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Lucarini A, Guida AM, Orville M, Panis Y. Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials. Colorectal Dis 2024; 26:408-416. [PMID: 38247221 DOI: 10.1111/codi.16868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/17/2023] [Accepted: 12/24/2023] [Indexed: 01/23/2024]
Abstract
AIM Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery. METHOD PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool. RESULTS Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG. CONCLUSION Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.
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Affiliation(s)
- Alessio Lucarini
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Martina Guida
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
- Department of Surgical Science, University Tor Vergata, Rome, Italy
| | - Marion Orville
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
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2
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Caminsky NG, Moon J, Morin N, Alavi K, Auer RC, Bordeianou LG, Chadi SA, Drolet S, Ghuman A, Liberman AS, MacLean T, Paquette IM, Park J, Patel S, Steele SR, Sylla P, Wexner SD, Vasilevsky CA, Rajabiyazdi F, Boutros M. Patient and surgeon preferences for early ileostomy closure following restorative proctectomy for rectal cancer: why aren't we doing it? Surg Endosc 2023; 37:669-682. [PMID: 36195816 DOI: 10.1007/s00464-022-09580-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 08/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early ileostomy closure (EIC), ≤ 2 weeks from creation, is a relatively new practice. Multiple studies have demonstrated that this approach is safe, feasible, and cost-effective. Despite the demonstrated benefits, this is neither routine practice, nor has it been studied, in North America. This study aimed to assess patient and surgeon perspectives about EIC. METHODS A mixed-methods, cross-sectional study of patients and surgeons was performed. Rectal cancer survivors from a single institution who underwent restorative proctectomy with diverting loop ileostomy and subsequent closure within the last 5 years were contacted. North American surgeons with high rectal cancer volumes (> 20 cases/year) were included. Surveys (patients) and semi-structured interviews (surgeons) were conducted. Analysis employed descriptive statistics and thematic analysis, respectively. RESULTS Forty-eight patients were surveyed (mean age 65.1 ± 11.8 years; 54.2% male). Stoma closure occurred after a median of 7.7 months (IQR 4.8-10.9) and 50.0% (24) found it "difficult" or "very difficult" to live with their stoma. Patients considered improvement in quality of life and quicker return to normal function the most important advantages of EIC, whereas the idea of two operations in two weeks being too taxing on the body was deemed the biggest disadvantage. Most patients (35, 72.9%) would have opted for EIC. Surgeon interviews (15) revealed 4 overarching themes: (1) there are many benefits to EIC; (2) specific patient characteristics would make EIC an appropriate option; (3) many barriers to implementing EIC exist; and (4) many logistical hurdles need to be addressed for successful implementation. Most surgeons (12, 80.0%) would "definitely want to participate" in a North American randomized-controlled trial (RCT) on EIC for rectal cancer patients. CONCLUSIONS Implementing EIC poses many logistical challenges. Both patients and surgeons are interested in further exploring EIC and believe it warrants a North American RCT to motivate a change in practice.
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Affiliation(s)
- Natasha G Caminsky
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Jeongyoon Moon
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, MA, USA
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Liliana G Bordeianou
- Department of Surgery, Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sami A Chadi
- Minimally Invasive and Colorectal Surgery, University Health Network and Princess Margaret Hospital, Toronto, ON, Canada
| | - Sébastien Drolet
- Department of Surgery, Centre Hospitalier Universitaire (CHU) de Québec, Laval University, Quebec City, QC, Canada
| | - Amandeep Ghuman
- Division of Colon and Rectal Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Alexander Sender Liberman
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Tony MacLean
- Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jason Park
- Department of Surgery, St. Boniface General Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Sunil Patel
- Department of Surgery, Queens University, Kingston, ON, Canada
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Marylise Boutros
- Department of Surgery, Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada. .,Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC, Canada.
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3
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Mathew AP, M S, K C, Muralee M, Wagh M. Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer. Indian J Surg Oncol 2022; 13:468-473. [PMID: 36187539 PMCID: PMC9515269 DOI: 10.1007/s13193-022-01501-1] [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: 07/20/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.
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Affiliation(s)
- Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Srinidhi M
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Chandramohan K
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
| | - Mira Wagh
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum, India
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Sciuto A, Peltrini R, Andreoli F, Di Santo Albini AG, Di Nuzzo MM, Pirozzi N, Filotico M, Lauria F, Boccia G, D’Ambra M, Lionetti R, De Werra C, Pirozzi F, Corcione F. Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases. J Clin Med 2022; 11:jcm11092632. [PMID: 35566757 PMCID: PMC9104879 DOI: 10.3390/jcm11092632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.
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Affiliation(s)
- Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
- Department of Electrical Engineering and Information Technology, University of Naples Federico II, 80125 Naples, Italy
- Correspondence:
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Andreoli
- Department of Minimally Invasive Surgery, Cristo Re Hospital, 00167 Rome, Italy;
| | - Andrea Gianmario Di Santo Albini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Nello Pirozzi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Giuseppe Boccia
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
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5
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Kostov G, Dimov R, Doykov M. Diverting ileostomy in low anterior resection: single center retrospective analysis. POLISH JOURNAL OF SURGERY 2022; 94:26-32. [DOI: 10.5604/01.3001.0015.8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b> Introduction:</b> Low anterior resection (LAR) is the standard procedure for distal rectal cancer allowing anal sphincter preservation. Anastomotic leakage remains one of the most dangerous complications following LAR and its management is difficult. </br></br> <b>Aim:</b> This study reviews our experience of LAR with and without protective ileostomy (PI). </br></br> <b> Methods:</b> One hundred ninety-nine patients undergoing LAR resection for low rectal cancer in this centre during the period 2015–2019 were divided retrospectively into two groups. Group A underwent rectal resection and coloanal/rectal anastomosis with diverting ileostomy and group B without ileostomy. </br></br> <b> Results:</b> Among our patients, 20 had a covering ileostomy (stoma group);179 did not (control group). The stoma group comprised 14 men and 6 women ranging in age from 36 to 89 years (mean, 64.2 ± 10.5 years). Conventional v. minimally invasive surgery was 6/14. Anastomotic leakage occurred in 16/179 (8.93%) patients without a PI, and in 6/20 (30%) with a stoma (Tab. I.). Of the 16 patients experiencing an anastomotic leak, 3 (18.75%) from Group A and 5 (83.33%) from Group B were classified as Grade B leakage and were treated conservatively. As many as 13/16 (81.25%) in Group A and 1/6 (16.77%) in Group B were classified as Grade C leakage and required emergency surgery. </br></br> <b>Conclusion:</b> These results do not show a preventive effect on the occurrence of anastomotic leakage in low anterior resection, but may significantly reduce the need for further surgery due to septic complications in the early postoperative period. Selection of patients for protective ileostomy requires great care as its creation and closure are associated with severe complications.
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Affiliation(s)
- Gancho Kostov
- Department of Special Surgery, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
| | - Rosen Dimov
- Department of Special Surgery, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
| | - Mladen Doykov
- Department of Urology and General Medicine, Medical University - Plovdiv, Bulgaria, University Hospital “Kaspela” - Plovdiv, Bulgaria
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6
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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7
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Warps ALK, Tollenaar RAEM, Tanis PJ, Dekker JWT. Time interval between rectal cancer resection and reintervention for anastomotic leakage and the impact of a defunctioning stoma: A Dutch population-based study. Colorectal Dis 2021; 23:2937-2947. [PMID: 34407272 DOI: 10.1111/codi.15878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/01/2023]
Abstract
AIM In the Netherlands, a selective policy of faecal diversion after rectal cancer surgery is generally applied. This study aimed to evaluate the timing, type, and short-term outcomes of reoperation for anastomotic leakage after primary rectal cancer resection stratified for a defunctioning stoma. METHOD Data of all patients who underwent primary rectal cancer surgery with primary anastomosis from 2013-2019 were extracted from the Dutch ColoRectal Audit. Primary outcomes were new stoma construction, mortality, ICU admission, prolonged hospital stay, and readmission. RESULTS In total, 10,772 rectal cancer patients who underwent surgery with primary anastomosis were included, of whom 46.6% received a primary defunctioning stoma. The reintervention rate for anastomotic leakage was 8.2% and 11.6% for patients with and without a defunctioning stoma (p < 0.001). Reintervention consisted of reoperation in 44.0% and 85.3% (p < 0.001), with a median time interval from primary resection to reoperation of seven days (IQR 4-14) vs. five days (IQR 3-13), respectively. In the presence of a defunctioning stoma, early reoperation (<5 days; n = 47) was associated with significantly more end-colostomy construction (51% vs. 33%) and ICU admission (66% vs. 38%) than late reoperation (≥5 days; n = 127). Without defunctioning stoma, early reoperation (n = 252) was associated with significantly higher mortality (4% vs. 1%), and more ICU admissions (52% vs.34%) than late reoperation (n = 302). CONCLUSIONS Early reoperations after rectal cancer resection are associated with worse outcomes reflected by a more frequent ICU admission in general, more colostomy construction, and higher mortality in patients with primary defunctioned and nondefunctioned anastomosis.
