Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis

Effect of transverse colostomy versus ileostomy in colorectal anastomosis on post-operative wound complications: A meta-analysis

A meta-analysis was conducted to evaluate the effect of colostomy or ileostomy on post-operative wound complications. The research was tested using Embase, PubMed and Cochrane Library databases. Included were randomized, controlled clinical trials (RCTs). A sensitivity analysis and a meta-analysis were carried out. The results indicated that there were no statistically significant differences in the reduction of wound infection between LC and LI. Out of 268 related studies, 5 publications were chosen and examined for compliance. Literature quality was evaluated throughout the trial. Studies with poor literature were excluded. The data were analysed with RevMan 5.3, and a decision was taken to analyse the data with either a stochastic or a fixed-effects model. There were no significant differences in the incidence of post-operative infection in patients with LC (OR, 0.79; 95% CI, 0.34, 1.81; p = 0.57), and the incidence of post-operative anastomotic fistulae (OR, 0.98; 95% CI, 0.30, 3.15; p = 0.97) was not significantly different from that with LI. These meta-analyses indicate that no significant reduction in the incidence of post-operative infections or anastomotic fistulae was observed by either LC or LI.

Transanal drainage tube for the prevention of anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta-analysis

OBJECTIVE

To evaluate the ability of the transanal drainage tube (TDT) to prevent anastomotic leakage (AL) and provide clinicians with the latest evidence in this area.

MATERIALS AND METHODS

We search for relevant studies according to a search strategy. Data extracted from the study were analyzed using RevMan 5.4 software.

RESULTS

Fourteen eligible studies were included in our meta-analysis. The results of this meta-analysis suggest that patients with TDT placement have a lower incidence of AL than those without TDT placement (6% vs. 9.1%) (RR = 0.58, 95% CI: 0.46, 0.73, P < 0.00001). However, pooled results from RCTs suggest that TDT does not appear to reduce the incidence of AL in patients (6.4% vs. 8%) (RR = 0.79, 95% CI 0.52, 1.18, P = 0.24). In addition, the results of the meta-analysis suggest that TDT appears to reduce patient reoperation rates (2.6% vs. 5.8%) (RR = 0.38, 95% CI 0.27, 0.54, P < 0.00001).

CONCLUSIONS

The results of the RCTs suggest that TDT placement does not reduce the AL rate in patients, however, it is undeniable that the placement of TDT does provide patients with some clinical benefits (such as reduced reoperation rates).

Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis.

RESULTS

Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality.

CONCLUSION

J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

Functional anorectal studies in patients with low anterior resection syndrome

BACKGROUND

Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device.

METHODS

Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores.

KEY RESULTS

The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p < 0.01). The resting anal pressure and squeeze pressure were lowest in LARS patients (p < 0.05). The urge volume was 11.8 ± 4.2, 59.6 ± 6.4, and 41.6 ± 6.4 ml in the LARS, FI, and NS groups, respectively (p < 0.001). The expulsion duration did not differ between groups. Defecation indices were lowest in the LARS patients (p < 0.05). ARM-BET confirmed the low urge volume in LARS patients whereas anal pressures did not differ between groups.

CONCLUSIONS AND INFERENCES

The LARS patients had low anal pressures and urge volume. Most Defecation Indices differed between the LARS group and the other groups.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery

BACKGROUND

Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure.

METHODS

A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy.

RESULTS

We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS.

CONCLUSION

Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.

Effects of probiotics on bowel function restoration following ileostomy closure in rectal cancer patients: a randomized controlled trial

AIM

The aim was to determine the efficacy of probiotics in restoring bowel function following ileostomy reversal in patients with rectal cancer.

METHOD

This was a pilot, randomized, double-blind, placebo-controlled trial. The probiotic used in this study, Lactobacillus plantarum CJLP243, was derived from kimchi. Patients were randomly allocated to a probiotic or placebo group and medication was taken once daily from preoperative day 1 to day 21. Primary outcomes were the Memorial Sloan Kettering Cancer Centre Bowel Function Index (MSKCC BFI) instrument and the low anterior resection syndrome score. The secondary outcomes were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and CR29 questionnaire responses.

RESULTS

Forty patients were enrolled, and 36 patients (probiotics, n = 17; placebo, n = 19) completed the primary outcomes. Total scores for the MSKCC questionnaire (56.2 ± 12.0 vs. 55.0 ± 10.7, P = 0.356) and low anterior resection syndrome scores (33.3 ± 7.6 vs. 36.0 ± 5.3, P = 0.257) were not significantly different between the probiotic and placebo groups, respectively. In the MSKCC BFI, the postoperative dietary scale score at week 1 was significantly higher in the probiotic group (13.1 ± 3.8 vs. 9.0 ± 3.0, P < 0.001). There were no other significant differences between the two groups for any other questionnaire scores.

CONCLUSION

There were no significant effects supporting the use of a probiotic for improved bowel function in patients following ileostomy reversal. Nevertheless, the administration of probiotics showed trends toward improvements in some subscale bowel function measures, suggesting further studies may be warranted.

Risk factors for peristomal skin disorders associated with temporary ileostomy construction

PURPOSE

Skin disorders are the most common stoma-related complications after temporary diverting loop ileostomy with proctectomy. The aim of the present study was to investigate risk factors for skin disorders associated with temporary ileostomy construction.

METHODS

A total of 185 consecutive patients who underwent curative proctectomy with temporary diverting loop ileostomy for rectal malignancies at a single comprehensive cancer center between 2013 and 2018 were collected and analyzed.

