Intraoperative rectal washout in rectal cancer surgery: a survey of current practice in the UK

Intraluminal washout in rectal and sigmoid colon cancer surgeries with double-stapling technique anastomosis: A single-institution prospective study

Aim

This study aimed to determine the necessity of intraluminal washout through cytological assessment to prevent implantation of exfoliated cancer cells (ECCs) in patients with rectal and sigmoid cancers.

Methods

We studied 140 patients with either sigmoid or rectal cancer who underwent anastomosis surgery using a double-stapling technique. An intraluminal washout sample was collected before and after irrigation with 1000, 1500, or 2000 mL of physiological saline or distilled water. Cytological assessments were conducted using the Papanicolaou classification system, where classes IV and V indicated positive cytological findings.

Results

Initially, 46.4% of the patients (65 out of 140) had positive ECCs. Patients with cancer cells had a significantly shorter distal free margin (DM) from the tumor (p < 0.001). The length of the DM was significantly associated with the tumor distance from the anal verge (p < 0.001). After irrigation with 2000 mL, ECCs were found in only 7.3% of patients. Logistic regression analysis showed that DM (≤50 mm) and tumor size (≥50 mm) were independent risk factors for positive ECCs after intraluminal washout, regardless of the type of irrigation solution used.

Conclusion

In patients with sigmoid colon cancer, adequate preoperative bowel preparation, a long DM, and a small tumor size, a 1000 mL intraluminal washout may be sufficient. By contrast, in patients with rectal cancer with a short DM and a large tumor size, a ≥2000 mL intraluminal washout is required. The different types of irrigation solution did not affect the ECCs. Large randomized controlled trials are required to confirm these results.

Risk of metachronous colorectal cancer associated with polypectomy during endoscopic diagnosis of colorectal cancer

BACKGROUND AND AIM

There are conflicting reports regarding the risk of metachronous colorectal cancer (CRC) subsequent to colonoscopy with polypectomy or biopsy performed concurrently with diagnostic biopsies for CRC. We aimed to establish the 5-year risk of CRC in patients who had synchronous polypectomy or biopsies during the colonoscopy at which CRC was diagnosed.

METHODS

This is a single-centre retrospective case-control study of adults who underwent surgical resection for CRC over a 2-year period (January 2016 to December 2017). Colonoscopy details of interest were the location of the CRC, polypectomy and non-CRC biopsy sites. In patients with CRC at index colonoscopy, we sought associations between the occurrence of metachronous CRC and the sites from which endoscopic specimens had been obtained.

RESULTS

Our study population comprised 225 patients with a median (IQR) age of 71 (60-77) years. Polypectomy or biopsy at a non-CRC site had been performed during the index colonoscopy in 108 patients (48%), including 83 (37%) polypectomies outside the surgical resection field. There were 8 (3.6%) metachronous CRCs: 1 (0.4%) at the site of endoscopic mucosal resection for a 15-mm sessile serrated lesion, 3 (1.3%) anastomotic site CRCs and 4 (1.8%) at other sites within the colon. There was no significant difference in the prevalence of metachronous CRC in patients who underwent polypectomy/biopsy at the index colonoscopy compared with those who did not (1.9% vs. 5.1%, p = 0.283).

CONCLUSION

There was no significant increased risk of metachronous CRC subsequent to synchronous polypectomy or biopsy during the colonoscopy at which CRC was diagnosed.

The influence of intraoperative rectal washout on local recurrence of colorectal cancer following curative resection: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of rectal washout in preventing local recurrence of distal colorectal cancer following curative resection.

METHODS

A systematic review and meta-analysis was performed after a literature search was conducted on MEDLINE, EMBASE, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the ISRCTN registry. The study was reported using PRISMA guidelines. The primary endpoint was incidence of local recurrence of cancer after distal colonic and rectal cancer surgery.

RESULTS

After screening, 8 studies with a total sample size of 6739 patients were identified. At 5-year follow-up, local recurrence in the washout group (WO) was 6.08% compared to 9.48% in the no-washout group (NWO) group (OR 0.63, 95% CI = 0.51-0.78, Chi² = 6.76, df = 7, p = 0.45). The relative risk reduction was 36.9%. To exclude a 36.9% relative risk reduction from 9.48 to 6.08% with a 5% significance level and 80% power a randomized control trial would require a total sample size of 1946 participants distributed equally between the two treatment arms.

CONCLUSION

It is safe to recommend the use of rectal washout for left sided and rectal tumour resections. It is a simple and safe step during colorectal surgery that appears to improve long-term oncological outcomes and was not reported to be associated with any complications.

