Does anastomotic leakage after rectal cancer resection worsen long-term oncologic outcome?

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Implementing a no-drain policy for extraperitoneal colorectal anastomosis in a real-life setting: analysis of outcomes and surgeons' adherence

AIM

Recent evidence has questioned the usefulness of anastomotic drain (AD) after low anterior resection (LAR). However, the implementation and adoption of a no-drain policy are still poor. This study aims to assess the clinical outcomes of the implementation of a no-drain policy for rectal cancer surgery into a real-life setting and the adherence of the surgeons to such policy.

METHOD

A retrospective analysis was conducted on patients who underwent elective minimally invasive LAR between January 2015 and December 2019 at two tertiary referral centers. In 2017, both centers implemented a policy aimed at reducing the use of AD. Patients were retrospectively categorized into two groups: the drain policy (DP) group, comprising patients treated before 2017, and the no-drain policy (NDP) group, consisting of patients treated from 2017 onwards. The endpoints were the rate of anastomotic leak (AL) and of related interventions.

RESULTS

Among the 272 patients included, 188 (69.1%) were in the NDP group, and 84 (30.9%) were in the DP group. Baseline characteristics were similar between the two groups. AL rate was 11.2% in the NDP group compared to 10.7% in the DP group (p = 1.000), and the AL grade distribution (grade A, 19.1% (4/21) vs 28.6% (2/9); grade B, 28.6% (6/21) vs 11.1% (1/9); grade C, 52.4% (11/21) vs 66.7% (6/9), p = 0.759) did not significantly differ between the groups. All patients with symptomatic AL and AD underwent surgical treatment for the leak, while those with symptomatic AL in the NPD group were managed with surgery (66.7%), endoscopic (19.0%), or percutaneous (14.3%) interventions. Postoperative outcomes were similar between the groups. Three years after implementing the no-drain policy, AD was utilized in only 16.5% of cases, compared to 76.2% at the study's outset.

CONCLUSION

The introduction of a no-drain policy received a good adoption rate and did not affect negatively the surgical outcomes.

Tumour, narrow pelvis and surgery specific factors for total mesorectal excision quality and morbidity following rectal cancer resection

BACKGROUND

Pelvic anatomy is critical in challenging rectal resections. This study investigated how pelvic anatomy relates to total mesorectal excision (TME) quality, anastomotic leakage rate, and long-term oncological outcomes.

METHODS

Patients undergoing elective rectal cancer resection from 2008 to 2017 in an Austrian institution were retrospectively reviewed regardless of the surgical approach. CT scans were analysed for pelvic measurements and volumes. The primary outcomes of interest were the correlation between pelvic dimensions and the TME quality and anastomotic leakage. Subanalysis was done by surgical approach (open, laparoscopic, transanal TME). Secondary outcomes were overall and disease-free survivals.

RESULTS

Among 154 eligible patients, 112 were included. The angle between pubic symphysis and promontory significantly correlated with worse TME grades (TME grade 1: mean(s.d.) 102.7(5.7)°; TME grade 2: 92.0(4.4)°; TME grade 3: 91.4(3.6)°; P < 0.001). A significantly lower distance between tumour and circumferential resection margin (CRM) was observed in grade 3 resections, whereas no difference appeared in grade 1 and grade 2 resection (TME grade 1: mean(s.d.) 11.92(9.4) mm; TME grade 2: 10.8(8.1) mm; TME grade 3: 3.1(4.1) mm; P = 0.003). The anastomotic leakage rate was significantly higher in case of a lower CRM (patients with anastomotic leakage: mean(s.d.) 6.8(5.8) mm versus others: 12.6(9.8) mm, P = 0.027), but not associated with pelvimetry measurements. The transanal TME (TaTME) subgroup displayed a wider angle between the pubic symphysis and promontory, younger age and improved TME quality compared to others (respectively, mean TME grades in TaTME versus open versus laparoscopic: 1.0 ± 0.0, 1.5 ± 0.7 and 1.3 ± 0.5, P = 0.013). Finally, oncological survival was not impacted by pelvic measurements or worse TME quality.