RESULTS

The most frequent stoma-related complications were skin disorders (n = 62, 33.5%), followed by mucocutaneous separation (n = 38, 20.5%) and high-output stoma (n = 34, 18.4%). Patients with skin disorders had a higher median body mass index (BMI; 22.4 vs. 21.3 kg/m², P = 0.002) and lower stoma height (16 vs. 20 mm, P < 0.001) than those without skin disorders. According to a multivariable logistic regression analysis, independent predictors of skin disorders included overweight (median BMI ≥ 25 kg/m² [odds ratio = 3.6, 95% confidence interval: 1.5-8.6], P = 0.004) and lower stomal height (median stoma height < 20 mm [odds ratio = 3.2, 95% confidence interval: 1.6-6.3], P < 0.001).

CONCLUSION

Overweight and lower stoma height are correlated with the presence of skin disorders. Construction of a well-elevated stoma can reduce skin disorders associated with temporary ileostomy construction.

Serial Radiographic Imaging for Real-Time Evaluation of Blood Flow During Low Anterior Resection: Initial Study in a Porcine Model

To determine whether real-time intraoperative serial radiographic imaging of the marginal artery and vasa recta is feasible in patients undergoing low anterior resection, we attempted such imaging in a porcine model using a specialized fluoroscopic digital X-ray system and thin flat panel detector. Of the possible complications after low anterior resection, anastomotic dehiscence is one of the most serious, with poor blood supply in the anastomotic region being a chief contributor. General anesthesia was induced in a male domestic pig, and a midline incision was made from the xiphoid process to just above the bladder. The rectum was transected at the peritoneal reflection and then mobilized by dissection of the right leaf of the sigmoid mesocolon from the inferior mesenteric artery to the superior rectal artery. The rectal stump was pulled out and placed directly on the detector. Noniodine contrast agent was injected, and blood flow to and from the area surrounding the rectum was evaluated. Serial radiographs depicting the superior rectal artery, colonic, rectal, surrounding mesenteric tissue, and the vasa recta were obtained. The region where the marginal artery ran along the distal portion of the rectal stump was poorly poor imaged in all 3 imaging phases. Diameters of arteries were easily determined. The success we had in radiographically observing blood flow in tissues that would be involved in low anastomosis convinced us that such intraoperative evaluation is clinically feasible.

Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature

AIM

Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future.

METHOD

A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population.

RESULTS

The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications.

CONCLUSION

Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

Whether stoma support rods have application value in loop enterostomy: a systematic review and meta-analysis

Purpose

The purpose of the systematic review and meta-analysis is to analyze the application value of the stoma support rods in loop enterostomy.

Methods

The studies on the application of stoma rods in loop enterostomy published from January 2000 to January 2020 were searched in the databases of PubMed, Embase, Cochrane library, and Clinical trials. All randomized controlled trials (RCTs) and cohort studies that observed the value of stoma rods were included according to inclusion criteria. The RevMan5.3 software was used for statistical analysis.

Results

A total of 1131 patients with loop enterostomy in six studies were included in this study; there were 569 cases in the experimental group and 562 cases in the control group. All six studies analyzed the effect of support rods on the incidence of stoma retraction; the meta-analysis showed that in a total of 32 patients, stoma retraction occurred, with a total incidence of about 2.8% in 1131 patients. The incidence of stoma retraction in the rod group was not significantly lower than that in the non-rod group, and the difference was not statistically significant (OR = 0.65, 95% CI 0.32~1.32, I² = 0%, P = 0.23), and the studies were homogeneous. The incidences of stoma necrosis (OR = 6.41, 95% CI 2.22~18.55, I² = 0%, P = 0.0006), peristomal dermatitis (OR = 2.93, 95% CI 2.01~4.27, I² = 0%, P < 0.00001), and mucocutaneous separation (OR = 2.14, 95% CI 1.03~4.47, I² = 0%, P = 0.04) were significantly increased in the rod group.

Conclusions

It is not recommended to routinely use stoma support rods in the clinical practice.

Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study

BACKGROUND

Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up.

METHODS

Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis.

RESULTS

Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal.

CONCLUSION

In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.

Morbidity of Diverting Ileostomy for Rectal Cancer: Analysis of the American College of Surgeons National Surgical Quality Improvement Program

There is controversy regarding the potential benefits of diverting ileostomy after low anterior resection (LAR). This study aims to examine the morbidity associated with diverting ileostomy in rectal cancer. A retrospective review of LAR cases was performed using the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). Patients who underwent LAR with and without diversion were selected. Demographics, intraoperative events, and postoperative complications were reviewed. Among the 6337 cases sampled, 991 (16%) received a diverting ileostomy. Patients who were diverted were younger (60 vs 63 years), predominantly male (64 vs 53%), and more likely to have received pre-operative radiation (39 vs 12%). There was no significant difference in steroid use, weight loss, or intraoperative transfusion. Postoperatively, there was no significant difference in length of stay, rate of septic complications, wound infections, and mortality. The rate of reoperation was lower in the diverted group (4.5 vs 6.9%). Diversion was associated with a higher risk-adjusted rate of acute renal failure (OR 2.4; 95% CI (1.2, 4.6); P < 0.05). The use of diverting ileostomy reduces the rate of reoperation but is associated with an increased risk of acute renal insufficiency. These findings emphasize the need for refinement of patient selection and close follow-up to limit morbidity.

Exploring optimal examination to detect occult anastomotic leakage after rectal resection in patients with diverting stoma

Background

When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage.

Methods

This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7.

Results

The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate.

Conclusions

Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.

Stoma rods in abdominal surgery: a systematic review and metaanalyses

BACKGROUND

Stoma rods are used traditionally to prevent retraction of loop stomas into the abdominal cavity. However, there is very little evidence to support or refute their use. The aim of the present systematic review and metaanalysis was to assess the current data on stoma rods in loop stomas. The primary outcomes were stoma necrosis and stoma retraction.

