Clinical characteristics of anastomotic leakage after an anterior resection for rectal cancer by assessing of the international classification on anastomotic leakage

Does aortic calcification really affect anastomotic leakage after rectal cancer surgery?

The purpose of the current study was to analyze whether aortic calcification had impact on the anastomotic leakage (AL) after rectal cancer (RC) surgery. We collected patients' information from January 2011 to January 2020 in a single teaching hospital. Preoperative computed tomography images were obtained. Abdominal aortic calcification (AAC), superior mesenteric aortic calcification, and inferior mesenteric aortic calcification were recorded. The difference of AL and grade C AL was calculated. A total of 2412 RC patients were included in this study. Ninety-seven (4.0%) RC patients experienced AL and 47 (1.9%) RC patients experienced grade C AL. The amount of AAC, superior mesenteric aortic calcification, and inferior mesenteric aortic calcification was 1546 (64.1%), 128 (5.3%), and 31 (1.3%). The AL group had higher portion of AAC (P = .019) than the no AL group, and the grade C AL group had higher portion of AAC (P = .016) than the no grade C AL group. In univariate logistic regression analysis, AAC was a significant potential factor for AL (P = .021, OR = 1.739, 95% CI = 1.088-2.779) and grade C AL (P = .019, OR = 2.339, 95% CI = 1.115-4.986). However, in multivariate logistic regression, AAC was not an independent predictive factor for AL (P = .157, OR = 1.443, 95% CI = 0.871-2.358) or grade C AL (P = .064, OR = 2.055, 95% CI = 0.960-4.399). AAC was associated with higher amount of AL and grade C AL, however, AAC was not an independent predictive factor for AL or grade C AL.

Association between circular stapler size and anastomotic leakage after laparoscopic low anterior resection for rectal cancer

Background

Anastomotic leakage (AL) is one of the most severe and frequent complications occurring after laparoscopic low anterior resection (LAR) for rectal cancer. This study aimed to examine the association between circular stapler size and AL after laparoscopic LAR.

Methods

This retrospective single-institution study involved 181 patients with rectal cancer who underwent laparoscopic LAR performed by a single surgical team between July 2016 and June 2021. The characteristics of the patients were analyzed. Risk factors for AL were identified via univariate and multivariate analyses. Additionally, a further propensity score matching (PSM) analysis was performed to reduce the selection bias.

Results

Among the 181 patients who underwent laparoscopic LAR for rectal cancer, 17 (9.4%) developed clinical AL. In the univariate and multivariate analyses, male sex, incomplete intestinal obstruction, and the usage of a 32-mm stapler during the surgery were independent risk factors for the occurrence of AL. Furthermore, the PSM analysis confirmed that the incidence of AL with a 32-mm stapler was higher than that with a 29-mm stapler after laparoscopic low anterior resection. However, there was no difference in the incidence of anastomotic bleeding and stenosis.

Conclusion

Choosing a smaller-diameter circular stapler may reduce the incidence of AL after laparoscopic LARfor rectal cancer without increasing the incidence of anastomotic stenosis.

Complications after bowel resection for inflammatory bowel disease associated cancer: a systematic literature review

INTRODUCTION

Inflammatory bowel disease (IBD) associated colorectal cancer represents the 1-2% of all patients affected by colorectal carcinoma, but it is frequent responsible for death in these patients. Aim of this systematic review was to report the complications after bowel resection in patients with IBD associated cancer.

EVIDENCE ACQUISITION

A systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was carried out in PubMed, Embase, Cochrane and Web of Science databases. A total of 54,084 articles were found. Of these 38,954 were eliminated because were duplicates between the searches. Of the remaining 15,130 articles, 14,888 were excluded after screening title and abstract.

EVIDENCE SYNTHESIS

Two-hundred-forty-two articles were fully analyzed, and 239 further articles were excluded. Finally, three articles were included for a total of 63 patients. Overall, 38 early postoperative complications (60.3%) were observed. Of these, anastomotic leakage occurred in 13 patients (20.6%). The indication for surgery was ulcerative colitis in 52 patients (82.5%), Crohn's disease in 8 patients (12.7%) and indeterminate colitis in 3 patients (4.8%). Intraoperative complications, readmission and postoperative mortality were not observed.

CONCLUSIONS

Complication rate after bowel resection for IBD associated cancer is not different from complication rate after colorectal surgery for other diseases. Given the high probability of developing a cancer and the time correlated occurrence of malignancy in IBD patients, it should be debated if a surgical resection should be performed as soon as dysplasia is detected in IBD patients or earlier in their life.