CONCLUSION

The angle between the pubic symphysis and promontory and the distance between tumour and CRM were associated with worse TME grades. The anastomotic leakage was associated with a lower CRM but not with pelvimetric measures.

The Postoperative Utilization of Intensive Care Beds After Visceral Surgery Procedures

BACKGROUND

The necessary number of intensive care beds has been under debate in recent years. This study aims to provide a descriptive analysis of postoperative intensive care for visceral surgery patients based on three indicator procedures, with particular attention to the frequency and duration of intensive care among these patients, trends in the occupancy of intensive care units, and the course during the COVID-19 pandemic.

METHODS

Routine data from inpatient cases of the Helios group (24 888 cases from 71 acute care hospitals) from 01.01.2016 to 31.12.2021 were analyzed retrospectively. The indicator procedures were colorectal resection, surgery for gastric carcinoma, and left pancreatic resection.

RESULTS

Routine data reveal a decline in the utilization of intensive care by these patients over the years, e.g., after colorectal resection, from 84.2% in 2016 to 63.1% in 2021. The percentage of patients requiring mechanical ventilation declined to a small extent as well (2016: 10.3%; 2021: 8.9%). In-hospital mortality remained stable in the range of 4.1% to 5.2%. The number of gastric carcinomas operated on fell from 355 in 2016 to 239 in 2021, while the number of left pancreatic resections remained stable in the range of 147 to 172 per year.

CONCLUSION

In the hospitals studied, visceral surgery patients still commonly undergo intensive care postoperatively, at a rate that is declining slowly over the years. No adjustments were made for age, sex, or Elixhauser comorbidity index.

Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study

BACKGROUND

Anastomotic leak after restorative surgery for rectal cancer is a major complication and may lead to worse long-term oncological and survival outcomes.

OBJECTIVE

The purpose of this study was to identify risk factors associated with anastomotic leak and to assess the perioperative and long-term oncological impact of anastomotic leak in our cohort of patients with rectal cancer.

DESIGN

A retrospective analysis was performed on data from the prospectively maintained Cabrini Monash colorectal neoplasia database. Patients who had undergone rectal cancer resection and subsequently received anastomosis between November 2009 and May 2020 were included in this study. Patient and tumor characteristics, technical risk factors, and short-term and perioperative as well as long-term oncological and survival outcomes were assessed.

SETTINGS

The study was conducted in 3 tertiary hospitals.

PATIENTS

A total of 693 patients met the inclusion criteria for this study.

MAIN OUTCOME MEASURES

Univariate analyses were performed to assess the relationship between anastomotic leak and patient and technical risk factors, as well as perioperative and long-term outcomes. Univariate and multivariate proportional HR models of overall and disease-free survival were calculated. Kaplan-Meier survival analyses assessed disease-free and overall survival.

RESULTS

Anastomotic leak rate was 3.75%. Males had an increased risk of anastomotic leak, as did patients with hypertension and ischemic heart disease. Patients who experience an anastomotic leak were more likely to require reoperation and hospital readmission and were more likely to experience an inpatient death. Disease-free and overall survival were also negatively impacted by anastomotic leaks.

LIMITATIONS

This is a retrospective analysis of data from only 3 centers with the usual limitations. However, these effects have been minimized because of the high quality and completeness of the prospective data collection.

CONCLUSIONS

Anastomotic leaks after restorative surgery negatively affect long-term oncological and survival outcomes for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/C81 .