METHODS

A systematic review and metaanalyses were conducted using the preferred reporting items for systematic reviews and metaanalysis guidelines (PRISMA). The study protocol was registered prospectively on PROSPERO. An electronic search was performed by two reviewers independently using predefined search strategy and Medline. Bibliographies of selected studies were screened for additional references. RevMan was used to generate forest plots and calculate odds ratios and 95% confidence intervals (CIs).

RESULTS

In total, five studies were identified that met inclusion criteria, including four randomized controlled trials. Three studies examined only ileostomies, while one included both colostomies and ileostomies, and one only examined colostomies. In total, 561 patients underwent a stoma with a rod compared to 443 without. There was a higher rate of dermatitis (rod 29.86% vs no rod 16% OR 2.65; 95% CI 1.79-3.93) and stoma necrosis (rod 7% vs no rod 1.15% OR 5.58; 95% CI 1.85-16.84) in the rod group, but there was no significant difference in stoma retraction (rod 2.28% vs no rod 3.45%; OR 0.7; 95% CI 0.32-1.54).

CONCLUSIONS

Stoma rods do not reduce the incidence of stoma retraction and instead lead to increased rates of dermatitis and stoma necrosis.

Fecal diverting device for the substitution of defunctioning stoma: preliminary clinical study

BACKGROUND

A novel fecal diverting device (FDD) made for the prevention of sepsis resulting from anastomotic leakage (AL) was tested successfully in an animal study. This study was undertaken to evaluate the clinical safety and effectiveness of the FDD.

METHODS

A prospective observation trial was implemented in a tertiary referral university hospital. The study enrolled patients who needed a defunctioning stoma to preserve low-lying rectal anastomosis. The FDD was fixed to the proximal colon 15 cm from the anastomosis and scheduled to divert feces for 3 weeks. The duration could be extended for more than 3 weeks if AL was noted. Postoperative evaluations of AL were performed by obtaining a computed tomography (CT) scan after 1 week and a contrast study after 3 weeks. The outcomes were FDD-related complications, and the capacity of the FDD to preserve the anastomosis. The median follow-up period was 10 (range 5-40) months.

RESULTS

Thirty-one patients, including 5 benign cases, were evaluated. There was no case of stoma conversion or surgical re-intervention. Evidence of AL was identified in 10 (32%) patients using the CT scan at 1 week after surgery. However, in the contrast study at 3 weeks after surgery, only 5 cases of AL sinus were noted. Conservative treatments including 1-3 weeks prolongation of FDD maintenance were enough to preserve the anastomosis. There were 3 cases of partial colonic wall erosions at the FDD attachment area. All of these patients showed improvement with conservative treatment. The limitations were that the study was performed in a single institute and without a control group.

CONCLUSIONS

The FDD showed a sufficient capacity of fecal diversion and maintenance duration that prevented aggravation of sepsis in the case of AL without significant complications.

Prolonged hospital stay and readmission rate in an enhanced recovery after surgery cohort undergoing colorectal cancer surgery

AIM

The present database study aimed to identify patients with a longer postoperative length of stay (LOS) or patients readmitted and to characterize both groups based on perioperative factors.

METHOD

A retrospective review of the Danish Colorectal Cancer Group database and a local database was performed of all patients undergoing elective resection for colorectal cancer in a 25-month period. The primary outcome was the number of patients with a prolonged hospital stay (LOS ≥ 10 days after the primary operation) and readmissions within 30 days after discharge.

RESULTS

A total of 372 patients with colon resection and 215 patients with rectal resection were included. Patients undergoing colonic resection had a rate of prolonged hospital stay of 10.6% and a readmission rate of 13.7%; prolonged hospital stay was significantly associated with age ≥ 76 years and those who underwent a conversion from a laparoscopic procedure. Patients undergoing rectal cancer resection had a rate of prolonged hospital stay of 17.7% and a readmission rate of 14.0%; Charlson comorbidity score (CCS) ≥ 2, total mesorectal excision (TME) and laparoscopic conversion were significantly associated with prolonged hospital stay, and American Society of Anesthesiologists (ASA) score ≥ 3, TME and a duration of surgery ≥ 300 min were significantly associated with readmission.

CONCLUSION

In patients with colon cancer, older age and conversion to open surgery were associated with prolonged hospital stay. In patients with rectal cancer, CCS ≥ 2, TME and conversion were associated with prolonged hospital stay, and a preoperative ASA score ≥ 3, TME and a duration of surgery ≥ 300 min were associated with readmission.

[Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]

Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.

Transanal Tube NO COIL® after Rectal Cancer Proctectomy. The “G. Paolo II” Cancer Centre Experience

Aims and background

Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study.

Methods

From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL®, 60–80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventhpostoperative day if no signs of leakage occurred.

Results

The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%.

Conclusions

The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.

