The impact of anastomotic leak on long-term oncological outcomes after low anterior resection for mid-low rectal cancer: extended follow-up of a randomised controlled trial

Mitigating 'inevitable' anastomotic leaks in left-sided colorectal surgery: a combined strategy using indocyanine green fluorescence, intraoperative colonscopy and patient risk profiling

This study aimed to identify patient-specific risk factors and intraoperative findings obtained from indocyanine green fluorescence angiography (ICG-FA) and intraoperative colonoscopy (IOC), using a structured endoscopic grading scale, to guide surgical decisions and minimize the risk of anastomotic leakage in colorectal surgery. One hundred-eleven patients undergoing elective left-sided colorectal resections were evaluated intraoperatively using both ICG-FA and IOC, with anastomoses classified by a new endoscopic grading scale (Grades 1-5). Anastomoses classified as suboptimal (grade > 3) were taken down and reconstructed or repaired. The primary aim of the study was to determine the rate of anastomotic leakage (AL) using this integrated strategy and subsequently to identify patient-specific risk factors associated with AL. Among 111 patients, 102 patients (91.8%) at the IOC were classified as Grade 1, 4 patients (3.6%) as Grade 2, 4 patients (3.6%) as Grade 3, and 1 patient (0.9%) as Grade 4. The overall AL rate was 10.8% (12 patients). On multivariate logistic regression analysis, only anastomotic level ≤ 12 cm emerged as an independent risk factor of AL (OR 0.064, 95% CI 0.008-0.517, p = 0.010). Among patients who developed an AL, 3 (25%) required surgical intervention, the others were managed endoscopically or conservatively. An integrated approach involving ICG-FA and IOC may aid to construct a technically optimal colorectal anastomosis. Nevertheless, anastomotic leakage can still occur due to factors unrelated to intraoperative technique, particularly low anastomosis height. These factors should prompt routine consideration of protective loop ileostomy and pelvic drainage to mitigate AL clinical consequences.

Postoperative C-Reactive Protein Trend Is a More Accurate Predictor of Anastomotic Leak than Absolute Values Alone

Background/Objectives: An anastomotic leak (AL) following colorectal surgery is one of the most feared complications due to its associated morbidity and mortality. Early detection of ALs remains difficult, as the development of clinical signs of deterioration can be a late finding. This is particularly problematic in patients with poor access to care after discharge. C-reactive protein (CRP) is a systemic marker of inflammation that has been proposed as an early AL screening. However, absolute cut-off values have been shown to have limited sensitivity and specificity. We propose the use of CRP trends for early AL detection. Methods: A retrospective chart review of patients undergoing surgery requiring at least one anastomosis at a single tertiary care center was performed. Patients with two or fewer postoperative CRP values were excluded. Postoperative CRP trends were compared between control and AL patients using a mixed model with a Geisser-Greenhouse correction. Results: CRP trends differed significantly between AL and control patients, with a 10% CRP increase after postoperative day two showing 100% sensitivity and 84% specificity for an AL as well as a 100% negative predictive value. Accepted CRP cut-off values on postoperative days three and four had sensitivities of only 71.4% and 80% and specificities of 70.0% and 76.5%, respectively. CRP trends differed in AL versus control patients despite the surgical approach or presence of additional procedures. Conclusions: Daily monitoring of CRP trends (versus absolute cut-offs) may enhance early anastomotic leak detection and aid in discharge decision-making, particularly important in rural settings with limited healthcare access.

Machine learning and deep learning to improve prevention of anastomotic leak after rectal cancer surgery

Anastomotic leakage (AL) is a significant complication following rectal cancer surgery, adversely affecting both quality of life and oncological outcomes. Recent advancements in artificial intelligence (AI), particularly machine learning and deep learning, offer promising avenues for predicting and preventing AL. These technologies can analyze extensive clinical datasets to identify preoperative and perioperative risk factors such as malnutrition, body composition, and radiological features. AI-based models have demonstrated superior predictive power compared to traditional statistical methods, potentially guiding clinical decision-making and improving patient outcomes. Additionally, AI can provide surgeons with intraoperative feedback on blood supply and anatomical dissection planes, minimizing the risk of intraoperative complications and reducing the likelihood of AL development.