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Affiliation(s)
- Anne-Loes K Warps
- Department of Surgery, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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8
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Yoon BJ, Oh HK, Lee J, Cho JR, Kim MJ, Kim DW, Kang SB. Effects of probiotics on bowel function restoration following ileostomy closure in rectal cancer patients: a randomized controlled trial. Colorectal Dis 2021; 23:901-910. [PMID: 33247529 DOI: 10.1111/codi.15463] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/14/2020] [Accepted: 11/17/2020] [Indexed: 12/13/2022]
Abstract
AIM The aim was to determine the efficacy of probiotics in restoring bowel function following ileostomy reversal in patients with rectal cancer. METHOD This was a pilot, randomized, double-blind, placebo-controlled trial. The probiotic used in this study, Lactobacillus plantarum CJLP243, was derived from kimchi. Patients were randomly allocated to a probiotic or placebo group and medication was taken once daily from preoperative day 1 to day 21. Primary outcomes were the Memorial Sloan Kettering Cancer Centre Bowel Function Index (MSKCC BFI) instrument and the low anterior resection syndrome score. The secondary outcomes were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and CR29 questionnaire responses. RESULTS Forty patients were enrolled, and 36 patients (probiotics, n = 17; placebo, n = 19) completed the primary outcomes. Total scores for the MSKCC questionnaire (56.2 ± 12.0 vs. 55.0 ± 10.7, P = 0.356) and low anterior resection syndrome scores (33.3 ± 7.6 vs. 36.0 ± 5.3, P = 0.257) were not significantly different between the probiotic and placebo groups, respectively. In the MSKCC BFI, the postoperative dietary scale score at week 1 was significantly higher in the probiotic group (13.1 ± 3.8 vs. 9.0 ± 3.0, P < 0.001). There were no other significant differences between the two groups for any other questionnaire scores. CONCLUSION There were no significant effects supporting the use of a probiotic for improved bowel function in patients following ileostomy reversal. Nevertheless, the administration of probiotics showed trends toward improvements in some subscale bowel function measures, suggesting further studies may be warranted.
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Affiliation(s)
- Byung Jun Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeehye Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Rae Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myung Jo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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9
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Kryzauskas M, Bausys A, Degutyte AE, Abeciunas V, Poskus E, Bausys R, Dulskas A, Strupas K, Poskus T. Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery. World J Surg Oncol 2020; 18:205. [PMID: 32795348 PMCID: PMC7427291 DOI: 10.1186/s12957-020-01968-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/23/2020] [Indexed: 02/03/2023] Open
Abstract
Background Anastomotic leakage (AL) significantly impairs short-term outcomes. The impact on the long-term outcomes remains unclear. This study aimed to identify the risk factors for AL and the impact on long-term survival in patients with left-sided colorectal cancer. Methods Nine-hundred patients with left-sided colorectal carcinoma who underwent sigmoid or rectal resection were enrolled in the study. Risk factors for AL after sigmoid or rectal resection were identified, and long-term outcomes of patients with and without AL were compared. Results AL rates following sigmoid and rectal resection were 5.1% and 10.7%, respectively. Higher ASA score (III–IV; OR = 10.54, p = 0.007) was associated with AL in patients undergoing sigmoid surgery on multivariable analysis. Male sex (OR = 2.40, p = 0.004), CCI score > 5 (OR = 1.72, p = 0.025), and T3/T4 stage tumors (OR = 2.25, p = 0.017) were risk factors for AL after rectal resection on multivariable analysis. AL impaired disease-free and overall survival in patients undergoing sigmoid (p = 0.009 and p = 0.001) and rectal (p = 0.003 and p = 0.014) surgery. Conclusion ASA score of III–IV is an independent risk factor for AL after sigmoid surgery, and male sex, higher CCI score, and advanced T stage are risk factors for AL after rectal surgery. AL impairs the long-term survival in patients undergoing left-sided colorectal surgery.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Vilius Abeciunas
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania.
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rimantas Bausys
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania
| | - Audrius Dulskas
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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10
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Kitaguchi D, Enomoto T, Ohara Y, Owada Y, Hisakura K, Akashi Y, Takahashi K, Ogawa K, Shimomura O, Oda T. Exploring optimal examination to detect occult anastomotic leakage after rectal resection in patients with diverting stoma. BMC Surg 2020; 20:53. [PMID: 32192490 PMCID: PMC7081590 DOI: 10.1186/s12893-020-00706-x] [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: 11/29/2019] [Accepted: 02/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage. Methods This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7. Results The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate. Conclusions Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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11
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Chapman WC, Subramanian M, Jayarajan S, Makhdoom B, Mutch MG, Hunt S, Silviera ML, Glasgow SC, Olsen MA, Wise PE. First, Do No Harm: Rethinking Routine Diversion in Sphincter-Preserving Rectal Cancer Resection. J Am Coll Surg 2019; 228:547-556.e8. [PMID: 30639302 DOI: 10.1016/j.jamcollsurg.2018.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures. STUDY DESIGN The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated. RESULTS Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01). CONCLUSIONS No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.
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Affiliation(s)
- William C Chapman
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO.
| | - Melanie Subramanian
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Senthil Jayarajan
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Bilal Makhdoom
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Matthew G Mutch
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Steven Hunt
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Matthew L Silviera
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Sean C Glasgow
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
| | - Margaret A Olsen
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO
| | - Paul E Wise
- Department of Surgery, Division of General Surgery, Washington University School of Medicine, St Louis, MO
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12
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Fecal diverting device for the substitution of defunctioning stoma: preliminary clinical study. Surg Endosc 2019; 33:333-340. [PMID: 30109482 PMCID: PMC6336740 DOI: 10.1007/s00464-018-6389-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND A novel fecal diverting device (FDD) made for the prevention of sepsis resulting from anastomotic leakage (AL) was tested successfully in an animal study. This study was undertaken to evaluate the clinical safety and effectiveness of the FDD. METHODS A prospective observation trial was implemented in a tertiary referral university hospital. The study enrolled patients who needed a defunctioning stoma to preserve low-lying rectal anastomosis. The FDD was fixed to the proximal colon 15 cm from the anastomosis and scheduled to divert feces for 3 weeks. The duration could be extended for more than 3 weeks if AL was noted. Postoperative evaluations of AL were performed by obtaining a computed tomography (CT) scan after 1 week and a contrast study after 3 weeks. The outcomes were FDD-related complications, and the capacity of the FDD to preserve the anastomosis. The median follow-up period was 10 (range 5-40) months. RESULTS Thirty-one patients, including 5 benign cases, were evaluated. There was no case of stoma conversion or surgical re-intervention. Evidence of AL was identified in 10 (32%) patients using the CT scan at 1 week after surgery. However, in the contrast study at 3 weeks after surgery, only 5 cases of AL sinus were noted. Conservative treatments including 1-3 weeks prolongation of FDD maintenance were enough to preserve the anastomosis. There were 3 cases of partial colonic wall erosions at the FDD attachment area. All of these patients showed improvement with conservative treatment. The limitations were that the study was performed in a single institute and without a control group. CONCLUSIONS The FDD showed a sufficient capacity of fecal diversion and maintenance duration that prevented aggravation of sepsis in the case of AL without significant complications.
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13
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Kjaer M, Kristjánsdóttir H, Andersen L, Heegaard AM, Ågren MS, Jorgensen LN. The effect of gender on early colonic anastomotic wound healing. Int J Colorectal Dis 2018; 33:1269-1276. [PMID: 29850942 DOI: 10.1007/s00384-018-3089-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Clinically, male patients subjected to colorectal surgery are more prone to develop anastomotic leakage than female patients by unknown mechanisms. Our aim was to investigate the impact of gender on anastomotic wound healing using an experimental model. METHODS One-layer colonic anastomosis was constructed in 8-week-old 28 male and 32 female Sprague-Dawley rats. Animals of one group (n = 30) were sacrificed immediately after surgery day 0 and the other group (n = 30) on postoperative day 3. Anastomotic breaking strength, total collagen (hydroxyproline), soluble collagen (Sircol), matrix metalloproteinase (MMP)-9, and transforming growth factor (TGF)-β1 were measured. RESULTS The anastomotic breaking strength decreased from day 0 to day 3 with no significant gender differences either in the extent of decline (P = 0.122) or absolute day 3 strengths (P = 0.425). Analogously, total collagen concentration in the anastomotic wounds decreased postoperatively and were lower (P = 0.043) in the male compared with the female rats on day 3. MMP-9 levels increased in the anastomoses postoperatively, but they did not differ (P = 0.391) between male and female animals. Soluble collagen levels were lower in the day-3 anastomoses of male versus female rats (P = 0.015) and correlated positively with total TGF-β1 levels (rS = 0.540, P = 0.006). Although TGF-β1 tended to be lower in male compared with the female rats, the differences did not reach statistical significance. CONCLUSION Our findings point towards a less favorable collagen metabolism in colonic anastomoses of male compared with female rats during early wound healing.