Application of spontaneously closing cannula ileostomy in laparoscopic anterior resection of rectal cancer

An anastomotic leak (AL) is the most serious complication observed in laparoscopic anterior resection of rectal cancer (LARRC). In order to protect anastomosis from AL and avoid stoma reversal surgery in patients with ileostomy, spontaneously closing cannula ileostomy (SCCI) was used in LARRC and its safety and feasibility were assessed in the present study. To the best of our knowledge, this is the first time that SCCI has been used in such a case. A total of 41 patients who underwent LARRC with SCCI or ileostomy procedures between November 2013 and August 2014 were retrospectively analyzed. The patient demographics, clinical features and surgical data were evaluated using a Mann-Whitney U-test, Fisher's exact test or linear-by-linear association. Demographics, surgical data and the majority of clinical features of the two groups were consistently similar. In the SCCI group, the length of postoperative stay, total cost and stoma period were significantly improved compared with those in the ileostomy group. Additionally, the median protective period in the SCCI group was 22 days [interquartile range (IQR), 19–22 days], the median time to cannula removal was 23 days (IQR, 20–24 days) and the median time to cannula stoma closure was 12 days (IQR, 11–13 days). No SCCI-associated complications occurred. No significant differences in routine complications, including staple-line bleeding, anastomotic leak, anastomotic dehiscence, anastomotic stenosis and wound infection, were identified between the two groups. In LARRC, the SCCI procedure was demonstrated to be a safe and feasible diverting technique to protect anastomosis from AL. In contrast to ileostomy, the SCCI procedure obviated the requirement for stoma reversal surgery, which resulted in decreased lengths of postoperative hospital stay, hospitalization costs and stoma periods.

Predictors of High-Output Stoma After Low Anterior Resection With Diverting Ileostomy for Rectal Cancer

Background:

The aim of this study was to identify predictors of high-output stoma (HOS) after low anterior resection (LAR) with diverting ileostomy for rectal cancer.

Methods:

The medical records of 60 patients who underwent LAR with diverting ileostomy for rectal cancer between 2012 and 2015 were reviewed. HOS was defined as ileostomy output greater than 1500 mL per 24 hours. Patient and surgical characteristics and patient laboratory data were examined to assess for predictors of HOS using univariate and multivariate logistic regression.

Results:

The incidence of HOS was 43.3% (26/60). In univariate analysis, age ≥ 70 years, diabetes mellitus (DM), preoperative albumin level ≤ 4.0 g/dL, and preoperative serum hemoglobin level ≤ 12 g/dL were significantly associated with HOS. Multivariate analysis identified DM (odds ratio, 9.74; 95% confidence interval, 1.86–77.3) as an independent predictor of HOS.

Conclusions:

DM might be a predictor of HOS in patients undergoing LAR with diverting ileostomy for rectal cancer.

Morbidity Associated with Diverting Loop Ileostomies: Weighing Diversion in Rectosigmoid Resection

Anterior resection with primary anastomosis is the procedure of choice for patients with rectosigmoid cancers with good sphincter function. Surgeons may perform an associated diverting loop ileostomy (DLI) to minimize the likelihood and/or the severity of an anastomotic leak. To examine the morbidity of DLIs, we performed a review of a prospectively maintained database. Participants included all patients at the Massachusetts General Hospital who underwent anterior resection from January 2013 to July 2015 for rectosigmoid cancers and who subsequently underwent adjuvant chemotherapy. The primary outcome was time to start of adjuvant chemotherapy. Secondary outcomes included length of hospitalization, perioperative complications, and 60-day postoperative complications. Inclusion criteria were met in 57 patients and DLI was performed in 21 (37%). The DLI group had higher estimated blood loss (431.7 vs 192.1 mL, P = 0.03) and a longer operation time (3.7 vs 2.3 hours, P = 0.0007). The DLI group took over a week longer to start adjuvant chemotherapy than the non-DLI group (median time to chemo: 43 vs 34 days, P = 0.002). Postoperatively, DLI was associated with a longer hospitalization (6.7 vs 3.1 days, P = 0.0003), more perioperative complications (57.1% vs 13.9%, P = 0.0006), and more 60-day read-missions or emergency department visits (38.1% vs 5.6%, P = 0.002). Ostomies are associated with appreciable morbidity. In turn, they do not eliminate postoperative complications. Surgeons should closely consider ostomy morbidity in rectosigmoid resection and institute a proactive approach toward identification and prevention of complications.

Randomized clinical trial of biodegradeable intraluminal sheath to prevent anastomotic leak after stapled colorectal anastomosis

Background

Anastomotic leakage is a potential major complication after colorectal surgery. The C-seal was developed to help reduce the clinical leakage rate. It is an intraluminal sheath that is stapled proximal to a colorectal anastomosis, covering it intraluminally and thus preventing intestinal leakage in case of anastomotic dehiscence. The C-seal trial was initiated to evaluate the efficacy of the C-seal in reducing anastomotic leakage in stapled colorectal anastomoses.

Methods

This RCT was performed in 41 hospitals in the Netherlands, Germany, France, Hungary and Spain. Patients undergoing elective surgery with a stapled colorectal anastomosis less than 15 cm from the anal verge were eligible. Included patients were randomized to the C-seal and control groups, stratified for centre, anastomotic height and intention to create a defunctioning stoma. Primary outcome was anastomotic leakage requiring invasive treatment.

Results

Between December 2011 and December 2013, 402 patients were included in the trial, 202 in the C-seal group and 200 in the control group. Anastomotic leakage was diagnosed in 31 patients (7·7 per cent), with a 10·4 per cent leak rate in the C-seal group and 5·0 per cent in the control group (P = 0·060). Male sex showed a trend towards a higher leak rate (P = 0·055). Construction of a defunctioning stoma led to a lower leakage rate, although this was not significant (P = 0·095).

Conclusion

C-seal application in stapled colorectal anastomoses does not reduce anastomotic leakage. Registration number: NTR3080 (http://www.trialregister.nl/trialreg/index.asp).

Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure

BACKGROUND

Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery.

OBJECTIVE

The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure.

DESIGN

This was a retrospective review.

SETTINGS

The study was conducted at a tertiary referral center.

PATIENTS

Patients who underwent ileostomy closure (2006-2015) were stratified into early (≤48 hours) and late discharge groups.