Anastomotic leakage after resection for rectal cancer and recurrence-free survival in relation to postoperative C-reactive protein levels

BACKGROUND

Anastomotic leakage after rectal cancer surgery is linked to reduced survival and higher recurrence rates. While an aggravated inflammatory response may worsen outcomes, few studies have explored the combined effects of leakage and inflammation.

METHODS

This is a retrospective multicenter cohort study including patients operated with anterior resection for rectal cancer in Sweden during 2014-2018. Anastomotic leakage within 12 months was exposure and primary outcome was recurrence-free survival. Mediation analysis was performed to evaluate the potential effect of systemic inflammatory response, as measured by the highest postoperative C-reactive protein (CRP) level within 14 days of surgery. Confounders were chosen using a causal diagram.

RESULTS

Some 1036 patients were eligible for analysis, of whom 218 (21%) experienced an anastomotic leakage. At the end of follow-up at a median of 61 months after surgery, recurrence-free survival amounted to 82.6% and 77.8% in the group with and without leakage, respectively. The median highest postoperative CRP value after surgery was higher in the leakage group (219 mg/l), compared with the group without leakage (108 mg/l). Leakage did not lead to worse recurrence-free survival (HR 0.66; 95% CI 0.43-0.94), and there was no apparent effect through postoperative highest CRP (HR 1.12; 95% CI 0.93-1.29).

CONCLUSIONS

In conclusion, anastomotic leakage, with its accompanying CRP increase, was not found to be associated with recurrence-free survival after anterior resection for rectal cancer in this patient cohort. Larger, even more detailed studies are needed to further investigate this topic.

Quality of Reporting on Anastomotic Leaks in Colorectal Cancer Trials: A Systematic Review

BACKGROUND

Although attempts have been made in the past to establish consensus regarding the definitions and grading of the severity of colorectal anastomotic leakage, widespread adoption has remained limited.

OBJECTIVE

A systematic review of the literature was conducted to examine the various elements used to report and define anastomotic leakage in colorectal cancer resections.

DATA SOURCES

A systematic review was conducted using the PubMed, Embase, and Cochrane Library Database.

STUDY SELECTION

All published randomized controlled trials, systematic reviews, and meta-analyses containing data related to adult patients undergoing colorectal cancer surgery and reporting anastomotic leakage as a primary or secondary outcome, with a definition of anastomotic leakage were included.

MAIN OUTCOME MEASURES

Definitions of anastomotic leakage, clinical symptoms, radiological modalities and findings, findings at reoperation, and grading terminology or classifications for anastomotic leakage.

RESULTS

Of the 471 articles reporting anastomotic leakage as a primary or secondary outcome, a definition was reported in 95 studies (45 randomized controlled trials, 13 systematic reviews, and 37 meta-analyses) involving a total of 346,140 patients. Of these 95 articles, 68% reported clinical signs and symptoms of anastomotic leakage, 26% biochemical criteria, 63% radiological modalities, 62% radiological findings, and 13% findings at reintervention. Only 45% (n = 43) of included studies reported grading of anastomotic leakage severity or leak classification, and 41% (n = 39) included a time frame for reporting.

LIMITATIONS

There was a high level of heterogeneity between the included studies.

CONCLUSIONS

This evidence synthesis confirmed incomplete and inconsistent reporting of anastomotic leakage across the published colorectal cancer literature. There is a great need to develop and implement a consensus framework for defining, grading, and reporting anastomotic leakage.

REGISTRATION

Prospectively registered at PROSPERO (ID 454660).

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

Survival and cancer recurrence after short-course perioperative probiotics in a randomized trial

BACKGROUND & AIMS

The long-term impact of perioperative probiotics remains understudied while mounting evidence links microbiome and oncogenesis. Therefore, we analyzed overall survival and cancer recurrence among patients enrolled in a randomized trial of perioperative probiotics.

METHODS

6-year follow-up of surgical patients participating in a randomized trial evaluating short-course perioperative oral probiotic VSL#3 (n = 57) or placebo (n = 63).