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Affiliation(s)
- Marie Kjaer
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Hrefna Kristjánsdóttir
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Line Andersen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Marie Heegaard
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Magnus S Ågren
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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14
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Mak JCK, Foo DCC, Wei R, Law WL. Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma. World J Surg 2018; 41:2912-2922. [PMID: 28620675 DOI: 10.1007/s00268-017-4090-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. OBJECTIVE The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. METHOD From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. RESULTS This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. CONCLUSION Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.
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Affiliation(s)
- Joanna Chung Kiu Mak
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Dominic Chi Chung Foo
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Rockson Wei
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Wai Lun Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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15
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Loriau J, Petit E, Mephon A, Angliviel B, Sauvanet E. [Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29525185 DOI: 10.1016/j.gofs.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.
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Affiliation(s)
- J Loriau
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France.
| | - E Petit
- Service d'imagerie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - A Mephon
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - B Angliviel
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - E Sauvanet
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
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16
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Montemurro S, De Luca R, Caliandro C, Ruggieri E, Rucci A, Sciscio V, Ranaldo N, Federici A. Transanal Tube NO COIL® after Rectal Cancer Proctectomy. The “G. Paolo II” Cancer Centre Experience. TUMORI JOURNAL 2018; 98:607-14. [DOI: 10.1177/030089161209800511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study. Methods From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL®, 60–80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventhpostoperative day if no signs of leakage occurred. Results The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%. Conclusions The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.
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Affiliation(s)
- Severino Montemurro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Cosimo Caliandro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Eustachio Ruggieri
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Antonello Rucci
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Vito Sciscio
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Nunzio Ranaldo
- Institute of Gastroenterology, University Medical School, Bari, Italy
| | - Antonio Federici
- Department of Physiology, University Medical School, Bari, Italy
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17
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Muralee M, Acharya NR, Sudham WM, Mathew AP, Cherian K, Chandramohan K, Augustine P, Ahamed MI. Triple Test-a Predictor of Anastomotic Integrity in Patients Undergoing Low Anterior Resection After Neoadjuvant Chemoradiotherapy. Indian J Surg Oncol 2017; 8:506-510. [PMID: 29203981 PMCID: PMC5705510 DOI: 10.1007/s13193-017-0676-8] [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: 08/04/2016] [Accepted: 06/27/2017] [Indexed: 11/24/2022] Open
Abstract
Anastomotic leak after low anterior resection for rectal cancer is a dreaded complication. Diversion stoma helps tiding over this crisis and it is routinely practised in most centres, especially in post chemoradiotherapy setting. But a diversion stoma has got its own problems. In this study, we attempt to use the triple test as a predictor of anastomotic integrity and thereby avoid a diverting stoma, and patients undergoing low anterior resection after neoadjuvant chemoradiotherapy were spared the trouble of a diverting stoma if the on table triple test was negative. Two hundred such consecutive patients were prospectively followed up in the postoperative period. The incidence of anastomotic leak and the factors predicting the same were analysed in this group of patients. The incidence of anastomotic leak in our study was 7%, which is much less when compared to published literature. The triple test was a reliable predictor of the integrity of anastomosis and if the test is negative, a diverting stoma can be avoided. Age more than 60 years and end-to-end anastomosis were found to be associated with increased incidence of leak, and patients with a negative triple test need not routinely undergo diversion stoma after a low anterior resection even in post chemoradiotherapy setting.
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Affiliation(s)
- Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Nithish R. Acharya
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Wagh Mira Sudham
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Kurian Cherian
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - K. Chandramohan
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Paul Augustine
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - M. Iqbal Ahamed
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
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18
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To Drain or Not to Drain Infraperitoneal Anastomosis After Rectal Excision for Cancer: The GRECCAR 5 Randomized Trial. Ann Surg 2017; 265:474-480. [PMID: 27631776 DOI: 10.1097/sla.0000000000001991] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the effect of pelvic drainage after rectal surgery for cancer. BACKGROUND Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed infectiveness of drainage after colectomy, there is still a controversy after rectal surgery. METHODS This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months. RESULTS A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 ± 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P = 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P = 0.83), rate of reoperation (16.6% vs 21.0%; P = 0.22), length of hospital stay (12.2 vs 12.2; P = 0.99) and rate of stoma closure (80.1% vs 77.3%; P = 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio = 1.757; 95% confidence interval 1.078-2.864; P = 0.024). CONCLUSIONS This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.
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19
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Haksal M, Okkabaz N, Atici AE, Civil O, Ozdenkaya Y, Erdemir A, Aksakal N, Oncel M. Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer. Ann Surg Treat Res 2016; 92:35-41. [PMID: 28090504 PMCID: PMC5234425 DOI: 10.4174/astr.2017.92.1.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/23/2016] [Accepted: 09/12/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer. METHODS All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival. RESULTS Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143). CONCLUSION Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.
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Affiliation(s)
- Mustafa Haksal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey.; Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Nuri Okkabaz
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Osman Civil
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Yasar Ozdenkaya
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Ayhan Erdemir
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Oncel
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
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Yang CS, Choi GS, Park JS, Park SY, Kim HJ, Choi JI, Han KS. Rectal tube drainage reduces major anastomotic leakage after minimally invasive rectal cancer surgery. Colorectal Dis 2016; 18:O445-O452. [PMID: 27611180 DOI: 10.1111/codi.13506] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/23/2016] [Indexed: 12/25/2022]
Abstract
AIM Anastomotic leakage is the most serious complication following low anterior resection for rectal cancer and is a major cause of postoperative morbidity and mortality. The object of the present study was to investigate whether rectal tube drainage can reduce anastomotic leakage after minimally invasive rectal cancer surgery. METHOD Three hundred and seventy-four patients who underwent laparoscopic or robotic LAR for tumours located ≤ 15 cm above the anal verge between 1 April 2012 and 31 October 2014 were assessed retrospectively. Of these, 107 with intermediate risk of anastomotic leakage received transanal rectal tube drainage. The rectal tube group was matched by propensity score analysis with patients not having rectal tube drainage, giving 204 patients in the study. Covariates for propensity score analysis included age, sex, body mass index, tumour height from the anal verge and preoperative chemoradiation. RESULTS Patient demographics, tumour location, preoperative chemoradiation and operative results were similar between the two groups. The overall leakage rate was 10.8% (22/204), with no significant difference between the rectal tube group (9.8%) and the nonrectal tube group (11.8%, P = 0.652). Of the patients with anastomotic leakage, major leakage requiring reoperation developed in 11.8% of those without and 3.9% of those with a rectal tube. On multivariate analysis, age over 65 years and nonuse of a rectal tube were found to be independent risk factors for major anastomotic leakage. CONCLUSION Rectal tube placement may be a safe and effective method of reducing the rate of major anastomotic leakage, alleviating the clinical course of leakage following minimally invasive rectal cancer surgery.
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Affiliation(s)
- C-S Yang
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - G-S Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - J S Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - S Y Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - H J Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - J-I Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - K S Han
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Liu L, Huang Q, Wang J, Chen Q, Lin R, Ge B. Protection of low rectal anastomosis with a new tube ileostomy using a biofragmentable anastomosis ring: A retrospective study. Medicine (Baltimore) 2016; 95:e5345. [PMID: 27828857 PMCID: PMC5106063 DOI: 10.1097/md.0000000000005345] [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: 11/25/2022] Open
Abstract
A temporarily defunctioning stoma, while effective at reducing symptomatic anastomotic leakage after low anterior resection (LAR) of rectal cancer, and its subsequent closure, is associated with significant morbidity. Here, we devised a new tube ileostomy using a biofragmentable anastomosis ring (TIB) with no need for reversal.This is a retrospective cohort study. From June 2011 to March 2015, TIBs were performed on 31 consecutive patients with mid- or low-rectal cancer who underwent elective laparoscopic LARs. From January 2008 to May 2011, 25 similarly diseased patients underwent elective laparoscopic LARs and conventional loop ileostomy (LI) and were included as controls. All of the anastomotic sites were within 6 cm of the anal verge. Demographic, clinical feature, and operative data were recorded.The demographic features of both groups were similar. The TIB mean surgical duration was significantly lower than in the LI group (215 ± 28 vs 245 ± 54 min, P = 0.010). Because of readmission for stoma closure, the total hospital stay of the LI group was longer than that of the TIB group (38.1 ± 26.5 vs 19.1 ± 7.9 days, respectively, P = 0.002). Ileal content was completely diverted by TIB for 13.7 ± 2.1 (range, 10-19) days postoperatively. The drainage tube was removed on postoperative day 27.8 ± 6.9 (range, 20-44), and the mean continued duration of the discharge tract, before fistula healing, was 4.5 ± 1.9 (range, 2-10) days. Postoperative complications of the 2 modalities were not significant. In the TIB group, 1 rectovaginal fistula occurred 30 days postsurgery. In the LI group, 1 rectovaginal fistula occurred 3 months after stoma closure. Both complications were treated with transverse colostomy. No major TIB associated complications were observed in the present study.TIB is a safe, feasible, effective, but time-limited diversion technique, which may reduce symptomatic anastomosis leakage after LAR for rectal cancer.
