Oncologic impact of anastomotic leakage after low anterior resection for rectal cancer

Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases

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.

Healing of colonic anastomosis in rats under obstructive ileus conditions

BACKGROUND

The anastomosis leak in colon resections is a crucial post-operative complication with significant morbidity and mortality.  Methods: Forty (40) Wistar rats were allocated in two groups. In SHAM group only anastomosis was performed. In ILEUS group anastomosis was performed following one day of ileus. Animals in both groups were subdivided in two groups according to the day they were sacrificed, 4th or 8th post-operative day. A number of variables between the groups were estimated.

RESULTS

Body weight loss was higher following obstructive ileus on both days. Adhesion score in 4th and 8th post-operative day was higher in ILEUS1, ILEUS2 groups compared to SHAM1, SHAM2 groups respectively (p<0.001 for both). Neovascularization decreased following obstructive ileus compared to control on the 4th day (ILEUS1 vs. SHAM1, p=0.038). Bursting pressure was lower in ILEUS2 group than SHAM2 group (p<0.001). The number of fibroblasts decreased following obstructive ileus compared to control on the 4th and 8th day (ILEUS1 vs. SHAM1, p=0.001, ILEUS2 vs SHAM2, p=0.016). Hydroxyproline concentration was decreased in ILEUS2 group compared to SHAM2 group (p<0.001).

CONCLUSIONS

The balance of collagenolysis and collagenogenesis plays a decisive role in the healing of anastomoses following bowel obstruction. Under those circumstances, anastomosis' bursting pressure is reduced owning to decreased neovascularization, reduced fibroblast presence and lower hydroxyproline concertation. In our study, local inflammation, neocollagen concentration and collagenase activity were not associated with this adverse effect. However, further research should delineate the mechanisms of healing of colonic anastomoses and identify those factors that can improve our outcomes.

Redefined hyponatremia as a marker to exclude the diagnosis of anastomotic leakage after colorectal cancer surgery

Objective

Our objective was to investigate the association between anastomotic leakage (AL) and hyponatremia after colorectal cancer surgery.

Methods

All anastomoses in colorectal cancer surgery performed in our hospital between January 2015 and December 2017 were retrospectively identified. According to the diagnostic criteria of AL, the patients were divided into an AL group and a no anastomotic leakage (NAL) group.

Results

We reviewed records of 498 consecutive colorectal cancer patients. The total incidence of AL was 5.4%. Postoperative serum sodium levels differed significantly: 137.63 ± 4.29 and 139.81 ± 3.41 mmol/L in the AL and NAL groups, respectively. By using area under the receiver-operating characteristic (auROC) curves, we determined the optimum postoperative serum sodium cut-off to be 139.5 mmol/L and redefined hyponatremia as postoperative serum sodium <139.5 mmol/L. Redefined hyponatremia had an auROC of 0.65, corresponding to a 97.2% negative predictive value. The negative predictive value reached 99.1% when serum sodium level was combined with leukocytosis. Multivariable analysis found that redefined hyponatremia (odds ratio, 1.176) was an independent predictive factor for AL.

Conclusions

Redefined hyponatremia has good negative predictive value for AL diagnosis after colorectal cancer surgery and could be used as a marker to exclude the diagnosis.

Diverting Stoma Versus No Diversion in Laparoscopic Low Anterior Resection: A Single-center Retrospective Study in Japan

BACKGROUND/AIM

The purpose of this retrospective study was to describe the benefits and risks of a diverting stoma (DS) in laparoscopic low anterior resection (LAR) for rectal cancer.

MATERIALS AND METHODS

A total of 140 and 167 patients without and with DS, respectively, were included in this study in a high-volume cancer center of Japan within an 8-year period.

RESULTS

Small bowel obstruction occurred more frequently in patients with DS (2.86% vs. 16.17%, p<0.001). The difference in anastomotic leakage rate was not statistically significant (11.43% vs. 10.18%, p=0.72). In multivariate analysis, the operating time was associated with a higher rate of leakage in LAR [odds ratio (OR) 8.772, 95% confidence interval (CI)=1.002-1.012, p=0.027].

CONCLUSION

Operating time was associated with a higher rate of leakage in LAR for low rectal cancer. A DS did not reduce anastomotic leakage but increased the risk of postoperative intestinal obstruction in laparoscopic LAR.

Does robotics improve minimally invasive rectal surgery? Functional and oncological implications

OBJECTIVE

Robot-assisted surgery has been reported to be a safe and effective alternative to conventional laparoscopy for the treatment of rectal cancer in a minimally invasive manner. Nevertheless, substantial data concerning functional outcomes and long-term oncological adequacy is still lacking. We aimed to assess the current role of robotics in rectal surgery focusing on patients' functional and oncological outcomes.

METHODS

A comprehensive review was conducted to search articles published in English up to 11 September 2015 concerning functional and/or oncological outcomes of patients who received robot-assisted rectal surgery. All relevant papers were evaluated on functional implications such as postoperative sexual and urinary dysfunction and oncological outcomes.

RESULTS

Robotics showed a general trend towards lower rates of sexual and urinary postoperative dysfunction and earlier recovery compared with laparoscopy. The rates of 3-year local recurrence, disease-free survival and overall survival of robotic-assisted rectal surgery compared favourably with those of laparoscopy.

CONCLUSIONS

This study fails to provide solid evidence to draw definitive conclusions on whether robotic systems could be useful in ameliorating the outcomes of minimally invasive surgery for rectal cancer. However, the available data suggest potential advantages over conventional laparoscopy with reference to functional outcomes.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients

OBJECTIVE

We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection.

BACKGROUND

The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial.

METHODS

The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections.

RESULTS

The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)].

CONCLUSIONS

The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

Closure of loop ileostomy: potentially a daycase procedure?

BACKGROUND

Four thousand four hundred and twenty-seven ileostomy closures were performed in the UK in 2008-2009, (35,432 bed days). None were recorded as being performed as a daycase procedure. Our aim is to evaluate the morbidity and mortality associated with this procedure and to investigate whether daycase surgery is feasible.

METHOD

Patients having closure of loop ileostomy were identified retrospectively from May 2005 to July 2010. The primary surgery, method of ileostomy closure, length of hospital stay and early (≤30 days) or late (>30 days) complications were recorded.

RESULTS

A total of 138 patients were evaluated. The median age was 63 (17-83) years and 64% were male patients. The primary surgery was predominantly anterior resection (74%). Median time from initial surgery to reversal was 37 (1-117) weeks. The median length of hospital stay was 4 (1-39) days. Applying a 23-h discharge protocol to our results excluded 18 patients categorised as ASA3. Ninety-six patients (80%) met the discharge criteria for a potential 23-h hospital stay. The expected readmission rate within 30 days of surgery was 12% (n = 14). 85 patients (71%) did not suffer an early complication. There were 35 early complications (30%), 10 general and 25 specific to the procedure, but serious only in 5%. There were no deaths in the eligible patients.

CONCLUSION

Closure of loop ileostomy in our series is safe, with a low serious morbidity rate. It may be feasible to perform reversal of ileostomy as a daycase/23-h stay. We intend to implement a 23-h stay for reversal of ileostomy.