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR). Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis. Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation. Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Retrospective study of active drainage in the management of anastomotic leakage after anterior resection for rectal cancer

Objective

Anastomotic leakage (AL) is the most serious postoperative complication following anterior resection for rectal cancer. We aimed to investigate the efficacy of active drainage for the management of AL.

Methods

This was a retrospective study using information from a database of patients who underwent colorectal resection without a defunctioning ileostomy at our center between September 2013 and January 2021. We identified 122 cases with definitive AL who did not require revision emergent laparotomy. Among these patients, we evaluated those who received active drainage to replace the original passive drainage.

Results

There were 62 cases in the active drainage group and 60 cases in the passive drainage group. The active drainage group had a shorter mean AL spontaneous resolution time (26.9 ± 3.3 vs. 32.2 ± 4.8 days) and lower average hospitalization costs (82,680.6 vs. 92,299.3 renminbi (RMB)) compared with the passive drainage group, respectively. Moreover, seven patients in the passive drainage group subsequently underwent diverting stoma to resolve the Al, while all ALs resolved spontaneously after replacing the passive drainage with active drainage.

Conclusions

Our study suggests that active drainage may accelerate the spontaneous resolution of AL.

Perioperative intrapelvic hyaluronate application as prophylaxis against complications following rectal anastomotic dehiscence: An experimental study

PURPOSE

The aim of this experimental study was to test the method of prevention of postoperative complications, especially infectious, in partial dehiscence following stapler anastomosis in rectal surgeries.

METHODS

The method includes the application of a hyaluronic acid-based gel in combination with triclosan, which has antibacterial properties. The gel was applied to the space around the rectum with an artificial, precisely defined dehiscence so that the dehiscence was separated from the rest of pelvis and the peritoneal cavity to avoid the spread of infection. The study included 30 female pigs. The rectosigmoid colon was mobilized and transected completely. Anastomosis was constructed with circular staplers. A perforator was then used to create precisely defined artificial dehiscence. Subsequently the lesser pelvis was filled with hyaluronic gel such that the site of artificial dehiscence was covered completely.

RESULTS

All animals survived for 14 days until the second-look revision with no signs of failure in the anastomosis healing, local inflammation, and sepsis or postoperative complications, such as chills, refusal of liquid or feed, abdominal distension, and bowel obstruction.

CONCLUSION

Hyaluronic acid applied as a precursor solution around the rectal anastomosis fills the lesser pelvis perfectly. It prevents the leakage of intestinal contents in the lesser pelvis. Triclosan as an antibacterial substance prevents the spread of inflammation in the pelvis or even in the abdominal cavity.

A systematic review and meta-analysis on complications of transanal total mesorectal excision

AIM

Transanal total mesorectal excision (TaTME) is a surgical approach for treating mid to low rectal cancer as well as other colorectal diseases. Since the procedure is difficult to master, perioperative complications of TaTME should be examined precisely, especially during the early implementation phase of this procedure. The primary aim of this review was to determine a pooled morbidity and anastomotic leakage (AL) rate after TaTME surgery, and the secondary aim was to show the completeness of reporting of complications among the included studies, as well as the correlation between completeness and reported incidence of complications.

METHOD

A systematic review of literature was conducted using Medline, Embase and Cochrane databases, searching for observational studies reporting on complications after TaTME. Studies published between 1 January 2010 and 15 October 2019 were included. Meta-analysis on the proportion of morbidity, AL and intraoperative complications was performed.

RESULTS

Forty-one studies (2446 TaTME cases), consisting of 27 noncomparative studies and 14 comparative studies, were included, after screening 1711 possible studies. The pooled rates of overall morbidity and AL were 30.0% (95% CI 26.4%-34.0%) and 6.8% (95% CI 5.2%-8.9%), respectively. Subgroup analysis showed that the morbidity rate in studies that reported 30-day results (35.5%; 95% CI 31.8%-39.4%) was significantly higher than the rate in studies that did not define the follow-up length for complications (23.4%; 95% CI 17.8%-30.1%; p = 0.003). The rates of intraoperative urethral injury, rectal injury, vaginal injury and bladder injury were 0.3% (95% CI 0.1%-1.7%), 0.4% (95% CI 0.1%-2.2%), 0.3% (95% CI 0.1%-0.8%) and 0.3% (95% CI 0.1%-1.7%), respectively.

CONCLUSION

This meta-analysis shows that pooled perioperative complication rates were within acceptable ranges. However, the significant difference in overall morbidity rate between the studies with 30-day results and the studies without a specified follow-up time, indicates a large under-reporting of complications in many studies.