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Affiliation(s)
| | | | | | | | | | - Bujun Ge
- Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Correspondence: Bujun Ge, Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, 389 XinCun Road, Shanghai 200065, China (e-mail: )
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Zong Z, Zhou T, Jiang Z, Li Y, Yang B, Hou Z, Han F, Chen S. Temporary Tube Stoma versus Conventional Loop Stoma for the Protection of a Low Anastomosis in Colorectal Surgery: A Systematic Review and Meta-analysis. Am Surg 2016. [DOI: 10.1177/000313481608200319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The aim of this systematic review is to evaluate and compare the efficacy and safety of temporary tube stoma and conventional loop stoma for the protection of a low anastomosis in colorectal cancer. A systematic literature search was performed using PubMed, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trails. Primary outcome measures were anastomotic leakage rate, the reoperation rate for anastomotic leakage, and stoma-related complications. Secondary outcome measures were operation time, length of hospital stay, time to stoma closure, and permanent stoma rate. Four studies were carried out and 642 patients (332 with temporary tube stoma and 310 with conventional loop stoma) met the inclusion criteria. The incidences of anastomotic leakage and reoperation rate were statistically similar in tube stoma and loop stoma groups. In comparison with conventional loop stoma, temporary tube stoma was associated with a significantly less stoma-related complications (odds ratio = 0.20; 95% confidence interval [CI]: 0.08–0.50), and shorter operation and hospital stay time (weighted mean difference = -47.28 minutes, 95% CI: -74.68 to -19.88; and weighted mean difference = -5.22 days, 95% CI: -10.32 to -0.13, respectively). Time to stoma closure was significantly shorter in the temporary tube stoma groups (weighted mean difference = -114.58 days, 95% CI: -148.38 to -80.77). Patients receiving temporary tube stoma had lower rates of stoma-related complications, shorter operation and hospital stay time, and stoma closure time. Tube can be easily removed without second surgery in most cases. Therefore, temporary tube stoma is a feasible and effective alternative to conventional loop stoma for the protection of a low colorectal anastomosis.
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Affiliation(s)
- Zhen Zong
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Taicheng Zhou
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
- Department of General Surgery, Affiliated Guangzhou First People's Hospital, Guangzhou Medical University, Guangdong, China
| | - Zhipeng Jiang
- Department of Gastroenterological Surgery and Hernia Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong, China; and
| | - Yingru Li
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
- Department of Gastroenterological Surgery and Hernia Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong, China; and
| | - Bin Yang
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Zehui Hou
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Fanghai Han
- Department of Gastroenterological Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, China
| | - Shuang Chen
- Department of Gastroenterological Surgery and Hernia Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangdong, China; and
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Ihnát P, Guňková P, Peteja M, Vávra P, Pelikán A, Zonča P. Diverting ileostomy in laparoscopic rectal cancer surgery: high price of protection. Surg Endosc 2016; 30:4809-4816. [PMID: 26902615 DOI: 10.1007/s00464-016-4811-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/03/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anastomotic leakage presents the most feared complication after low anterior resection (LAR). A proximal diversion of the gastrointestinal tract is recommended to avoid septic complications of anastomotic leakage. The aim of the present study was to evaluate the benefits and risks of diverting ileostomy (DI) created during laparoscopic LAR because of low rectal cancer. METHODS This was a retrospective clinical cohort study conducted to assess outcomes of laparoscopic LAR with/without DI in a single institution within a 6-year period. RESULTS In total, 151 patients were enrolled in the study (73 patients without DI, 78 patients with DI). There were no significant differences between both groups regarding demographic and clinical features. Overall 30-day morbidity rates were significantly lower in patients without DI (23.3 vs. 42.3 %, P = 0.013). Symptomatic anastomotic leakage occurred more frequently in patients without DI (9.6 vs. 2.5 %, P = 0.090); surgical intervention was needed in 6.8 % of patients without DI. Post-operative hospital stay was significantly longer in the group of patients with DI (11.3 ± 8.5 vs. 8.1 ± 6.9 days, P = 0.013). Stoma-related complications occurred in 42 of 78 (53.8 %) patients with DI; some patients had more than one complication. Acute surgery was needed in 9 patients (11.5 %) because of DI-related complications. Small bowel obstruction due to DI semi-rotation around its longitudinal axis was seen in 3 patients (3.8 %) and presents a distinct complication of DI laparoscopic construction. The mean interval between LAR and DI reversal was more than 8 months; only 19.2 % of patients were reversed without delay (≤4 months). Morbidity after DI reversal was 16.6 %; re-laparotomy was necessary in 2.5 % of patients. CONCLUSIONS The present study indicates that DI protects low rectal anastomosis from septic complications at a cost of many stoma-related complications, substantial risk of acute surgery necessity and long stoma periods coupled with decreased quality of life.
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Affiliation(s)
- Peter Ihnát
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic.
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic.
| | - Petra Guňková
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Matúš Peteja
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Petr Vávra
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Anton Pelikán
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
| | - Pavel Zonča
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, 17. listopadu 1790, 70852, Ostrava, Czech Republic
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Park JS, Huh JW, Park YA, Cho YB, Yun SH, Kim HC, Lee WY. Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery. Medicine (Baltimore) 2016; 95:e2890. [PMID: 26937928 PMCID: PMC4779025 DOI: 10.1097/md.0000000000002890] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Anastomotic leakage (AL) is one of the most serious complications of colorectal surgery. It can affect long-term oncologic outcomes, but the impact on long-term survival remains uncertain. The aim of this study is to evaluate the operative characteristics of leakage and no leakage groups and to analyze long-term oncologic outcomes.We prospectively enrolled 10,477 patients from 2000 to 2011 and retrospectively reviewed the data.Male sex (odds ratio [OR], 3.90; P < 0.001), intraoperative transfusion (OR, 2.31; P = 0.042), and operative time (OR, 1.73; P = 0.032) were independent risk factors of AL in the colon. In the rectum, male sex (OR, 2.37; P < 0.001), neoadjuvant chemoradiotherapy (OR, 2.26; P < 0.001), and regional lymph node metastasis (OR, 1.43; P = 0.012) were independent risk factors of AL, and diverting stoma (OR, 0.24; P < 0.001) was associated with a deceased risk of AL. AL in the rectum without a diverting stoma was associated with disease-free survival (DFS, OR, 1.47; P = 0.037). Colonic leakage was not associated with 5-year DFS (leakage group vs nonleakage group, 72.4% vs 80.9%, P = 0.084); however, in patients undergoing rectal resection, there was a significant difference in 5-year DFS (67.0% vs 76.6%, P = 0.005, respectively).AL in the rectum is associated with worse long-term DFS and overall survival. A diverting stoma was shown to protect against this effect and was associated with long-term survival in rectal surgery. Therefore, creating a diverting stoma should be considered in high-risk patients undergoing rectal surgery.
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Affiliation(s)
- Jong Seob Park
- From the Department of Surgery, CHA Gangnam Medical Center, CHA University School of Medicine (JSP); and Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine (JWH, YAP, YBC, SHY, HCK, WYL), Seoul, Korea
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Low or Ultralow Anterior Resection of Rectal Cancer Without Diverting Stoma: Experience with 28 Patients. Indian J Surg 2016; 77:423-6. [PMID: 26730038 DOI: 10.1007/s12262-013-0863-y] [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: 09/18/2012] [Accepted: 01/17/2013] [Indexed: 10/27/2022] Open
Abstract
A diverting temporary stoma is frequently used to decrease the chance of anastomosis leakage in the middle and lower rectum cancer surgeries, but its role in preventing the leakage is still doubtful. This study has been designed to evaluate any possible anastomosis complications after a rectum resection and a low or ultralow anastomosis when no diverting stoma is applied in patients with rectal cancer. Twenty-eight patients suffering from rectal cancer were treated by a low anterior resection between the years 2005 and 2008 in Imam Reza University Hospital, Mashhad, Iran. Out of the 28 patients, 6 patients had already undergone a course of neoadjuvant radiotherapy. Anastomosis was performed manually in 23 patients, using a stapler in 5 of them. None of the patients had a diverting stoma. Then, the outcome was evaluated. Fecal incontinence occurred in one of the patients (6.7 %) who had already undergone a course of radiotherapy preoperatively and had a stapler used for anastomosis. No leakage was detected in any of them. The very low incidence of complications in this study, such as those not preventable by a diverting stoma, suggest a very low chance of leakage in low or ultralow anastomosis in patients with rectal cancer and in those who were treated with neoadjuvant radiotherapy.