MAIN OUTCOME MEASURES

The Modified Frailty Index, morbidity, and readmission rates were measured.

RESULTS

A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ≤1 and ≤2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53).

LIMITATIONS

The study was limited by nature of being a retrospective review.

CONCLUSIONS

Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.

Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?

BACKGROUND

Diverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary.

MATERIALS AND METHODS

All mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed.

RESULTS

Three hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %.

CONCLUSION

Routine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.

Long-term results of extended intersphincteric resection for very low rectal cancer: a retrospective study

Background

Intersphincteric resection (ISR) has become an increasingly popular optional surgical tool for the treatment of very low rectal cancer. The purpose of this study was to assess the long-term oncological and functional outcomes of intersphincteric resection for T2 and T3 rectal cancer situated below 4 cm from the anal verge.

Methods

A total of 62 consecutive patients with very low rectal cancer who underwent ISR from 2001 to 2010 were classified into standard ISR for T2 lesions (Group I, n = 24) and extended ISR for T3 lesions (Group II, n = 38).

Results

The 5-year overall survival rates were 95.8 % for group I and 94.7 % for group II. The 5-year recurrence-free survival rates were 87.5 % for group I and 86.8 % for group II. Bowel functions were evaluated at the 12^th and 24^th months after ileostomy closure in both groups. The frequency of bowel evacuation was higher in patients who underwent extended ISR than in those who underwent standard ISR at the 12^th month (p < 0.05). However, at the 24^th month, the frequencies decreased in both groups, exhibiting no significant difference. In the comparison based on the Kirwan classification, group I showed better continence status than group II but no significant difference. The Wexner scores of both groups revealed that the average score was 7.33 ± 2.8 in group I and 8.18 ± 2.9 in group II at the 12^th month, and at the 24^th month, the average score was 5.21 ± 1.7 in group I and 5.82 ± 1.9 in group II. There were no statistically significant differences between the two groups.

Conclusions

Extended ISR with quadrant resection of the upper external sphincter achieved good post-operative continence status, OS and RFS. Extended ISR can thus be an alternative to abdominoperineal resection for very low rectal cancer without compromising the chance of cure and improving quality of life.

Temporary Tube Stoma versus Conventional Loop Stoma for the Protection of a Low Anastomosis in Colorectal Surgery: A Systematic Review and Meta-analysis

The aim of this systematic review is to evaluate and compare the efficacy and safety of temporary tube stoma and conventional loop stoma for the protection of a low anastomosis in colorectal cancer. A systematic literature search was performed using PubMed, EMBASE, Science Citation Index, and Cochrane Central Register of Controlled Trails. Primary outcome measures were anastomotic leakage rate, the reoperation rate for anastomotic leakage, and stoma-related complications. Secondary outcome measures were operation time, length of hospital stay, time to stoma closure, and permanent stoma rate. Four studies were carried out and 642 patients (332 with temporary tube stoma and 310 with conventional loop stoma) met the inclusion criteria. The incidences of anastomotic leakage and reoperation rate were statistically similar in tube stoma and loop stoma groups. In comparison with conventional loop stoma, temporary tube stoma was associated with a significantly less stoma-related complications (odds ratio = 0.20; 95% confidence interval [CI]: 0.08–0.50), and shorter operation and hospital stay time (weighted mean difference = -47.28 minutes, 95% CI: -74.68 to -19.88; and weighted mean difference = -5.22 days, 95% CI: -10.32 to -0.13, respectively). Time to stoma closure was significantly shorter in the temporary tube stoma groups (weighted mean difference = -114.58 days, 95% CI: -148.38 to -80.77). Patients receiving temporary tube stoma had lower rates of stoma-related complications, shorter operation and hospital stay time, and stoma closure time. Tube can be easily removed without second surgery in most cases. Therefore, temporary tube stoma is a feasible and effective alternative to conventional loop stoma for the protection of a low colorectal anastomosis.

Low or Ultralow Anterior Resection of Rectal Cancer Without Diverting Stoma: Experience with 28 Patients

A diverting temporary stoma is frequently used to decrease the chance of anastomosis leakage in the middle and lower rectum cancer surgeries, but its role in preventing the leakage is still doubtful. This study has been designed to evaluate any possible anastomosis complications after a rectum resection and a low or ultralow anastomosis when no diverting stoma is applied in patients with rectal cancer. Twenty-eight patients suffering from rectal cancer were treated by a low anterior resection between the years 2005 and 2008 in Imam Reza University Hospital, Mashhad, Iran. Out of the 28 patients, 6 patients had already undergone a course of neoadjuvant radiotherapy. Anastomosis was performed manually in 23 patients, using a stapler in 5 of them. None of the patients had a diverting stoma. Then, the outcome was evaluated. Fecal incontinence occurred in one of the patients (6.7 %) who had already undergone a course of radiotherapy preoperatively and had a stapler used for anastomosis. No leakage was detected in any of them. The very low incidence of complications in this study, such as those not preventable by a diverting stoma, suggest a very low chance of leakage in low or ultralow anastomosis in patients with rectal cancer and in those who were treated with neoadjuvant radiotherapy.

The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer

AIM

The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer.

METHOD

From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis.

RESULTS

During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1 year to 22% at 10 years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P = 0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age > 65 years and surgical morbidity.

CONCLUSION

The risk of a definitive stoma after SSR increased two-fold between 1 and 10 years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.

Colonic transit: what is the impact of a diverting loop ileostomy?