IMPACTO DE LA FUGA ANASTOMTICA EN LOS RESULTADOS ONCOLGICOS A LARGO PLAZO TRAS CIRUGA RESTAURADORA PARA EL CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO

ANTECEDENTES:La fuga anastomótica tras una cirugía restauradora para el cáncer de recto es una complicación mayor y puede conducir a peores resultados oncológicos y de supervivencia a largo plazo.OBJETIVO:El propósito de este estudio fue identificar los factores de riesgo asociados con la fuga anastomótica y evaluar el impacto oncológico perioperatorio y a largo plazo de la fuga anastomótica en nuestra cohorte de pacientes con cáncer de recto.DISEÑO:Se realizó un análisis retrospectivo de datos obtenidos de la base de datos Cabrini Monash sobre neoplasia colorrectal la cual es mantenida prospectivamente. Se incluyeron en este estudio pacientes que fueron sometidos a una resección del cáncer de recto y que posteriormente recibieron una anastomosis entre noviembre de 2009 y mayo de 2020. Se evaluaron las características del paciente y del tumor, los factores de riesgo relacionados a la técnica, los resultados oncológicos y de supervivencia perioperatorio, así como los resultados a corto y largo plazo.AJUSTES:El estudio se realizó en tres hospitales terciarios.PACIENTES:Un total de 693 pacientes cumplieron con los criterios de inclusión para este estudio.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis univariados para evaluar la relación entre la fuga anastomótica y aquellos factores relacionados al paciente, a la técnica, así como los resultados perioperatorios y a largo plazo. Se calcularon modelos de razón de riesgo proporcional univariante y multivariante de supervivencia global y libre de enfermedad. Los análisis de supervivencia de Kaplan-Meier evaluaron la supervivencia libre de enfermedad y la supervivencia global.RESULTADOS:La tasa de fuga anastomótica fue del 3,75%. Los hombres tenían un mayor riesgo de fuga anastomótica al igual que aquellos pacientes con hipertensión y cardiopatía isquémica. Los pacientes que sufrieron una fuga anastomótica tuvieron mayores probabilidades de requerir una reintervención y reingreso hospitalario, así como también tuvieron mayores probabilidades de sufrir una muerte hospitalaria. La supervivencia libre de enfermedad y general también se vio afectada negativamente por las fugas anastomóticas.LIMITACIONES:Este es un análisis retrospectivo de datos de solo tres centros con las limitaciones habituales. Sin embargo, estos efectos han sido minimizados debido a la alta calidad y la exhaustividad de la recopilación prospectiva de datos.CONCLUSIONES:Las fugas anastomóticas después de una cirugía restauradora afectan negativamente los resultados oncológicos y de supervivencia a largo plazo para los pacientes con cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C81 . (Traducción-Dr. Osvaldo Gauto ).

Sarcopenic Obesity Is a Risk Factor for Worse Oncological Long-Term Outcome in Locally Advanced Rectal Cancer Patients: A Retrospective Single-Center Cohort Study

BACKGROUND

Malnutrition and skeletal muscle waste (sarcopenia) are known as predictive factors for a poor postoperative outcome. Paradoxically, obesity seems to be associated with a survival advantage in wasting diseases such as cancer. Thus, the interpretation of body composition indices and their impact on rectal cancer therapy has become more and more complex. The aim of this study was to evaluate body composition indices in locally advanced rectal cancer patients prior to therapy and their impact on short- and long-term outcomes.

METHODS

Between 2008 and 2018, 96 patients were included in this study. Pre-therapeutic CT scans were used to evaluate visceral and subcutaneous fat mass, as well as muscle mass. Body composition indices were compared to body mass index, morbidity, anastomotic leakage rate, local recurrency rate, and oncological long-term outcomes.

RESULTS

Increased visceral fat (p < 0.01), subcutaneous fat (p < 0.01), and total fat mass (p = 0.001) were associated with overweight. Skeletal muscle waste (sarcopenia) (p = 0.045), age (p = 0.004), comorbidities (p < 0.01), and sarcopenic obesity (p = 0.02) were significantly associated with increased overall morbidity. The anastomotic leakage rate was significantly influenced when comorbidities were present (p = 0.006). Patients with sarcopenic obesity showed significantly worse disease-free (p = 0.04) and overall survival (p = 0.0019). The local recurrency rate was not influenced by body composition indices.