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Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, Weihs D, Eberl T, Tschmelitsch J. Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: A prospective, randomized, multicenter trial. Surgery 2015; 159:1129-39. [PMID: 26706610 DOI: 10.1016/j.surg.2015.11.006] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/20/2015] [Accepted: 11/05/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study sought to determine whether a protective diverting ileostomy improves short-term outcomes in patients with rectal resection and colonic J-pouch reconstruction for low anastomoses. Criteria for the use of a proximal stoma in rectal resections with colonic J-pouch reconstruction have not been defined sufficiently. METHODS In a multicenter prospective study, rectal cancer patients with anastomoses below 8 cm treated with low anterior resection and colonic J-pouch were randomized to a defunctioning loop ileostomy or no ileostomy. The primary study endpoint was the rate of anastomotic leakage, and the secondary endpoints were surgical complications related to primary surgery, stoma, or stoma closure. RESULTS From 2004 to 2014, a total of 166 patients were randomized to 1 of the 2 study groups. In the intention-to-treat analysis, the overall leakage rate was 5.8% in the stoma group and 16.3% in the no stoma group (P = .0441). However, some patients were not treated according to randomization and only 70% of our patients with low anastomoses received a pouch. Therefore, we performed a second analysis as to actual treatment. In this analysis, as well, leakage rates (P = .044) and reoperation rates for leakage (P = .021) were significantly higher in patients without a stoma. In multivariate analysis, male gender (P = .0267) and the absence of a stoma (P = .0092) were significantly associated with anastomotic leakage. CONCLUSION Defunctioning loop ileostomy should be fashioned in rectal cancer patients with anastomoses below 6 cm, particularly in male patients, even if reconstruction was done with a J-pouch.
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Affiliation(s)
- Karl Mrak
- Department of Surgery, Hospital of the Brothers of Mercy, St. Veit/Glan, Austria
| | - Stefan Uranitsch
- Department of Surgery, Hospital of the Brothers of Mercy, Graz, Austria
| | - Florian Pedross
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | | | - Anton Klingler
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | - Michael Jagoditsch
- Department of Surgery, Hospital of the Brothers of Mercy, St. Veit/Glan, Austria
| | - Dominik Weihs
- Department of Surgery, Hospital of the Brothers of Mercy, St. Veit/Glan, Austria
| | - Thomas Eberl
- Department of Surgery, Hospital of the Brothers of Mercy, St. Veit/Glan, Austria
| | - Jörg Tschmelitsch
- Department of Surgery, Hospital of the Brothers of Mercy, St. Veit/Glan, Austria.
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Huang S, Theophilus M, Cui J, Bell SW, Wale R, Chin M, Farmer C, Warrier SK. Colonic transit: what is the impact of a diverting loop ileostomy? ANZ J Surg 2015; 87:795-799. [PMID: 26572072 DOI: 10.1111/ans.13376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Diverting loop ileostomy (DLI) is used following low anterior resections (LAR) or ultra-low anterior resections (ULAR) to reduce anastomotic leak (AL). Preoperative mechanical bowel preparation (MBP) is traditionally used with DLI. However, clearance of the left colon can be achieved with a fleet enema without the physiological compromise of MBP. We aimed to assess colonic transit following DLI in this context. METHODS A prospective, observational study was performed with patients with rectal cancer undergoing LAR or ULAR in a tertiary colorectal unit with preoperative fleet enema. Radiopaque markers were inserted into the caecum following rectal resection and formation of a DLI with placement confirmed by image intensifier and endoscopy. X-rays were performed at days 1, 3, 5 and 14 post-operation with data collected prospectively. RESULTS Ten patients (mean age 57, nine males) were enrolled. Mean time to functioning stoma was 1.9 days (range 1-3). There was no movement in the majority of markers in all patients at Day 5 post-operation. In all seven patients with Day 14 X-rays, the majority of markers remained in the right colon. Two patients had delayed AL, with markers found within the pelvis in both of these patients. CONCLUSIONS This is the first study to assess colonic transit following DLI using fleet enema only, with results suggesting colonic motility is abolished in this setting. The use of a fleet enema without MBP may be sufficient prior to rectal resection surgery when DLI is employed. AL may actually increase colonic transit. Further research is warranted.
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Affiliation(s)
- Sean Huang
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Mary Theophilus
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jiamei Cui
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen W Bell
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Roger Wale
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Martin Chin
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Chip Farmer
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Shigeta K, Okabayashi K, Baba H, Hasegawa H, Tsuruta M, Yamafuji K, Kubochi K, Kitagawa Y. A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer. Surg Endosc 2015; 30:543-550. [PMID: 26091985 DOI: 10.1007/s00464-015-4237-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/14/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The safety and efficacy of transanal drainage tube (TDT) placement to decrease the risk of postoperative anastomotic leakage after rectal cancer surgery has not been validated. The objective of this meta-analysis was to evaluate the usefulness of a TDT for the prevention of anastomotic leakage after an anterior resection for rectal cancer. METHODS The PubMed and Cochrane Library databases were searched for studies comparing TDT and non-TDT. The endpoint utilized in this study was defined as the rates of anastomotic leakage and re-operation. The relative effects of these variables were synthesized using Review Manager 5.1 software. RESULTS Four trials including 909 participants (401 TDT cases and 508 non-TDT cases) met our inclusion criteria. The weighted mean anastomotic leakage rate was 4% [95% confidence interval (CI) 1-6%], and a significantly lower risk of anastomotic leakage was identified in the TDT group compared with the non-TDT group [odds ratio (OR) 0.30; 95% CI 0.16-0.55; p = 0.0001]. Furthermore, there were significant differences between the TDT and non-TDT groups in terms of the re-operation rate (OR 0.18; 95% CI 0.07-0.44; p = 0.0002). No significant covariates related to anastomotic leakage or re-operation were identified in meta-regression analysis. Both the anastomotic leakage and re-operation rates for all studies lay inside the 95% confidence interval boundaries. No visible publication bias was found by visual assessment of the funnel plot (Egger's test; anastomotic leakage: p = 0.056, re-operation: p = 0.681). CONCLUSIONS Placement of a TDT is an effective and safe procedure that can decrease the rate of anastomotic leakage and re-operation after an anterior resection.
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Affiliation(s)
- Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
- Department of Surgery, Saitama City Hospital, Saitama, Japan.
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hideo Baba
- Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Hirotoshi Hasegawa
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masashi Tsuruta
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazuo Yamafuji
- Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Kiyoshi Kubochi
- Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Anderson BJ, Hill EG, Sweeney RE, Wahlquist AE, Marshall DT, O'Carroll KFS, Cole DJ, Camp ER. The Impact of Surgical Diversion Before Neoadjuvant Therapy for Rectal Cancer. Am Surg 2015. [DOI: 10.1177/000313481508100522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Up-front fecal diversion can palliate emergent symptoms related to locally advanced rectal cancer (LARC) allowing patients to receive neoadjuvant chemoradiation therapy (nCRT). We analyzed outcomes of pretreatment-diverted LARC patients relative to nondiverted patients to define the impact of this management strategy. We retrospectively collected data on 103 LARC patients treated with nCRTand surgery. Medical records were reviewed for patient characteristics, staging, treatment plan, and outcomes. Thirteen LARC patients underwent pretreatment diversion for urgent symptoms and 90 LARC patients proceeded directly to nCRT. In all, 50 per cent of diverted patients presented with T4 tumor compared with 14 per cent in the nondiverted patients ( P = 0.003). Diverted patients experienced a delay in time-to-treatment initiation of 12 days, although this difference was not statistically significant. Similar rates of chemoradiation and surgical toxicities were observed. Even though diverted patients demonstrated less pathologic response to nCRT compared with nondiverted patients ( P = 0.04), there was no significant difference in overall survival. In conclusion, our study demonstrates the effectiveness of up-front fecal diversion at managing emergent obstructive symptoms related to advanced rectal cancer without additional complications, allowing patients to proceed with nCRT followed by radical surgery.