BACKGROUND

Diverting loop ileostomy (DLI) is used following low anterior resections (LAR) or ultra-low anterior resections (ULAR) to reduce anastomotic leak (AL). Preoperative mechanical bowel preparation (MBP) is traditionally used with DLI. However, clearance of the left colon can be achieved with a fleet enema without the physiological compromise of MBP. We aimed to assess colonic transit following DLI in this context.

METHODS

A prospective, observational study was performed with patients with rectal cancer undergoing LAR or ULAR in a tertiary colorectal unit with preoperative fleet enema. Radiopaque markers were inserted into the caecum following rectal resection and formation of a DLI with placement confirmed by image intensifier and endoscopy. X-rays were performed at days 1, 3, 5 and 14 post-operation with data collected prospectively.

RESULTS

Ten patients (mean age 57, nine males) were enrolled. Mean time to functioning stoma was 1.9 days (range 1-3). There was no movement in the majority of markers in all patients at Day 5 post-operation. In all seven patients with Day 14 X-rays, the majority of markers remained in the right colon. Two patients had delayed AL, with markers found within the pelvis in both of these patients.

CONCLUSIONS

This is the first study to assess colonic transit following DLI using fleet enema only, with results suggesting colonic motility is abolished in this setting. The use of a fleet enema without MBP may be sufficient prior to rectal resection surgery when DLI is employed. AL may actually increase colonic transit. Further research is warranted.

Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery

Purpose

This study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR).

Methods

Between January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine.

Results

Of the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis.

Conclusion

WCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.

Tube ileostomy for faecal diversion in elective distal colorectal anastomosis: a systematic review and pooled analysis

AIM

Tube ileostomy may be an alternative technique to loop ileostomy for protection of distal anastomosis, but its evidence base has not yet been established. This systematic review aims to evaluate the use of tube ileostomy and compare the outcomes associated with it.

METHOD

A systematic literature search of MEDLINE, EMBASE, Web of Science and the Cochrane database was conducted. Studies reporting on elective left-sided/colorectal anastomosis were included. Studies which reported on emergent surgery, small bowel anastomosis or tube ileostomy as a bridging procedure were excluded. The intra-operative technique, postoperative management and complications were assessed. Outcome measures included anastomotic leak, reoperation and complications related to the stoma or tube ileostomy.

RESULTS

Seven studies met the inclusion criteria. Three were case series with 101 patients and four were nonrandomized comparative studies with 665 patients. Pooled analyses of three comparative studies, comparing tube ileostomy (n = 278) with loop ileostomy (n = 254), revealed no significant differences in anastomotic leak rates (pooled OR 0.85, 95% CI 0.41-1.75; I(2) = 0%, P = 0.43).

CONCLUSION

There is a re-emergence of interest in the use of tube ileostomy to defunction a distal anastomosis. Pooled analyses of studies comparing tube ileostomy with loop ileostomy do not show statistically significant differences in anastomotic leak rates. Further refinement of this technique and randomized controlled studies are necessary for this technique to be routinely taken up by surgeons.

Risk Factors for Anastomotic Leakage After Intersphincteric Resection Without a Protective Defunctioning Stoma for Lower Rectal Cancer

BACKGROUND

Intersphincteric resection (ISR) is performed as an alternative to abdominoperineal resection for super-low rectal cancer. The purpose of this study was to evaluate risk factors for anastomotic leakage (AL) after ISR without a defunctioning stoma for lower rectal cancer.

METHODS

Between 1995 and 2012, 135 consecutive patients with lower rectal cancer underwent curative ISR without a protective defunctioning stoma. Univariate and multivariate analyses were performed to determine the risk factors for AL.

RESULTS

The radiological and symptomatic AL rate was 17.0 % (23/135). Univariate analysis demonstrated that male sex (P = 0.030), preoperative chemotherapy (P = 0.016), partial ISR (P < 0.001), lateral lymph-node dissection (P = 0.042), distal tumor distance from the dentate line (P = 0.007), and straight reconstruction (P < 0.001) were significantly associated with AL. Severe AL requiring re-laparotomy developed in 13 (9.6 %) patients. Univariate analysis demonstrated that male sex (P = 0.006), partial ISR (P < 0.001), distal tumor distance from the dentate line (P = 0.002), and straight reconstruction (P < 0.001) were significantly associated with AL requiring relaparotomy. Multivariate analysis demonstrated that partial ISR [odds ratio (OR) 6.701; P = 0.001] and straight reconstruction (OR 5.552; P = 0.002) were independently predictive of AL.

CONCLUSIONS

Partial ISR and straight reconstruction increased the risk of AL after ISR without a protective defunctioning stoma. A defunctioning stoma might be mandatory in patients with the risk factors identified in this analysis.

Diverting ileostomy in colorectal surgery: when is it necessary?

PURPOSE

The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice.

METHODS

Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion.

RESULTS

Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion.

CONCLUSIONS

Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.

Defunctioning cannula ileostomy after lower anterior resection of rectal cancer

BACKGROUND AND OBJECTIVE

Most surgeons suggest the use of fecal diversion in patients undergoing low anterior resections of rectal tumors at high risk for anastomotic leakage. We describe an exploratory study to evaluate the efficacy and safety of a new diversion method called a spontaneously closing cannula ileostomy, which was designed to protect rectal anastomoses in patients at high risk for anastomotic leakage. The outcomes of patients treated with cannula ileostomy were compared to those of patients treated with loop ileostomy.

MAIN OUTCOME MEASURES

Outcomes included the rates of anastomotic leakage, reoperation and other complications, as well as length of hospital stay and cost.

DESIGN AND PATIENTS

From January 2011 to December 2012, 294 patients undergoing low colorectal or coloanal anastomosis were treated with ileum diversion using cannula ileostomy or traditional loop ileostomy. Demographics, clinical features, and operational data were recorded.