CONCLUSION

Muscle waste, older age, and comorbidities were demonstrated as strong risk factors for increased overall morbidity. Sarcopenic obesity was associated with worse DFS and OS. This study underlines the role of nutrition and appropriate physical activity prior to therapy.

Integration of prolapsing technique and one-stitch method of ileostomy during laparoscopic low anterior resection for rectal cancer: a retrospective study

BACKGROUND

Prolapsing technique is a type of natural orifice specimen extraction surgery that can overcome the difficulty of precise transection of the distal rectum and subsequent anastomosis in a narrow pelvic space. Currently, protective ileostomy is widely utilized in low anterior resection for low rectal cancer, which may reduce the severe consequences caused by anastomotic leakage. The study aimed to combine the prolapsing technique with a one-stitch method of ileostomy and evaluate the surgical outcomes.

METHODS

A retrospective analysis was conducted on patients with low rectal cancer who underwent protective loop ileostomy in laparoscopic low anterior resection between January 2019 and December 2022. The patients were divided into prolapsing technique combined with the one-stitch method of ileostomy (PO) group and traditional method (TM) group, and the intraoperative details and early postoperative outcomes of the two groups were measured.

RESULTS

A total of 70 patients met the inclusion criteria, including 30 patients who underwent PO and 40 patients who underwent the traditional procedure. The PO group had a shorter total operative time than the TM group (197.8 ± 43.4 vs. 218.3 ± 40.6 min, P = 0.047). The time of intestine function recovery in the PO group was shorter than that in the TM group (24.6 ± 3.8 vs. 32.7 ± 5.4 h, P < 0.001). Compared with the TM group, the average VAS score was significantly lower in the PO group (P < 0.001). The incidence of anastomotic leakage in the PO group was significantly lower than that in the TM group (P = 0.034). The operative time of loop ileostomy was 2.0 ± 0.6 min in the PO group, which was significantly less than 15.1 ± 2.9 min in the TM group. Skin irritation was observed in 2 patients in the PO group and 10 patients in the TM group; therefore, there was a significant difference (P = 0.044).

CONCLUSION

This method is safe and feasible, which reduces the technical difficulty and achieves rapid postoperative recovery with few complications.

The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: A propensity score-matched study

BACKGROUND

The protective efficacy of transanal tube for anastomosis was compared with that of diverting stoma in patients with rectal cancer treated with neoadjuvant chemoradiotherapy.

METHODS

We included consecutive patients with rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery from January 2013 to December 2019. The patients were grouped into transanal tube or diverting stoma, according to the protection methods they received. Propensity score-matching with 1:1 ratio was done. The primary outcome was the incidence of anastomotic leakage.

RESULTS

Of the 656 eligible patients, 207 (31.6%) and 385 (58.7%) patients were grouped into transanal tube and diverting stoma, respectively, and 64 (9.7%) patients who did not undergo either transanal tube or diverting stoma were excluded. After matching, the incidence of anastomotic leakage was 9.7% and 10.6% in diverting stoma and transanal tube, respectively (P = .871). The overall morbidity was 23.2% and 15.0% in diverting stoma and transanal tube, respectively (P = .045). In the multivariate analysis, tumor size >2.5 cm and level of anastomosis <4 cm were significant risk factors for anastomotic leakage. In a subgroup analysis for patients with the level of anastomosis >4 cm, the incidence of anastomotic leakage was not significantly different between the transanal tube and diverting stoma groups. However, for patients with a level of anastomosis <4 cm, the incidence of grade C anastomotic leakage was significantly greater in the transanal tube than in the diverting stoma group (2.5% vs 9.9%, P = .040).

CONCLUSION

The protective efficacy of transanal tube may be comparable to diverting stoma, especially for those with a level of anastomosis >4 cm.

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study

PURPOSE

Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy.

METHODS

A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage -).

RESULTS

A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172-309] vs. 93 days [50-182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08-7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01-4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors.

CONCLUSION

We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.