goal was to perform a comparative cost analysis of taTME and laparoscopic TME (lapTME). Consecutive patients undergoing curative TME between 1 February 2014 and 31 October 2018 were selected from a prospectively maintained database and stratified, according to the type of procedure, into taTME and lapTME groups. Patient demographics, tumour characteristics, operative parameters, and short-term outcomes were analyzed. The main outcome measure was intraoperative costs of the two procedures. Secondary outcomes were short-term outcome and the utilization of hospital resources to manage the postoperative course. Hundred and fifty-two patients with rectal cancer (66 lapTME, 86 taTME) were included in the study. Surgical supplies required for taTME procedure exceeded the cost of lapTME of 754,54 €. The duration of surgery was not significantly different between the two approaches (266 ± 92.85 vs 271 ± 83.63, p = 0.50). Short-term outcomes were comparable including postoperative complication rate (17 vs 20%, p = 0.68), reintervention rate, and length of stay. There was no difference in hospital resources utilization to manage postoperative course including blood test, diagnostics, consultations, and medications. TaTME has higher intraoperative costs in terms of supplies with respect to lapTME. Short-term outcomes and hospital resources to manage postoperative course are comparable.
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Chang W, Liu T, Ren L, He G, Ji M, Jian M, Chen Y, Liang F, Wei Y, Xu J. A trinity technique for prevention of low rectal anastomotic leakage in the robotic era. Eur J Surg Oncol 2020; 46:e47-e54. [PMID: 32900608 DOI: 10.1016/j.ejso.2020.07.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/17/2020] [Accepted: 07/30/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a severe complication of low anterior resection (LAR) for rectal cancer, and effective prevention is urgently needed. In the robotic era, this study aimed to explore the role of innovative techniques in preventing AL in rectal cancer patients undergoing robotic LAR. METHODS From May 2012 to May 2017, a total of 601 patients underwent robotic LAR, with 191 patients participated as control subjects (non-PST group) and 410 patients are subjected to a trinity technique (PST group). The AL rate, short-term and long-term outcomes are analyzed and compared. RESULTS The overall rate of AL was 6.8% out of 601 patients, with Grade B at 5.7% and Grade C at 1.1%, using the ISREC grading system. The PST group presented lower incidence of both overall AL (5.1% vs 10.5%, P = 0.015) and major AL (0.2% vs 3.2%, P = 0.005), when compared with the non-PST group, respectively. Furthermore, the PST group had similar surgical complications (17.3% vs 20.9%, P = 0.286), while with lower re-hospitalization rate (2.7% vs 6.3%, P = 0.038) and reoperation rate (0.2% vs 4.2%, P = 0.001), compared with the non-PST group, respectively. Short-term recovery and long-term oncological outcomes were not significant in the two groups. By multivariate logistic regression models, the risk factors of AL of robotic LAR are confirmed as non-PST technique, estimated blood loss ≥100 mL, anastomosis from anal verge <5 cm, and distal resection margin from tumor <2 cm. CONCLUSIONS The innovative PST technique may shed light on an effective method for preventing occurrence of AL in robotic LAR.
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Affiliation(s)
- Wenju Chang
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive Technology, Shanghai, 200032, China
| | - Tianyu Liu
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Li Ren
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive Technology, Shanghai, 200032, China
| | - Guodong He
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive Technology, Shanghai, 200032, China
| | - Meiling Ji
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Mi Jian
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yijiao Chen
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Fei Liang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, 20032, China
| | - Ye Wei
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive Technology, Shanghai, 200032, China.
| | - Jianmin Xu
- Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China; Shanghai Engineering Research Cancer of Colorectal Cancer Minimally Invasive Technology, Shanghai, 200032, China.
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Valmasoni M, Capovilla G, Pierobon ES, Moletta L, Provenzano L, Costantini M, Salvador R, Merigliano S. A Technical Modification to the Circular Stapling Anastomosis Technique During Minimally Invasive Ivor Lewis Procedure. J Laparoendosc Adv Surg Tech A 2019; 29:1585-1591. [PMID: 31580751 DOI: 10.1089/lap.2019.0461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophagogastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient, and highly reproducible; however, the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog-ears and, therefore, increase the risk of anastomotic leak (AL). We describe a simple modification of the CS technique that consists of folding the linear esophageal transection line with a stitch around the anvil shaft, to include the staple line in the resection during the EEA™ firing. Methods: We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Feasibility has been evaluated as the percentage of cases in which the modified anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure-related complications. Results: MIE was performed in 10 patients using our modified CS technique. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complications. Only one patient developed a postoperative AL that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusion: Our modified CS technique is feasible and did successfully prevent the occurrence of clinically relevant ALs in this small case series of patients.