RESULTS

Study groups did not differ in age, preoperative hemoglobin, ASA status, and Charlson comorbidity index. There was a significant difference in preoperative serum albumin (placebo group 4.0 ± 0.1 vs. 3.7 ± 0.1 g/dL in the probiotic group, p = 0.030). Thirty-seven deaths (30.8 %) have occurred during a median follow-up of 6.2 years. Overall survival stratified on preoperative serum albumin and surgical specialty was similar between groups (p = 0.691). Age (aHR = 1.081, p = 0.001), serum albumin (aHR = 0.162, p = 0.001), and surgical specialty (aHR = 0.304, p < 0.001) were the only predictors of overall survival in the multivariate model, while the placebo/probiotic group (aHR = 0.808, p = 0.726) was not predictive. The progression rate among cancer patients was similar in the probiotic group (30.3 %, 10/33) compared to the placebo group (21.2 %, 7/33; p = 0.398). The progression-free survival was not significantly different (unstratified p = 0.270, stratified p = 0.317).

CONCLUSIONS

Perioperative short-course use of VSL#3 probiotics does not influence overall or progression-free survival after complex surgery for visceral malignancy.

Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study

PURPOSE

To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes.

METHODS

Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results.

RESULTS

Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks.

CONCLUSION

AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised.

TRIAL REGISTRATION

Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.

Anastomotic Leak in Colorectal Surgery: Predictive Factors and Survival

<br><b>Introduction:</b> Anastomotic leak (AL) is a serious complication following colorectal surgery.</br> <br><b>Aim:</b> The aim of this study was to identify factors associated with the development of AL and to analyze its impact on survival.</br> <br><b>Materials and methods:</b> All consecutive adult colorectal cancer resections performed between 2007 and 2020 with curative intent and anastomosis formation were included from a prospectively maintained database. The primary outcome measure was the rate of AL. The secondary outcome measure was 5-year overall survival (OS).</br> <br><b>Results:</b> There were 6837 eligible patients. The rate of AL was 2.2% and 4.0% in patients with colon and rectal cancer, respectively. AL was a significant independent predictor of reduced 5-year OS in patients who underwent curative surgery for rectal cancer (odds ratio 2.293, p = 0.009). Emergency surgery (p = 0.015), surgery at a public hospital (p = 0.002), and an open surgical approach (p = 0.021) were all associated with a significantly higher risk of AL in patients with colon cancer, with higher rates of AL noted in left colectomies as compared to right hemicolectomies (4.4% <i>vs.</i> 1.3%, p < 0.001). In rectal cancer patients, AL was associated with neoadjuvant chemoradiotherapy (p = 0.038) and male gender (p = 0.002). The anastomosis formation technique (hand-sewn <i>vs.</i> stapled) did not impact the rate of AL (p = 0.116 and p = 0.198 with colon and rectal cancer, respectively).</br> <br><b>Discussion:</b> Clinicians should be cognizant of the predictive factors for AL and should consider early intervention for at-risk patients.</br>.

Obesity may not be related to pathologic response in locally advanced rectal cancer following neoadjuvant chemoradiotherapy

Background

The aim of this study is to evaluate the correlation between body mass index (BMI) and body fat composition (measured with radiological fat parameters (RFP)) and pathological response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer patients. The secondary aim of the study was to assess the role of BMI and RFP on major surgical complications, overall survival (OS), and disease-free survival (DFS).

Methods

All patients who underwent surgical resection following nCRT between 2005 and 2017 for mid-low rectal cancer were retrospectively collected. Visceral fat area (VFA), superficial fat area (SFA), visceral/superficial fat area ratio (V/S), perinephric fat thickness (PNF), and waist circumference (WC) were estimated by baseline CT scan. Predictors of pathologic response and postoperative complications were investigated using logistic regression analysis. The correlations between BMI and radiologic fat parameters and survival were investigated using the Kaplan-Meier method and log-rank test.

Results

Out of 144 patients included, a complete (TRG1) and major (TRG1+2) pathologic response was reported in 32 (22%) and 60 (45.5%) cases, respectively. A statistically significant correlation between BMI and all the RFP was found. At a median follow-up of 60 (35-103) months, no differences in terms of OS and DFS were found considering BMI and radiologic fat parameters. At univariable analysis, neither BMI nor radiologic fat parameters were predictors of complete or major pathologic response; nevertheless, VFA, V/S>1, and BMI were predictors of postoperative major complications.

Conclusions

We found no associations between BMI and body fat composition and pathological response to nCRT, although VFA, V/S, and BMI were predictors of major complications. BMI and RFP are not related to worse long-term OS and DFS.