Rectal washout does not increase the complication risk after anterior resection for rectal cancer

Background

To reduce local recurrence risk, rectal washout (RW) is integrated in the total mesorectal excision (TME) technique when performing anterior resection (AR) for rectal cancer. Although RW is considered a safe practice, data on the complication risk are scarce. Our aim was to examine the association between RW and 30-day postoperative complications after AR for rectal cancer.

Methods

Patients from the Swedish Colorectal Cancer Registry who underwent AR between 2007 and 2013 were analysed using multivariable methods.

Results

A total of 4821 patients were included (4317 RW, 504 no RW). The RW group had lower rates of overall complications (1578/4317 (37%) vs. 208/504 (41%), p = 0.039), surgical complications (879/4317 (20%) vs. 140/504 (28%), p < 0.001) and 30-day mortality (50/4317 (1.2%) vs. 12/504 (2.4%), p = 0.020). In multivariable analysis, RW was a risk factor neither for overall complications (OR 0.73, 95% CI 0.60–0.90, p = 0.002) nor for surgical complications (OR 0.62, 95% CI 0.50–0.78, p < 0.001).

Conclusions

RW is a safe technique that does not increase the 30-day postoperative complication risk after AR with TME technique for rectal cancer.

Is Intraluminal Washout Necessary for Patients with Sigmoid Colon Cancer to Eliminate Exfoliated Cancer Cells as in Patients with Rectal Cancer? A Pilot Study at a Single Institute

Objectives:

Rectal stump washout has been widely performed to prevent the implantation of exfoliated cancer cells (ECCs) in patients with rectal cancer. However, it remains unclear whether intraluminal washout before transection is required in patients with sigmoid colon cancer. Therefore, this pilot study was conducted to elucidate the necessity of intraluminal washout for sigmoid colon cancer patients in comparison with rectal cancer patients by cytological assessments.

Methods:

A total of 16 patients with sigmoid colon cancer and 24 patients with rectal cancer who underwent sigmoidectomy or anterior resection with anastomosis using double-stapling technique were enrolled. A transanal washout sample was collected before washout and after irrigation with 500 and 1,000 mL of saline. Cytological assessments were conducted according to the Papanicolaou classification, and class IV and V cells were defined as malignant.

Results:

Before washout, exfoliated cancer cells were found in 15 of 24 (62.5%) patients with rectal cancer and in 1 of 16 (6.2%) patients with sigmoid colon cancer (p < 0.001). Distal-free margin from the tumor was significantly shorter in patients with cancer cells (p = 0.002), and the length of the distal-free margin was significantly associated with the tumor location. After irrigation with 500 and 1,000 mL of saline, no cancer cell was found in all patients with sigmoid colon cancer, whereas ECCs were still found in five patients with rectal cancer (20.8%).

Conclusions:

Intraluminal washout with 1,000 mL may be sufficient for sigmoid colon cancer patients with longer distal-free margin. A large-scale, randomized controlled study is necessary to confirm these results.

Ligating the rectum with cable tie facilitates rectum transection in laparoscopic anterior resection of rectal cancer

PURPOSE

Proper transection of the distal rectum is important for reconstruction of bowel continuity in rectal cancer surgery. In this study, we introduced a modified technique for ligation of the distal rectum, and investigated its safety and efficiency to facilitate the rectum transection.

METHODS

After complete mobilization and transection of the mesorectum, a cable tie was carefully positioned distal to the tumor, followed by washout and transecting the rectum with a linear stapler. From September 2017 to June 2018, consecutive 67 mid-low rectal cancer patients with laparoscopic anterior resection underwent this technique. Clinical data of these patients, including number of firings, pathological and operative variables, and postoperative outcomes, were compared with those of 132 consecutive patients who underwent traditional surgery from January 2016 to August 2017.

RESULTS

Compared with the traditional method, cable tie ligation significantly reduced the number of firings (1.1 ± 0.32 vs. 1.3 ± 0.52, p < 0.001). A very high ratio of one firing transection of rectum was observed in the cable tie group (94.0% vs. 68.9%, p < 0.001), even in patients with tumor at or below the peritoneal reflection (90.2% vs. 54.4%, p < 0.001), in male patients (95.5% vs. 65.8%, p < 0.001), and in obese patients (93.8% vs. 64.9%, p = 0.005). The mean distal margin was longer in the cable tie group (3.19 ± 1.77 cm vs. 2.54 ± 1.36 cm, p = 0.005), with no positive distal margin observed. The operation time, quality of mesorectum, and morbidity between two groups were comparable. Two leaks (3.0%) in the cable tie group were observed, similar to 3.8% in the control.