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Affiliation(s)
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - Robert E. Sweeney
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy E. Wahlquist
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - David T. Marshall
- Department of Radiation Oncology, Medical University of South Carolina
| | - Kevin F. Staveley O'Carroll
- Department of Surgery, Medical University of South Carolina
- Department of Public Health Sciences, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - David J. Cole
- Department of Surgery, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
| | - Ernest Ramsay Camp
- Department of Surgery, Medical University of South Carolina
- Hollings Cancer Center, Medical University of South Carolina
- the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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Anderin K, Gustafsson UO, Thorell A, Nygren J. The effect of diverting stoma on postoperative morbidity after low anterior resection for rectal cancer in patients treated within an ERAS program. Eur J Surg Oncol 2015; 41:724-30. [PMID: 25908011 DOI: 10.1016/j.ejso.2015.03.234] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 03/05/2015] [Accepted: 03/26/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) with total mesorectal excision (TME) for rectal cancer. Whether the Enhanced Recovery After Surgery (ERAS)-protocol influences the risk of short-term morbidity in relation to the use of a diverting stoma is unclear. METHODS Between 2002 and 2011, 287 consecutive patients underwent LAR with TME for rectal cancer at Ersta Hospital, Sweden. All patients were treated according to the ERAS program and thereby included. Between 2002 and 2006 15% had a diverting stoma compared to 91 %, 2007 to 2011. RESULTS One hundred and thirty-nine patients were operated with a diverting stoma at primary surgery (S+), 148 patients were not (S-). The groups were comparable regarding pre- and peroperative data and patients' characteristics. Postoperative morbidity within 30 days after surgery (S+ 53% vs. S- 43%) and hospital stay (S+ 11 days vs. S- 9 days) did not differ. AL occurred in 22% of all patients. In a multivariate analysis, no significant difference in AL was found in relation to the use of a diverting stoma (S+ vs. S-, OR 0.64, 95% CI 0.34-1.19). Eleven patients (8%) in the S+ group underwent relaparotomy versus 22 (15%) in the S- group (p = 0.065). Total overall compliance to the ERAS program was 65%. Patients in S- had faster postoperative recovery. CONCLUSION A diverting stoma did not affect postoperative morbidity in this large cohort of patients undergoing LAR within an ERAS program. However, the routine use of a diverting stoma could be expected to delay postoperative recovery.
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Affiliation(s)
- K Anderin
- Department of Surgical Gastroenterology, Karolinska University Hospital, Sweden; Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden.
| | - U O Gustafsson
- Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Danderyds Hospital, Sweden
| | - A Thorell
- Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden
| | - J Nygren
- Department of Clinical Sciences Danderyds Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden
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Snijders HS, van Leersum NJ, Henneman D, de Vries AC, Tollenaar RAEM, Stiggelbout AM, Wouters MWJM, Dekker JWT. Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens? Ann Surg Oncol 2015; 22:3582-9. [PMID: 25691277 PMCID: PMC4565862 DOI: 10.1245/s10434-015-4385-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Indexed: 12/17/2022]
Abstract
Background and Purpose
Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated. Methods Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction. Results Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals’ adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals’ adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates. Conclusions A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.
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Affiliation(s)
- Heleen S Snijders
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | | | - Daan Henneman
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anne M Stiggelbout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel W J M Wouters
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg 2015; 400:145-52. [PMID: 25633276 DOI: 10.1007/s00423-015-1275-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice. METHODS Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion. RESULTS Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion. CONCLUSIONS Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.
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Gu WL, Wu SW. Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies. World J Surg Oncol 2015; 13:9. [PMID: 25617234 PMCID: PMC4311499 DOI: 10.1186/s12957-014-0417-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/23/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recent studies have shown that a protective stoma can reduce morbidity in low anterior resection for rectal cancer; however, the necessity of it is still controversially discussed. METHODS We performed this meta-analysis to provide a comprehensive evaluation of the role of defunctioning stoma in low anterior resection for rectal cancer on the rates of anastomotic leakage and reoperation related to leakage with or without defunctioning stoma by calculating the pooled risk ratio. RESULTS Studies and relevant literature published between 2004 and 2014 regarding the construction of a protective stoma after low anterior resection were searched though PubMed and EMBASE databases. Finally, a total of 13 studies including 8,002 patients were included in this meta-analysis. The results indicated that protective stomas significantly reduced the rate of postoperative anastomotic leakage and reoperation after low anterior rectal resection. The pooled risk ratios were 0.47 (95% CI: 0.33-0.68, P <0.0001) and 0.36 (95% CI: 028-0.46, P <0.00001), respectively. CONCLUSIONS The findings from this present meta-analysis suggest that a defunctioning stoma could effectively reduce the clinical consequences of anastomotic leakage and reoperation, it is recommended in patients undergoing low rectal anterior resection for rectal cancer.
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Affiliation(s)
- Wen-long Gu
- Department of Medical Oncology, The Affiliated Jianhu Hospital of Nantong University, Jianhu People's Hospital, Jianhu, 224700, Jiangsu Province, China.
| | - Sheng-wen Wu
- Department of General Surgery, The Affiliated Jianhu Hospital of Nantong University, Jianhu People's Hospital, Jianhu, 224700, Jiangsu Province, China.
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Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg 2014; 220:186-94. [PMID: 25529899 DOI: 10.1016/j.jamcollsurg.2014.10.017] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Routine creation of a diverting stoma (DS) in every patient who undergoes low anterior resection (LAR) remains controversial. We aimed to investigate the effect of DS on symptomatic anastomotic leakage (AL) after LAR. STUDY DESIGN Patients with rectal cancer within 10 cm from the anal verge were eligible for this prospective, multicenter, cohort study (UMIN-CTR, number 000004017). Propensity score matching (PSM) was used to compare groups of patients with and without DS. RESULTS One thousand fourteen consecutive patients were registered, of whom 936 patients who underwent LAR were analyzed. Before PSM, the overall rate of symptomatic AL was 13.2% (52 of 394) in patients with DS vs. 12.7% (69 of 542) in cases without DS (p = 0.84). Symptomatic AL requiring re-laparotomy occurred in 4.7% (44 of 936) of all patients, occurring in 1.0% (4 of 394) of patients with DS vs. 7.4% (40 of 542) of patients without DS (p < 0.001). After PSM, the 2 groups were nearly balanced, and the incidence rates of symptomatic AL in patients with and without DS were 10.9% and 15.8% (p = 0.26). The incidences of AL requiring re-laparotomy in patients with and without DS were 0.6% and 9.1% (p < 0.001). Multivariate analysis identified male sex (p < 0.001; odds ratio [OR] 3.2; 95% confidence interval [CI] 1.8 to 5.7) and tumor size (p < 0.001; OR 1.2; 95% CI 1.1 to 1.4) as independent risk factors of symptomatic AL. CONCLUSIONS Diverting stoma did not have a significant relationship with symptomatic AL before and after PSM. However, DS does seem to mitigate the consequences of leakage, reducing the need for urgent abdominal reoperation.
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Affiliation(s)
- Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan.
| | - Masaaki Ito
- Division of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Kotaro Maeda
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Yusuke Kinugasa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Mitsuyoshi Ota
- Gastroenterological Center, Yokohama City University Medical Center, Kanagawa, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Shiozawa
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Kanagawa, Japan
| | - Hisanaga Horie
- Department of Surgery, School of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norio Saito
- Division of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan
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Abstract
BACKGROUND AND OBJECTIVE Most surgeons suggest the use of fecal diversion in patients undergoing low anterior resections of rectal tumors at high risk for anastomotic leakage. We describe an exploratory study to evaluate the efficacy and safety of a new diversion method called a spontaneously closing cannula ileostomy, which was designed to protect rectal anastomoses in patients at high risk for anastomotic leakage. The outcomes of patients treated with cannula ileostomy were compared to those of patients treated with loop ileostomy. MAIN OUTCOME MEASURES Outcomes included the rates of anastomotic leakage, reoperation and other complications, as well as length of hospital stay and cost. DESIGN AND PATIENTS From January 2011 to December 2012, 294 patients undergoing low colorectal or coloanal anastomosis were treated with ileum diversion using cannula ileostomy or traditional loop ileostomy. Demographics, clinical features, and operational data were recorded. RESULTS The anastomotic leakage rates were 8.1% (12/149) in the cannula ileostomy group and 8.3% (12/145) in the loop ileostomy group (p = 1.0). The reoperation rate was 3% (4/149) in patients treated with a cannula ileostomy and 3.4% (5/145) in those who underwent a loop ileostomy (p = 0.75). The median length of the hospital stay was 8.6 days in the cannula ileostomy group and 17.1 days (p < 0.01) in the loop ileostomy group, including time for the initial and reversal operations. In the cannula ileostomy group, the median time to defecation from the anus was 16.5 days after the operation. During the follow-up period, 13 patients in the loop ileostomy group retained their stoma, as compared to 2 in the cannula ileostomy group (p < 0.01). LIMITATIONS This study was a nonrandomized design and lacked contrast enema data to identify anastomotic leaks. CONCLUSIONS Cannula ileostomy is a safe and effective diverting technique that protects low colorectal and coloanal anastomoses. Patients receiving a cannula ileostomy had shorter hospital stays and lower rates of permanent stoma than those receiving a loop ileostomy.
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Snijders HS, Bakker IS, Dekker JWT, Vermeer TA, Consten ECJ, Hoff C, Klaase JM, Havenga K, Tollenaar RAEM, Wiggers T. High 1-year complication rate after anterior resection for rectal cancer. J Gastrointest Surg 2014; 18:831-8. [PMID: 24249050 DOI: 10.1007/s11605-013-2381-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies. METHODS Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality. RESULTS Nineteen percent of 388 included patients received a primary anastomosis, 55% an anastomosis with defunctioning stoma, and 27% an end colostomy. Short-term anastomotic leakage was 10% in patients with a primary anastomosis vs. 7% with a defunctioning stoma (P = 0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18%) readmissions and re-intervention (12%) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30% increase in patients with an end colostomy. CONCLUSIONS This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.