Management of postoperative complications after laparoscopic left hemicolectomy: an approach in modern times after incorporation of indocyanine green and full mobilization of the splenic flexure

BACKGROUND

The aim of this study was to report our experience in the management of complications after laparoscopic left hemicolectomy (LLH) after the incorporation in our clinical practice of intraoperative indocyanine green (ICG) fluorescence angiography (FA).

METHODS

In our last period after incorporation of ICG-FA, 277 unselected consecutive patients underwent laparoscopic colorectal surgery with this technology. Ninety-seven (35%) right hemicolectomy, 19 segmental resection of the splenic flexure (6.9%), 54 anterior resection of the rectum (19.5%) and 107 LLH (38.6%) were performed. Complications were graded according to Clavien-Dindo classification, and anastomotic leakages (AL) were graded according to Clavien-Dindo classification and to International Study Group of Rectal Cancer (ISGRC) classification.

RESULTS

Eight surgical and one medical complications (8.4%) were observed. Two AL occurred (1.9%). One drained spontaneously by drainage placed intraoperatively (Clavien-Dindo I, ISGRC A) and one treated by laparoscopic peritoneal lavage, leakage suture and ileostomy (Clavien-Dindo III-b, ISGRC C). Other complications were: wound infection (Clavien-Dindo II) (2); postoperative anemia caused by rectorrhagia (Clavien-Dindo II) (2); pelvic abscess between bladder and uterus (Clavien-Dindo III-a) (1); hemoperitoneum secondary to inferior mesenteric artery bleeding treated with peritoneal lavage and hemostasis (Clavien-Dindo III-b) (1); atrial fibrillation (Clavien-Dindo II) (1). All complications have been resolved.

CONCLUSIONS

The complication rate after LLH after the incorporation of ICG-FA is low, since the number of AL have dramatically decreased in comparison to our previous experience. The management of these patients proved to be safe and effective due to in all cases the complication has been resolved. Further studies are required to standardize the management of these patients.

Analysis of risk factors for anastomotic leakage after lower rectal Cancer resection, including drain type: a retrospective single-center study

Background

We investigated the correlations between surgery-related factors and the incidence of anastomotic leakage after low anterior resection (LAR) for lower rectal cancer.

Methods

A total of 630 patients underwent colorectal surgery between 2011 and 2014 in our department. Of these, 97 patients (15%) underwent LAR and were enrolled in this retrospective study. Temporary ileostomy was performed in each patient.

Results

Anastomotic leakage occurred in 21 patients (21.7%). Univariate analysis showed a significant association between operative duration (p = 0.005), transanal hand-sewn anastomosis (p = 0.014), and operation procedure (p = 0.019) and the occurrence of leakage. Multivariate regression reanalysis showed that underlying disease (p = 0.044), transanal hand-sewn anastomosis (p = 0.019) and drain type (p = 0.025) were significantly associated with the occurrence of leakage. The propensity-score analysis showed that closed drainage were 6.3 times more likely to have anastomotic leakage than open drainage in relation to the amount of postoperative drainage (ml), according to the inverse probability of treatment-weighted analysis.

Conclusions

Our results indicate that underlying disease, transanal hand-sewn anastomosis, and closed drain may be a risk and predictive factors for anastomotic leakage after LAR for lower rectal cancer. The notable finding was that closed drainage was related to the occurrence of anastomotic leakage and closed drainage was correlated with less volume of postoperative drain discharge than open drain.

Colorectal anastomosis dehiscence: a call for more detailed morphological classification

Introduction

A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology.

Aim

To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications.

Material and methods

This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7^th and 10^th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist.

Results

Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference.

Conclusions

Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Transanal drainage tube: alternative option to defunctioning stoma in rectal cancer surgery?

BACKGROUND

Anastomotic leakage (AL) remains the most dreaded complication after rectal cancer surgery. The aim of this study was to evaluate the role of transanal drainage tube in reducing the incidence, severity and hospital costs respect to defunctioning stoma (DS).

METHODS

Considering 429 patients consecutively operated for rectal adenocarcinoma, the tube was placed in 275 (Group A) and not placed in 154 (Group B) patients. A DS was created in a subgroup of 54 patients among the latter.

RESULTS

The incidence of AL was significantly higher in Group B (P=0.007). In patients with DS, the incidence was higher than Group A (P=NS). Grade C complications were significantly higher in Group B (P=0.006) and Grade B complications were significantly higher in patients with DS (P=0.03). Estimated economic benefit was 4,000 Euros for each patient.