CONCLUSIONS

Ligation of the rectum with a cable tie reduces the number of cartridges, and increases the rate of one stapler firing for rectal transection, even in those difficult cases like male, overweight, and low rectal cancer patients. It is also useful for occlusion of the rectum before washout. It is safe, feasible, and worthwhile for popularization.

TRIAL REGISTRATION

Registered at ClinicalTrial.gov, number NCT03570684.

A New Surgical Device for Anterograde Intraoperative Rectal Washout

BACKGROUND

Colorectal cancer is the fourth most diffuse cause of death in the world and local recurrence is associated with a reduced long-term life expectancy, with a reduced quality of life. Rectal washout at the anastomosis site leads to a statistically significant reduction of local recurrences.

METHODS

We developed the idea of a new laparoscopic stapler with an integrated washout system that could decontaminate the rectal stump before resection, without the need to enlarge the standard surgical incision or even to distort the incision site, closing the rectal stump just below the inferior part of the cancer, and then proceeding with the resection and stapling of the distal part of the tumor. Combined with these canonical functionalities, the new device, equipped with a patented washout system (patent number EP 3103401A1) will also allow to inject in the closed bowel a physiologic saline liquid.

RESULTS

In force of the mechanical action of the liquid injected, carcinogenic exfoliated cells eventually floating in the affected region of the colonic lumen will be expelled through the anal orifice. The intraoperative rectal washout, both in minimally invasive and in traditional open surgery, thus becomes a simple, effective, and reproducible procedure.

CONCLUSIONS

We describe the technical features and the possible clinical applications of a potentially new surgical laparoscopic stapler coupled with an integrated irrigation system. We have patented the system and we are developing a prototype with the aim to start an experimental pilot study.

The effect of rectal washout on local recurrence following rectal cancer surgery

Introduction Local recurrence after surgery for rectal cancer is associated with significant morbidity and debilitating symptoms. Intraoperative rectal washout has been linked to a reduction in local recurrence but there is no conclusive evidence. The aim of this study was to evaluate whether performing rectal washout had any effect on the incidence of local recurrence in patients undergoing anterior resection for rectal cancer in the context of the current surgical management. Methods A total of 395 consecutive patients who underwent anterior resection with or without rectal washout for rectal cancer between January 2003 and July 2009 at a high volume single institution were analysed retrospectively. A standardised process for performing washout was used and all patients had standardised surgery in the form of total mesorectal excision. Neoadjuvant and adjuvant therapy was used on a selected basis. Patients were followed up for five years and local recurrence rates were compared in the two groups. Results Of the 395 patients, 297 had rectal washout and 98 did not. Both groups were well matched with regard to various important clinical, operative and histopathological characteristics. Overall, the local recurrence rate was 5.3%. There was no significant difference in the incidence of local recurrence between the washout group (5.7%) and the no washout group (4.1%). Conclusions Among our cohort of patients, there was no statistical difference in the incidence of local recurrence after anterior resection with or without rectal washout. This suggests that other factors are more significant in the development of local recurrence.

The importance of rectal washout for the oncological outcome after Hartmann's procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry

BACKGROUND

During rectal cancer surgery the bowel may contain viable, exfoliated cancer cells, a potential source for local recurrence (LR). The amount and viability of these cells can be reduced using intraoperative rectal washout, a procedure that reduces the LR risk after anterior resection. The aim of this study was to analyse the impact of washout on oncological outcome when performed in Hartmann's procedure (HP) for rectal cancer.

METHODS

A national cohort study on data for patients registered from 1995 to 2007 in the Swedish Colorectal Cancer Registry was carried out. The final analysis included patients belonging to TNM stages I-III who had undergone R0 HP with a registered 5-year follow-up. Multivariate analysis was performed.

RESULTS

A total of 1188 patients were analysed (686 washout and 502 no washout). No differences were detected between the washout group and the no washout group concerning rates of LR [7% (49/686) vs. 10% (49/502); p = 0.13], distant metastasis (DM) [17% (119/686) vs. 18% (93/502); p = 0.65], and overall recurrence (OAR) [21% (145/686) vs. 24% (120/502); p = 0.29]. For both groups, the 5-year cancer-specific survival was below 50%. In multivariate analysis, washout neither decreased the risk of LR, DM, or OAR nor increased overall or the cancer-specific 5-year survival.

CONCLUSIONS

The oncological outcome did not improve when washout was performed in HP for rectal cancer.