Long-term outcome after chronic anastomotic leakage following surgery for low rectal cancer

Repeated Treatments for Chronic Colorectal and Coloanal Anastomotic Leaks are Associated With a Higher Chance of a Permanent Stoma

BackgroundWe aimed to identify risk factors associated with chronic anastomotic leak (AL) treatment failure.MethodsAdult patients surgically treated for chronic AL after colorectal or coloanal anastomosis for benign and malignant indications were included. The primary outcome was predictors of AL treatment failure, defined as failure to restore bowel continuity and/or having a permanent stoma at completion of treatment. Step-wise multivariable logistic regression analysis of factors that reached statistical significance on univariable analyses was undertaken.Results60 patients [41 (68.3%) males; average age: 56 (SD 6.7) years; and average BMI: 24 (SD 2.1) kg/m2] were included. 61% of patients were referred for treatment; 46 (76.7%) had colorectal and 14 (23.3%) had coloanal anastomosis at index surgery. 38 (63.3%) had successful treatment; 22 (36.7%) required permanent stoma. Patients who failed treatment on univariable analysis were likely older (OR 1.06; P = 0.045), had >2 prior attempted AL treatments (OR 9.53; P = 0.042), and end colostomy at AL surgery (OR 25.4; P = 0.032). Predictors of failed treatment of chronic AL on multivariable analysis were older age and >2 prior treatments.ConclusionMore than 1/3 of patients with chronic AL eventually fail to achieve restored intestinal continuity. Risk factors on multivariable regression are >2 treatments for chronic AL before definitive therapy and older age at treatment. We recommend considering redoing the anastomosis earlier in the treatment of chronic AL.

Bedside endoscopic inspection of colorectal anastomoses in the early postoperative period: a 2-center prospective feasibility study

PURPOSE

Early diagnosis of anastomotic leakage (AL) after colorectal surgery can reduce severe postoperative morbidity and ensure successful treatment. This study evaluated the feasibility of bedside endoscopic inspection of the anastomosis early postoperatively using a point-of-care digital rectoscope.

METHODS

This prospective study was conducted at 2 tertiary centers. Patients who underwent minimally invasive or open sphincter-preserving surgery with creation of a colorectal or coloanal anastomosis were included. Data were collected from December 2022 to October 2023. Bedside anastomotic inspections were performed postoperative day (POD) 3 to 5 using a point-of-care digital rectoscope. The primary outcome was feasibility, defined as adequate clinical assessment of the anastomosis during bedside inspection. Secondary outcomes included patient tolerability, efficacy compared to other diagnostic methods, and clinical outcomes during 90 days of follow-up.

RESULTS

In total, 35 patients were included. All bedside anastomotic inspections were carried out successfully. The examination showed complete visibility of the entire anastomosis in 30 patients (85.7%), with minimal discomfort reported by 3 (8.6%). No adverse events were recorded. AL occurred in 6 patients (17.1%), with 3 cases detected during bedside inspections between POD 3 and 5. Two leaks were detected without clinical or biochemical suspicion. Three patients with negative rectoscopy between POD 3 and 5 were later diagnosed with AL: 2 by a computed tomography scan and 1 by a bedside rectoscopy.

CONCLUSION

Bedside inspection of rectal anastomoses early postoperatively is feasible and tolerable for patients. Routine anastomotic inspections can detect early AL even without clear clinical or biochemical signs.

Nomogram for predicting the probability of rectal anastomotic re-leakage after stoma closure: a retrospective study

BACKGROUND

In this study, we aimed to identify the risk factors in patients with rectal anastomotic re-leakage and develop a prediction model to predict the probability of rectal anastomotic re-leakage after stoma closure.

METHODS

This study was a single-center retrospective analysis of patients with rectal cancer who underwent surgery between January 2010 and December 2020. Among 3225 patients who underwent Total or Partial Mesorectal Excision (TME/PME) surgery for rectal cancer, 129 who experienced anastomotic leakage following stoma closure were enrolled. Risk factors for rectal anastomotic re-leakage were analyzed, and a prediction model was established for rectal anastomotic re-leakage.

RESULTS

Anastomotic re-leakage after stoma closure developed in 13.2% (17/129) of patients. Multivariable analysis revealed that neoadjuvant chemoradiotherapy (odds ratio, 4.07; 95% confidence interval, 1.17-14.21; p = 0.03), blood loss > 50 ml (odds ratio, 4.52; 95% confidence interval, 1.31-15.63; p = 0.02), and intersphincteric resection (intersphincteric resection vs. low anterior resection: odds ratio, 6.85; 95% confidence interval, 2.01-23.36; p = 0.002) were independent risk factors for anastomotic re-leakage. A nomogram was constructed to predict the probability of anastomotic re-leakage, with an area under the receiver operating characteristic curve of 0.828 in the cohort. Predictive results correlated with the actual results according to the calibration curve.

CONCLUSIONS

Neoadjuvant chemoradiotherapy, blood loss > 50 ml, and intersphincteric resection are independent risk factors for anastomotic re-leakage following stoma closure. The nomogram can help surgeons identify patients at a higher risk of rectal anastomotic re-leakage.

Application of laparoscopic modified Bacon operation in patients with low rectal cancer and analysis of the changes in anal function: A retrospective single-center study

Purpose

To investigate the value of modified Bacon operation in patients with low rectal cancer.

Methods

Retrospective analysis of 60 patients treated with laparoscopic surgery for low rectal cancer in the Department of Colorectal and Anal Surgery, Jingzhou Hospital affiliated to Yangtze University, from 2019 to 2022, divided into observation and control groups based on the method of the operation (laparoscopic modified Bacon operation group and laparoscopic Dixon operation with prophylactic ileostomy group). We compared the variations between the two groups.

Results

The length of the abdominal surgical incision was shorter in the observation group than in the control group(P<0.05). In the observation group, the length of hospital stay after the first operation was shorter(P<0.05), the both operations time and the second intraoperative bleeding were less(P<0.05), the DET score at one week after the first operation and the VAS after both operations were fewer than in the control group(P<0.05), the postoperative rate of ischemic necrosis of the exposed bowel was higher(P<0.05), and the anal function was poorer in the short term after the second operation compared with the control group(P<0.05), but there was no significant difference between the anal function at 6 months after the second operation compared with the control group(P>0.05).12 months after the second operation, the anal function has recovered to the preoperative level in the observation group(P>0.05).

Conclusion

The laparoscopic modified Bacon operation has smaller abdominal wounds, which reduces postoperative pain; it does not require the use of staplers, which reduces the patient's financial burden; no postoperative anastomotic leakage occurs, and a more satisfactory anal function can be obtained.