CONCLUSIONS

Transanal drainage tube may be a safe and effective alternative to DS in many cases. The incidence of leakage and Grade C complications are reduced albeit not significantly but Grade B complications are significantly lower. Although the AL incidence was similar in our experience, the tube allows to avoid a stoma-related consequence and the need for reversal procedure with economic benefit.

A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study

Purpose. Protective ileostomy (PI) during anterior resection (AR) for rectal cancer decreases the incidence of anastomotic leakage (AL) and its subsequent complications, but it may itself be the cause of morbidity. The aim is to report our protocol in the management of selected patients with borderline risk to develop AL after laparoscopic AR and ghost ileostomy (GI) creation. Methods. Patients who underwent AR were stratified based on the risk to develop AL. Steps to avoid PI were splenic flexure mobilization, reduced pelvic bleeding, to employ different stapler charge if neoadjuvant chemo-radiotherapy is performed, to perform a horizontal section of the rectum, to evaluate the anastomotic vascularization with a fluorescence angiography, to perform a side-to-end anastomosis, intraoperative methylene blue test, pelvic and transanal drainage tubes placement, and the GI creation. After surgery, inflammatory blood markers were monitored to detect potential leakages. Results. Twelve patients were included. In one case, the specimen proximal section was changed after fluorescence angiography. There were no conversions in this group of patients. One postoperative AL occurred and was treated with radiological drainage placement, not being necessary to convert the GI. PI was avoided in 100% of cases. Conclusions. Patients' characteristics cannot be changed, but several steps were used to avoid routine PI creation. The present protocol could be a valuable option to avoid PI in selected patients. Further studies with a wider sample size, and defined criteria to stratify the patients based on the risk to develop AL, are required.

Pelvic Drain After Laparoscopic Low Anterior Resection for Rectal Cancer in Patients With Diverting Stoma

BACKGROUND

This study is intended to assess whether the use of pelvic drain reduces incidence of pelvic sepsis in the era of laparoscopic low anterior resection (LAR).

PATIENTS AND METHODS

In total, 200 of consecutive patients who underwent laparoscopic LAR for rectal cancer with diverting stoma were analyzed.

RESULTS

Pelvic sepsis occurred in 14 of 110 patients (12.7%) in the drain group and in 9 of 90 patients (10.0%) in the no drain group (P=0.548). Furthermore, there were no differences in the incidence of anastomotic leakage, time to diagnosis of pelvic sepsis, and type of treatments for pelvic sepsis.

CONCLUSIONS

Prophylactic pelvic drain use after laparoscopic LAR in patients with diverting stoma does not reduce incidence of pelvic sepsis. Routine use of pelvic drain is not recommended. This study was registered at UMIN (Registration Number: UMIN000026076).

Neopterin, kynurenine and tryptophan as new biomarkers for early detection of rectal anastomotic leakage

Introduction

At present, there are no strong predictors, nor a useful scoring system, that clearly identifies patients at risk for anastomotic leakage.

Aim

This study aimed to investigate a new method that assesses this risk by monitoring levels of neopterin, tryptophan, and kynurenine, in bodily fluids.

Material and methods

This prospective study included patients who underwent elective rectal resection for carcinoma. The basic condition for inclusion was rectal anastomosis using the double-stapling technique. Preoperative levels of neopterin, tryptophan, kynurenine, and their ratios, were assessed with blood and urine samples. These levels were then monitored for 6 postoperative days in venous blood, urine, and abdominal drainage fluid.

Results

A total of 42 patients were enrolled in the study. Thirty-six patients underwent a laparoscopic resection and 6 patients had an open procedure. No differences were found among neopterin, tryptophan, and kynurenine serum levels. However, the groups were observed to have significant differences in the urinary neopterin/creatinine ratio: the preoperative neopterin/creatinine ratio was 139.5 μmol/mol in the group with leakage, vs 114.8 μmol/mol in the group without complications, p = 0.037. The same results were observed during the postoperative period, p = 0.012. Additionally, the group with complications had a higher mean value of neopterin in drainage fluid, p = 0.048.

Conclusions

Our study demonstrated that high preoperative levels of urinary neopterin could be interpreted as a risk for anastomotic leakage. Moreover, pathological levels of neopterin in urine and abdominal drainage fluid could be useful for early identification of anastomotic leakage during the postoperative period prior to its clinical development.

Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database

BACKGROUND

Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant.

OBJECTIVE

This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer.

DESIGN

All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit.

SETTINGS

Data were derived from the Dutch Surgical Colorectal Audit.

MAIN OUTCOME MEASURES

The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured.

RESULTS

Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage.

LIMITATIONS

Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database.

CONCLUSIONS

Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.