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Affiliation(s)
- Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Elisa Sefora Pierobon
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
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Foo CC, Hung HT, Ho YC, Lam WWM, Law WL. Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision. Surg Endosc 2019; 34:3382-3387. [PMID: 31506793 DOI: 10.1007/s00464-019-07112-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The transection of rectum and fashioning of anastomosis is a crucial step in laparoscopic total mesorectal excision (TME) and the double-stapling technique (DST) is often employed. This study aimed to evaluate the factors that were associated with difficult DST. METHOD Cases of laparoscopic TME were retrospectively reviewed. The clinico-anatomical parameters were retrieved from a prospectively maintained database. In addition, pelvic dimensions were taken by reviewing the magnetic resonance imaging scan. The number of stapler cartridges used for intracorporeal transection of rectum was used as a surrogate for the level of difficulty of DST and its relationship with various parameters were evaluated. RESULTS There were a total of 121 consecutive cases analyzed. The mean number of stapler cartridges used was 2.1 ± 0.7. Pelvic inlet (p = 0.002) and tumor height (p = 0.015) were predictors of the number of cartridges used, R2 = 0.366. A model was developed to predict the likelihood of transecting the rectum with two or less stapler cartridges, which included the following parameters: gender, pelvic inlet, interspinous distance, intertuberous distance, and tumor height. The predicted probability also correlated with overall operation time (p = 0.009) and anastomotic leakage (p = 0.023). CONCLUSION The difficulty of DST was associated with patient's clinico-anatomical factors. Surgeons can consider other feasible alternatives, like transanal anastomosis, when a technically challenging DST is anticipated.
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Affiliation(s)
- Chi Chung Foo
- Department of Surgery, The University of Hong Kong, Hong Kong, China. .,Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
| | - Hing Tsun Hung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Yuen Chi Ho
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | | | - Wai Lun Law
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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Yin Z, Zheng B, Wei M, Zhai Y, Zhou S, Zhang B, Wu T, Qiao Q, Wang N, He X. b-Shaped Laparoscopic Dual Anastomosis for Mid-Low Rectal Cancer: A Safe and Feasible Technique. J Laparoendosc Adv Surg Tech A 2019; 29:1174-1179. [PMID: 31233371 DOI: 10.1089/lap.2019.0081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Zhiyuan Yin
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Bobo Zheng
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingguang Wei
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Yulong Zhai
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Shuai Zhou
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Bo Zhang
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Tao Wu
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Qing Qiao
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Nan Wang
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
| | - Xianli He
- Department of General Surgery, Tangdu Hospital, Airforce Military Medical University, Xi'an, China
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Spinelli A, Carvello M, D'Hoore A, Foppa C. Integration of transanal techniques for precise rectal transection and single-stapled anastomosis: a proof of concept study. Colorectal Dis 2019; 21:841-846. [PMID: 30943327 DOI: 10.1111/codi.14631] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/16/2019] [Indexed: 02/08/2023]
Abstract
AIM Transection of the distal rectum and subsequent anastomosis differ between the open, minimally invasive and transanal approaches. With the transanal technique, there is direct control of the transection level and the single-stapled anastomosis, thus overcoming two crucial limitations of rectal surgery. This study describes a technique for precise a transanal rectal transection with a single-stapled (TTSS) colorectal, coloanal or ileoanal anastomosis in 20 consecutive patients undergoing low rectal surgery. METHODS After completing rectal dissection by the preferred technique (open or minimally invasive), TTSS was created. The detailed video describes this technique. RESULTS TTSS was feasible in all patients: 13 underwent total mesorectal excision + TTSS for low rectal cancer and seven underwent ileoanal pouch + TTSS for benign disease. Complications included one Grade IIIa and three Grade I, according to the Clavien-Dindo classification (median follow-up 6 months). CONCLUSION TTSS represents a technique which can be applied regardless of the preferred approach (open, minimally invasive or transanal) for low rectal dissection. The adoption of TTSS could well allow for a more consistent comparison of the outcomes following the differing approaches to rectal surgery.