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Affiliation(s)
- H S Snijders
- Department of Surgery, Leiden University Medical Centre, P.O. Box 9600, 2300, RC, Leiden, The Netherlands,
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Hanju H, Jiahe X, Caizhao L, Sen L, Jianjiang L. Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy. Colorectal Dis 2014; 16:O117-22. [PMID: 24128335 DOI: 10.1111/codi.12456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/19/2013] [Indexed: 12/12/2022]
Abstract
AIM This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy. METHOD Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy (n = 28) or conventional loop ileostomy (n = 22). Demographics, clinical features and operation data were recorded. RESULTS Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy. CONCLUSION Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma.
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Affiliation(s)
- H Hanju
- Department of Colorectal Surgery, First Affiliated Hospital, Zhejiang University, Zhejiang, China
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Safety of Simultaneous Bowel and Liver Resections for Colon and Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2013. [DOI: 10.1007/s11888-013-0168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Snijders HS, Henneman D, van Leersum NL, ten Berge M, Fiocco M, Karsten TM, Havenga K, Wiggers T, Dekker JW, Tollenaar RAEM, Wouters MWJM. Anastomotic leakage as an outcome measure for quality of colorectal cancer surgery. BMJ Qual Saf 2013; 22:759-67. [PMID: 23687168 DOI: 10.1136/bmjqs-2012-001644] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION When comparing mortality rates between hospitals to explore hospital performance, there is an important role for adjustment for differences in case-mix. Identifying outcome measures that are less influenced by differences in case-mix may be valuable. The main goal of this study was to explore whether hospital differences in anastomotic leakage (AL) and postoperative mortality are due to differences in case-mix or to differences in treatment factors. METHODS Data of the Dutch Surgical Colorectal Audit were used. Case-mix factors and treatment-related factors were identified from the literature and their association with AL and mortality were analysed with logistic regression. Hospital differences in observed AL and mortality rates, and adjusted rates based on the logistic regression models were shown. The reduction in hospital variance after adjustment was analysed with Levene's test for equality of variances. RESULTS 17 of 22 case-mix factors and 4 of 11 treatment factors related to AL derived from the literature were available in the database. Variation in observed AL rates between hospitals was large with a maximum rate of 17%. This variation could not be attributed to differences in case-mix but more to differences in treatment factors. Hospital variation in observed mortality rates was significantly reduced after adjustment for differences in case-mix. CONCLUSIONS Hospital variation in AL is relatively independent of differences in case-mix. In contrast to 'postoperative mortality' the observed AL rates of hospitals evaluated in our study were only slightly affected after adjustment for case-mix factors. Therefore, AL rates may be suitable as an outcome indicator for measurement of surgical quality of care.
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Affiliation(s)
- H S Snijders
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
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Guirao X, Juvany M, Franch G, Navinés J, Amador S, Badía JM. Value of C-Reactive Protein in the Assessment of Organ-Space Surgical Site Infections after Elective Open and Laparoscopic Colorectal Surgery. Surg Infect (Larchmt) 2013; 14:209-15. [DOI: 10.1089/sur.2012.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Xavier Guirao
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Montserrat Juvany
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Guzmán Franch
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Jordi Navinés
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Sara Amador
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Jose M. Badía
- Department of Surgery, Hospital General de Granollers, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
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Baek JH, Alrubaie A, Guzman EA, Choi SK, Anderson C, Mills S, Carmichael J, Dagis A, Qian D, Kim J, Garcia-Aguilar J, Stamos MJ, Bening L, Pigazzi A. The association of hospital volume with rectal cancer surgery outcomes. Int J Colorectal Dis 2013; 28:191-6. [PMID: 22842664 DOI: 10.1007/s00384-012-1536-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE An association between hospital volume and postoperative mortality has been identified for several oncologic surgical procedures. Our objective was to analyze differences in surgical outcomes for patients with rectal cancer according to hospital volume in the state of California. METHODS A cross-sectional study from 2000 to 2005 was performed using the state of California Office of Statewide Health Planning and Development database. Hospitals were categorized into low (≤30)-, medium (31-60)-, and high (>60)-volume groups based on the total number of rectal cancer operations performed during the study period. RESULTS Overall, 7,187 rectal cancer operations were performed. Of the 321 hospitals in the study cohort, 72 % (n = 232), 20 % (n = 65), and 8 % (n = 24) were low-, medium-, and high-volume hospitals, respectively. Postoperative mortality was significantly lower- in high-volume hospitals (0.9 %) when compared to medium- (1.1 %) and low-volume hospitals (2.1 %; p < 0.001). High-volume hospitals also performed more sphincter-preserving procedures (64 %) when compared to medium- (55 %) and low-volume hospitals (51 %; p < 0.001). CONCLUSIONS These data indicate that hospital volume correlates with improved outcomes in rectal cancer surgery. Rectal cancer patients may benefit from lower mortality and increased sphincter preservation in higher-volume centers.
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Affiliation(s)
- Jeong-Heum Baek
- City of Hope National Medical Center, General and Oncologic Surgery, Duarte, CA, USA
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Yoo SB, Jeong SY, Lim SB, Park JW, Choi HS, Oh JH. Left-sided ileostomy at specimen extraction site in laparoscopic-assisted low anterior resection for rectal cancer. J Laparoendosc Adv Surg Tech A 2012; 23:22-5. [PMID: 23272725 DOI: 10.1089/lap.2012.0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Prophylactic ileostomy is usually created at the right lower quadrant (RLQ) because of its vicinity to the ileocecal valve. In the laparoscopic procedure, however, another wound is required for stoma, resulting in a scar after takedown. This study assessed the feasibility of left-sided ileostomy (LI) at the specimen extraction site in laparoscopic-assisted low anterior resection (LAR) for rectal cancer. SUBJECTS AND METHODS One hundred five patients underwent laparoscopic LAR with diverting ileostomy for rectal cancer. Among them, 82 (78.1%) received preoperative chemoradiotherapy (CRT). Diverting stomas were created in the RLQ in 49 (46.7%) and in the left lower quadrant in 53 patients (53.3%). We compared surgical morbidity and recovery data between the right-sided ileostomy (RI) and LI groups. RESULTS The two groups were similar with regard to age, sex, type of CRT, distance from the anal verge, and TNM stage. Parastomal hernia developed in 3 patients (1 in RI, 2 in LI) and postoperative ileus in 10 patients (4 in RI, 6 in LI). The frequency of complications showed no difference between the two groups (10.2% in RI, 14.3% in LI; P=.53). There was also no difference in terms of time to resumption of regular diet (2.9 versus 3.2 days; P=.25) or length of hospital stay (7.9 versus 7.7 days; P=.61). CONCLUSIONS LI in laparoscopic LAR was not associated with increased postoperative morbidity or delay in postoperative recovery. Because it can provide better cosmesis, it would be a possible option for diversion in laparoscopic LAR.
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Affiliation(s)
- Sang Bum Yoo
- Research Institute & Hospital, National Cancer Center, Goyang, Korea
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Léonard D, Remue C, Kartheuser A. The transanal endoscopic microsurgery procedure: standards and extended indications. Dig Dis 2012. [PMID: 23207938 DOI: 10.1159/000342033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Transanal endoscopic microsurgery (TEM) was developed in the early 1980s as a minimally invasive technique allowing the resection of benign rectal adenomas. For this indication, TEM was reported to be safe and effective and even exceeded the results compared to classical local excision. Unsurprisingly, the indication expanded to small rectal cancer. There is still much debate, though, whether it is oncologically safe to perform TEM for rectal cancer. Much has been published about the need for proper patient selection, i.e. patients presenting a low-risk T1 rectal cancer seem to be the most adequate subgroup for this technique. Nevertheless, TEM remains controversial concerning high-risk T1 rectal adenocarcinomas and deeper infiltrating tumors. Several retrospective case series and a small prospective study suggest that radiochemotherapy before local excision reduces recurrence to a level comparable with classic radical surgery (total mesorectal excision). However, these studies are collectively limited, and prospective data from larger multicenter trials are awaited. Reports about functional results after TEM have shown that the procedure has no permanent impact on anorectal function. Even if transient anal resting pressure weakening has been repeatedly described, patients do not suffer from any long-term functional sequelae. Nor do they complain of quality of life impairment.