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Affiliation(s)
- A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - M Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Leuven, Belgium
| | - C Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
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The current state of the transanal approach to the ileal pouch-anal anastomosis. Surg Endosc 2019; 33:1368-1375. [PMID: 30675660 DOI: 10.1007/s00464-019-06674-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The transanal approach to pelvic dissection has gained considerable traction and utilization continues to expand, fueled by the transanal total mesorectal excision (TaTME) for rectal cancer. The same principles and benefits of transanal pelvic dissection may apply to the transanal restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)-the TaPouch procedure. Our goal was to review the literature to date on the development and current state of the TaPouch. MATERIALS AND METHODS We performed a PubMed database search for original articles on transanal pelvic dissections, IPAA, and the TaPouch procedure, with a manual search from relevant citations in the reference list. The main outcomes were the technical aspects of the TaPouch, clinical and functional outcomes, and potential advantages, drawbacks, and future direction for the procedure. RESULTS The conduct of the procedure has been defined, with the safety and feasibility demonstrated in small series. The reported rates of conversion and anastomotic leakage are low. There are no randomized trials or large-scale comparative studies available for comparative effectiveness compared to the traditional IPAA. CONCLUSIONS The transanal approach to ileal pouch-anal anastomosis is an exciting adaption of the transanal total mesorectal excision for refining the technical steps of a complex operation. Additional experience is needed for comparative outcomes and defining the ideal training and implementation pathways.
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43
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Foppa C, Sacchi M, Spinelli A. The reverse smile trick: how to transform a double-stapled anastomosis into a single-stapled anastomosis - a video vignette. Colorectal Dis 2018; 20:1054-1055. [PMID: 30216621 DOI: 10.1111/codi.14419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/30/2018] [Indexed: 02/08/2023]
Affiliation(s)
- C Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - M Sacchi
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
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The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery. Surg Laparosc Endosc Percutan Tech 2018; 27:273-281. [PMID: 28614172 PMCID: PMC5542784 DOI: 10.1097/sle.0000000000000422] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose: Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery. Materials and Methods: In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups. Results: Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis. Conclusions: The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.
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Crafa F, Smolarek S, Missori G, Shalaby M, Quaresima S, Noviello A, Cassini D, Ascenzi P, Franceschilli L, Delrio P, Baldazzi G, Giampiero U, Megevand J, Maria Romano G, Sileri P. Transanal Inspection and Management of Low Colorectal Anastomosis Performed With a New Technique: the TICRANT Study. Surg Innov 2017; 24:483-491. [PMID: 28514887 DOI: 10.1177/1553350617709182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anastomotic leakage is one of the most serious complications after rectal cancer surgery. METHOD A prospective multicenter interventional study to assess a newly described technique of creating the colorectal and coloanal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak. RESULT Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included in the study. There were 35 males and 18 females, with a median age of 68 years (range = 49-89 years). The median tumor distance from the anal verge was 8 cm (range = 4-12 cm), and the median body mass index was 24 kg/m2 (range = 20-35 kg/m2). Thirty patients underwent open, 16 laparoscopic, and 7 robotic surgeries. Multiple firing (2-charges) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colorectal anastomosis, and 8 patients had coloanal anastomosis. The protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with transanal drainage and intravenous antibiotics. One patient required reoperation and ileostomy. The median length of hospital stay was 10 days (range = 4-20 days). CONCLUSION Our technique is a safe and efficient method of creation of colorectal anastomosis. It is also a universal method that can be used in open, laparoscopic, and robotic surgeries.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paolo Delrio
- 5 Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale," Naples, Italy
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Kawada K, Sakai Y. Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis. World J Gastroenterol 2016; 22:5718-5727. [PMID: 27433085 PMCID: PMC4932207 DOI: 10.3748/wjg.v22.i25.5718] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/30/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.
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Laparoscopic double-stapled colorectal anastomosis without "dog-ears". Tech Coloproctol 2016; 20:243-7. [PMID: 26902367 DOI: 10.1007/s10151-016-1437-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
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Zhuo C, Liang L, Ying M, Li Q, Li D, Li Y, Peng J, Huang L, Cai S, Li X. Laparoscopic Low Anterior Resection and Eversion Technique Combined With a Nondog Ear Anastomosis for Mid- and Distal Rectal Neoplasms: A Preliminary and Feasibility Study. Medicine (Baltimore) 2015; 94:e2285. [PMID: 26683958 PMCID: PMC5058930 DOI: 10.1097/md.0000000000002285] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The transanal eversion and prolapsing technique is a well-established procedure, and can ensure an adequate distal margin for patients with low rectal neoplasms. Potential leakage risks, however, are associated with bilateral dog ear formation, which results from traditional double-stapling anastomosis. The authors determined the feasibility of combining these techniques with a commercial stapling set to achieve a nondog ear (end-to-end) anastomosis for patients with mid- and distal rectal neoplasms. Patients with early-stage (c/ycT1-2N0), mid- to distal rectal neoplasms and good anal sphincter function were included in this study. Laparoscopic low anterior resection was performed with a standard total mesorectal excision technique downward to the pelvic floor as low as possible. The bowel was resected proximal to the lesion with an endoscopic linear stapler. An anvil was inserted extracorporeally into the proximal colon via an extended working pore. The distal rectum coupled with the lesion was prolapsed and everted out of the anus. The neoplasm was resected with a sufficient margin above the dentate line under direct sight. A transrectal anastomosis without dog ears was performed intracorporeally to reconstitute the continuity of the bowel. Eleven cases, 6 male and 5 female patients, were included in this study. The mean operative time was 191 (129-292) minutes. The mean blood loss was 110 (30-300) mL. The median distal margin distance from the lower edge of the lesion to the dentate line was 1.5 (0.5-2.5) cm. All the resection margins were negative. Most patients experienced uneventful postoperative recoveries. No patient had anastomotic leak. Most patients had an acceptable stool frequency after loop ileostomy closure. Our preliminary data demonstrated the safety and feasibility of achieving a sound anastomosis without risking potential anastomotic leakage because of dog ear formation.
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Affiliation(s)
- Changhua Zhuo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center (CZ, LL, QL, DL, YL, JP, LH, SC, XL); Department of Oncology, Shanghai Medical College, Fudan University, Shanghai (CZ, LL, QL, DL, YL, JP, LH, SC, XL); and Department of Surgical Oncology, Fujian Provincial Cancer Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, China (CZ, MY)
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49
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Endoscopic evaluation of clinical colorectal anastomotic leakage. J Surg Res 2015; 193:126-34. [DOI: 10.1016/j.jss.2014.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/25/2014] [Accepted: 07/02/2014] [Indexed: 01/18/2023]
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50
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Ikeda T, Kumashiro R, Oki E, Taketani K, Ando K, Aishima S, Akahoshi T, Morita M, Maehara Y. Evaluation of techniques to prevent colorectal anastomotic leakage. J Surg Res 2014; 194:450-457. [PMID: 25544478 DOI: 10.1016/j.jss.2014.11.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/14/2014] [Accepted: 11/26/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a major complication after anterior resection for rectal cancer. The double-stapling technique (DST) is the main method for creating a colorectal anastomosis. However, the rate of anastomotic leakage after DST remains high, and the technical risk factors have not been well established. MATERIALS AND METHODS Five methods of colorectal anastomosis were performed on the porcine rectum and colon: single-stapled double-purse-string (SSDP), DST, side-to-side with a linear stapler (SS-L), side-to-side with a circular stapler (SS-C), and SS-C with hand-sewn reinforcement (n = 6 for each method). In each group, burst pressures were tested, paying special attention to the locations of the first disruptions. The anastomosis line, including staples, was embedded in polyester resin, and polished sections were examined histologically. RESULTS Burst pressures were significantly higher in the SS-L and SS-C than those in the SSDP and DST groups (P < 0.001) and were higher in the SS-C with hand-sewn reinforcement than those in the SS-L and SS-C groups (P < 0.001). Remarkably, in the SSDP, DST, and SS-C groups, the first disruptions occurred on the staple line created by the circular stapler. CONCLUSIONS The experimentally strongest colorectal anastomosis created with instruments currently in use was a SS-C. This anastomosis does not overlap staple lines and does not require a purse-string suture. Hand-sewn reinforcement was effective in increasing the anastomotic strength.
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Affiliation(s)
- Tetsuo Ikeda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Ryuichi Kumashiro
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eiji Oki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Taketani
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Ando
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichi Aishima
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohiko Akahoshi
- Department of Integration of Advanced Medicine, Life Science and Innovative Technology, Kyushu University, Fukuoka, Japan
| | - Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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