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Affiliation(s)
- Daniel Léonard
- Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
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Rivadeneira DE, Verdeja JC, Sonoda T. Improved access and visibility during stapling of the ultra-low rectum: a comparative human cadaver study between two curved staplers. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2012; 6:11. [PMID: 23148602 PMCID: PMC3539907 DOI: 10.1186/1750-1164-6-11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 10/22/2012] [Indexed: 12/13/2022]
Abstract
UNLABELLED BACKGROUND The purpose of this study was to compare in human cadavers the applicability of a commonly used stapling device, the CONTOUR® curved cutter (CC) (Ethicon Endo-Surgery, Cincinnati, OH) to a newly released, curved stapler, the Endo GIA™ Radial Reload with Tri-Staple™ Technology (RR) (Covidien, New Haven, CT) METHODS: Four experienced surgeons performed deep pelvic dissection with total mesorectal excision (TME) of the rectum in twelve randomized male cadavers. Both stapling devices were applied to the ultra-low rectum in coronal and sagittal configurations. Extensive measurements were recorded of anatomic landmarks for each cadaver pelvis along with various aspects of access, visibility, and ease of placement for each device. RESULTS The RR reached significantly lower into the pelvis in both the coronal and sagittal positions compared to the CC. The median distance from the pelvic floor was 1.0 cm compared to 2.0 cm in the coronal position, and 1.0 cm versus 3.3 cm placed sagitally, p < 0.0001. Surgeons gave a higher visibility rating with less visual impediment in the sagittal plane using the RR Stapler. Impediment of visibility occurred in only 10% (5/48) of RR applications in the coronal position, compared to a rate of 48% (23/48) using the CC, p = 0.0002. CONCLUSIONS The RR device performed significantly better when compared to the CC stapler in regards to placing the stapler further into the deep pelvis and closer to the pelvic floor, while causing less obstructing of visualization.
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Snijders HS, Wouters MWJM, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, Tollenaar RAEM, Bonsing BA. Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 2012; 38:1013-9. [PMID: 22954525 DOI: 10.1016/j.ejso.2012.07.111] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/25/2012] [Accepted: 07/19/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer. METHODS A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed. RESULTS Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes. CONCLUSION We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.
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Affiliation(s)
- H S Snijders
- Leiden University Medical Centre, Department of Surgery, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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Bhangu A, Nepogodiev D, Futaba K. Systematic review and meta-analysis of the incidence of incisional hernia at the site of stoma closure. World J Surg 2012; 36:973-983. [PMID: 22362042 DOI: 10.1007/s00268-012-1474-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The incidence of incisional hernias at the site of stoma closure is surprisingly unclear. A review of the current literature was undertaken to determine how commonly this complication may occur and to assess the quality of evidence available. METHODS A systematic review was performed to identify studies reporting the incidence of incisional hernia after closure of an ileostomy or colostomy. Studies including children (<16 years old) and studies in which >10% of the total number were trauma patients were excluded. RESULTS Thirty-four studies provided outcomes for 2,729 closed stomas. Median follow-up time was 36 months but was only described in seven studies. Closure of loop ileostomies was the most commonly performed procedure (48%). The overall reported hernia rate was 7%, but with a wide range among studies (0-48%). Most studies based their hernia rates on retrospective clinical findings only. A separate analysis of three studies that were specifically designed to assess for stoma site hernias found the clinical hernia rate to be 30% (28/93) and the combined clinical/radiological hernia rate to be 35% (33/93). From 11 studies reporting reoperation rates, 51% of patients who developed a hernia required a surgical repair (34/66). There was a lower risk of hernia following reversal of ileostomy versus colostomy (odds ratio 0.28, 95% confidence interval 0.12-0.65). CONCLUSIONS One in three patients may develop a hernia after stoma closure, and around half of hernias that are detected require repair. Risk of hernia is greater after colostomy closure than after ileostomy closure. Clinical measures to reduce the development of these hernias warrant consideration.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Surgery, West Midlands Research Collaborative, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK.
| | - Dmitri Nepogodiev
- Academic Department of Surgery, West Midlands Research Collaborative, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK
| | - Kaori Futaba
- Academic Department of Surgery, West Midlands Research Collaborative, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK
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The impact of heavy smoking on anastomotic leakage and stricture after low anterior resection in rectal cancer patients. World J Surg 2012; 35:2806-10. [PMID: 21959931 DOI: 10.1007/s00268-011-1286-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic complications after low anterior resection are associated with perianastomotic ischemia. Smoking is one of the main causes of microvascular disease that is correlated with tissue ischemia. The purpose of the present study was to assess the impact of smoking on anastomotic complications after low anterior resection in rectal cancer patients. METHODS Between January 2005 and December 2008, 412 patients underwent low anterior resection for rectal cancers by a single surgeon at Seoul National University Hospital. Excluded from this series were 197 patients with postoperative radiation therapy, cancers that were located above 10 cm from the anal verge, or lack of medical records, and the remaining 215 patients were included for analysis. Significant variables in the univariate analysis were subsequently subject to multivariate analysis for identification of risk factors for complications. RESULTS The rate of anastomotic complications was 10.7% (23 of 215 patients). Univariate analysis showed that male gender, body mass index higher than 25 kg/m(2), smoking history, smoking amount, type of operation, and presence of a protective stoma were associated with anastomotic complications. In multivariate analysis, a history of heavy smoking was a significant risk factor for anastomotic complications. CONCLUSIONS A history of heavy smoking (more than 40 pack-years) is an independently significant risk factor for anastomotic complications after low anterior resection in rectal cancer patients.
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Steinkamp M, Gress TM. Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum. Visc Med 2012. [DOI: 10.1159/000345837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.
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Shiomi A, Ito M, Saito N, Hirai T, Ohue M, Kubo Y, Takii Y, Sudo T, Kotake M, Moriya Y. The indications for a diverting stoma in low anterior resection for rectal cancer: a prospective multicentre study of 222 patients from Japanese cancer centers. Colorectal Dis 2011; 13:1384-9. [PMID: 20977591 DOI: 10.1111/j.1463-1318.2010.02481.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The aim of the study was to determine the present state of diverting stoma construction in Japanese cancer centres and to investigate the relationship between symptomatic leakage and diverting stoma after low anterior resection for rectal cancer. METHOD Two hundred and twenty-two consecutive patients undergoing low anterior resection for rectal cancer located within 10 cm from the anal verge were investigated in a prospective, multicenter study. RESULTS The overall leakage rate was 9.0% (20/222). Of 31 cases with an anastomosis within 2.0 cm from the anal verge, 22 (71%) had a diverting stoma. Of cases anastomosed within 5.0 cm, the absence of a diverting stoma and tumour size were significantly related to an increased rate of leakage [leakage in 13 (12.7%) of 102 cases without a diverting stoma; in three (3.8%) of 80 cases with a diverting stoma]. Among anastomoses within 2.0 cm from the anal verge, leakage occurred in four (44.4%) of nine cases without and in none (0%) of 22 cases with a diverting stoma. CONCLUSION We recommend a diverting stoma for an anastomosis within 5.0 cm of the anal verge and strongly recommend it for a very low anastomosis within 2.0 cm.
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Affiliation(s)
- A Shiomi
- Division of Colorectal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan.
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Palmisano S, Piccinni G, Casagranda B, Balani A, De Manzini N. The Reversal of a Protective Stoma Is Feasible Before the Complete Healing of a Colorectal Anastomotic Leak. Am Surg 2011. [DOI: 10.1177/000313481107701232] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A proximal diverting stoma is recommended in “high-risk” conditions after total mesorectal excision. The aim of the study is to assess whether, after checking the anastomosis by using a water-soluble contrast enema (WCE), the closure of the ileostomy is feasible and safe, even in the presence of a persistent radiological leak. From 2003 to 2010, 210 colorectal anastomoses were performed. Ileostomy was carried out in “high-risk” anastomosis. A radiological control was performed 2 weeks later. If a leakage was present, conservative therapy controlled by serial WCEs was prescribed. Ileostomy closure was performed in the absence of leakage or with persistent leakage without clinical signs of pelvic infections. Seventy patients (33.3%) had a protective ileostomy. Fifty-eight of these (82.9%) had an uneventful course, whereas 12 (17.1%) had clinical leakage. All 70 patients were submitted to WCE after 2 weeks. Nine of 58 patients (15.5%) and eight of 12 patients with clinical anastomotic leakage showed a leakage at radiology. All these patients were scheduled another WCE 2 months later. It showed that the anastomosis had been healed in seven patients, whereas the 10 patients with leaks remained with ostomy until the third enema 1 month later. For all these patients, closure of the ileostomy was planned despite persistent radiological and subclinical leakage. A radiological study using WCE before closure of the stoma is essential and stoma closure, in the presence of a persistent leakage, is possible in selected patients.
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Affiliation(s)
- Silvia Palmisano
- Department of Surgery, University of Trieste and Cattinara Hospital, Strada di Fiume, Trieste, Italy
| | - Giuseppe Piccinni
- Department of Biological Sciences and Human Oncology, University of Bari, Bari, Italy
| | - Biagio Casagranda
- Department of Surgery, University of Trieste and Cattinara Hospital, Strada di Fiume, Trieste, Italy
| | - Alessandro Balani
- Department of Surgery, University of Trieste and Cattinara Hospital, Strada di Fiume, Trieste, Italy
| | - Nicolo De Manzini
- Department of Surgery, University of Trieste and Cattinara Hospital, Strada di Fiume, Trieste, Italy
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