RESULTS

The anastomotic leakage rates were 8.1% (12/149) in the cannula ileostomy group and 8.3% (12/145) in the loop ileostomy group (p = 1.0). The reoperation rate was 3% (4/149) in patients treated with a cannula ileostomy and 3.4% (5/145) in those who underwent a loop ileostomy (p = 0.75). The median length of the hospital stay was 8.6 days in the cannula ileostomy group and 17.1 days (p < 0.01) in the loop ileostomy group, including time for the initial and reversal operations. In the cannula ileostomy group, the median time to defecation from the anus was 16.5 days after the operation. During the follow-up period, 13 patients in the loop ileostomy group retained their stoma, as compared to 2 in the cannula ileostomy group (p < 0.01).

LIMITATIONS

This study was a nonrandomized design and lacked contrast enema data to identify anastomotic leaks.

CONCLUSIONS

Cannula ileostomy is a safe and effective diverting technique that protects low colorectal and coloanal anastomoses. Patients receiving a cannula ileostomy had shorter hospital stays and lower rates of permanent stoma than those receiving a loop ileostomy.

Learning curve of laparoscopic low anterior resection in terms of local recurrence

BACKGROUND

Experience in terms of surgical case numbers required to develop proficiency for oncologic adequacy after sphincter-saving laparoscopic rectal cancer surgery has not been established.

METHOD

Three hundred seventeen consecutive patients underwent sphincter-saving laparoscopic rectal cancer surgery with curative intent performed by single surgeon. The learning curve was estimated using risk-adjusted cumulative sum (RA-CUSUM) and the graph of 195 consecutive patients who were treated by another surgeon was used to evaluate inter-surgeon variability in the learning curve.

RESULTS

Overall, the 3-year local recurrence rate was 7.7% (95% confidence interval [CI], 6.4%-9.0%). The RA-CUSUM analysis demonstrated a learning curve of 110 cases for local recurrence for both of surgeons and 50-70 cases for CRM involvement. The 3-year local recurrence-free rate was better during the experienced period than during the learning period (95.1% [95% CI, 91.6%-97.1%] vs. 89.5% [95% CI, 84.4%-93.0%]; P = 0.029). These differences were obvious in subgroup analysis of stage III tumors (93.4% [95% CI, 86.6%-96.8%] vs. 78.6% [95% CI, 68.5%-85.3%]; P = 0.013).

CONCLUSIONS

Local recurrence rates decreased with increasing surgeon experience, as did other short-term outcomes, especially in advanced disease cases.

What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis?

OBJECTIVE

The objective of this study was to identify clinical leak in diverted colorectal anastomoses.

DESIGN

Cohort analysis.

SETTING

The study was conducted in a subspecialty practice at a tertiary care facility.

PATIENTS

Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012.

INTERVENTIONS

No intervention was applied.

MAIN OUTCOME MEASURES

Clinical anastomotic leak.

RESULTS

Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14%) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5%) patients within 30 days of surgery (early leaks) and in 21 (9%) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing.

CONCLUSIONS

In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.

Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study

BACKGROUND

Our primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion.

STUDY DESIGN

This is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States.

RESULTS

A total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA.

CONCLUSIONS

PINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

Mitigating the Consequences of Anastomotic Leakage After Laparoscopic Rectal Cancer Resection

Background. With regard to laparoscopic low anterior resection, anastomotic leakage still remains a challenge and continues to account for approximately 30% of postoperative deaths. This study was designed to evaluate whether the intracolonic and perineal drainage is associated with a decreased risk for anastomotic leakage after laparoscopic rectal cancer surgery without stool diversion. Patients and Methods. Prospective data were collected from 337 patients with rectal cancer who underwent laparoscopic resection without defunctioning stoma. Results. A total of 157 patients underwent laparoscopic rectal resection, followed by the placement of intracolonic and perineal drainage, while 180 underwent laparoscopic surgery routinely. No difference in clinically significant leakage was observed between the intracolonic and perineal drainage and the control groups (3.8% vs 8.3%, P = .0874). However, reoperation was underwent at a significantly lower rate after the placement of intracolonic and perineal drainage (intracolonic and perineal drainage: 1 of 6 [16.7%] vs control: 14 of 15 [93.3%]; P < .01). In multivariate analysis, extraperitoneal tumor location and operation duration ≥180 minutes were independently associated with anastomotic leakage. Conclusions. Significant risk factors of anastomotic leakage include extraperitoneal tumor location and operation duration ≥180 minutes. The placement of intracolonic and perineal drainage was not found to be significantly associated with anastomotic leakage, but this method could mitigate the clinical consequences of leakage and decrease the rate of reoperation and transverse colostomy after laparoscopic anterior resection for rectal cancer.

Laparoscopic Colorectal Surgery: An Update (with Special Reference to Indian Scenario)

Laparoscopic cholecystectomy, being already declared as gold standard technique, laparoscopic surgery has advanced far and wide, touching almost every corner of the abdomen. This advancement has gradually expanded to colorectal surgery which is done for malignant diseases as well. However, laparoscopic colorectal surgery has not been accepted as quickly as was laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomized control trials (RCTs) and initial reports on high port site recurrences which occurred after curative resections. But all these initial concerns have been overcome by doing a series of RCTs globally, in the past decade, that revealed that laparoscopic colorectal surgery for malignant disease offered short term benefits without compromising on oncological principles of radicality of resection, tumour resection margins and completeness of lymph node harvesting as compared to those of open surgery. Favourable post-operative results with respect to less blood loss, less pain, lesser surgical site infections, lesser requirement of analgesics, early return of bowel function and shorter hospital stay in patients who underwent laparoscopic colorectal resections were obtained in studies done on individual series, including those done in India and more recently, in large trials. An update on recent studies done on laparoscopic colorectal surgery by reviewing many RCTs and individual series, including our experiences, was made, to support the advantages of this procedure which were obtained when it was carried out by skilled hands.

Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy

AIM

This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy.

METHOD

Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy (n = 28) or conventional loop ileostomy (n = 22). Demographics, clinical features and operation data were recorded.

RESULTS

Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy.

CONCLUSION

Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma.

To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis

AIM

Anastomotic leakage is the one of the most serious complications in rectal cancer surgery and is associated with high mortality, morbidity and an increased incidence of local recurrence. Although many studies have compared drained and undrained colorectal anastomoses, to date the role of pelvic drainage in extraperitoneal colorectal anastomosis remains undefined.

METHOD

We carried out a systematic review of the literature, performing an unrestricted search in MEDLINE and Embase up to 30 October 2012. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We performed a meta-analysis of the data currently available on the incidence of extraperitoneal anastomotic leakage, according to the presence or absence of pelvic drainage.

RESULTS

Overall, eight studies - three randomized clinical trials (RCTs) and five non-RCTs, comprising a total of 2277 patients - were included in the meta-analysis. Pelvic drainage was demonstrated to reduce both the leak rate and the rate of reintervention in patients who underwent anterior rectal resection with extraperitoneal colorectal anastomosis (OR = 0.51, 95% CI: 0.36-0.73; and OR = 0.29, 95% CI: 0.18-0.46, respectively) compared with patients without drainage. Overall mortality and infection rates were also evaluated, but a nonsignificant correlation was found with the presence of drainage.

CONCLUSION

The meta-analysis shows that the presence of a pelvic drain reduces the incidence of extraperitoneal colorectal anastomotic leakage and the rate of reintervention after anterior rectal resection.

The influence of fluorescence imaging on the location of bowel transection during robotic left-sided colorectal surgery

BACKGROUND

Hypoperfusion is an important risk factor for anastomotic leakage in colorectal surgery. This study was designed to evaluate the impact of fluorescence imaging on visualization of perfusion and subsequent change of transection line during left-sided robotic colorectal resections.

METHODS

Patients scheduled for robotic left-sided colon or rectal resections were enrolled in this prospective, multicenter study. Resections were performed as per each surgeon's preference. After complete colorectal mobilization, ligation of blood vessels, and distal transection of the bowel, the mesocolon was completely divided to the planned proximal or distal transection line, which was marked in white light. Indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. Imaging information, perioperative, and early postoperative outcomes were recorded. An independent video review of the surgeries was performed.

RESULTS

Data for 40 patients (20 female/20 male) with a mean age of 63.9 years and a mean body mass index of 27.6 kg/m(2) were analyzed. Fluorescence imaging resulted in a change of the proximal transection location in 40 % (16/40) of patients. There was one change in the distal transection location in a patient with benign disease. The use of fluorescence imaging took an average of 5.1 min of the mean overall operative room time of 232 min. Two patients (5 %) with a change in transection line developed an anastomotic leak at postoperative days 15 and 40.

CONCLUSION

Fluorescence imaging provides additional information during determination of transection location in left-sided colorectal procedures. This results in a significant change of transection location, particularly at the proximal transection site. Further research needs to be conducted with larger patient cohorts and in comparative design to determine actual effect on anastomotic leak rate.

Cumulative incidence of permanent stoma after sphincter preserving low anterior resection of mid and low rectal cancer

BACKGROUND

Changes in the treatment of rectal cancer during the past decades have led to an increase in sphincter preservation with a consecutive decline in abdominoperineal resection rates.

OBJECTIVE

The aim of this study was to analyze the cumulative incidence of permanent stoma in patients undergoing sphincter-preserving resection of mid and low rectal cancer.

DESIGN

This study is a retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a tertiary referral cancer hospital.

PATIENTS

From 2003 to 2010, 125 patients with primary mid and low rectal cancer who underwent sphincter-preserving low anterior resection were included.

MAIN OUTCOME MEASURES

The occurrence of a permanent stoma over time was investigated by using a Cox proportional hazards regression model and competing-risk models, with death as a competing risk. The risk factors were assessed by computing HRs and a Cox proportional hazards regression.

RESULTS

After a median follow-up time of 61 months (range, 22-113), 15 of 125 patients ended up with a permanent stoma, accounting for a 5-year cumulative incidence of 6% (95% CI, 4%-11%). The reasons for obtaining a permanent stoma were anastomotic leakage (60%, 9/15), intractable fecal incontinence (27%, 4/15), and local recurrence (13%, 2/15). The Cox proportional hazards regression identified anastomotic leakage (HR, 6.10; 95% CI, 2.23-16.71; p = 0.0004) and coloanal anastomosis (HR, 4.31; 95% CI, 1.49-12.47; p = 0.007) as statistically significant risk factors.

LIMITATIONS

Because of the small number of events in this sample, further investigations with a larger number of patients are required. Fecal incontinence was assessed by patient self-reported data without the use of a validated score.

CONCLUSION

The 5-year cumulative incidence of a permanent stoma was 6%. Anastomotic leakage and coloanal anastomosis were identified as risk factors. These details should be considered before sphincter-preserving surgery.

Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer

BACKGROUND

A generally acceptable definition and a severity grading system for anastomotic leakages (ALs) following rectal resection were not available until 2010, when the International Study Group of Rectal Cancer (ISGRC) proposed a definition and a grading system for AL.

METHODS

A search for published data was performed using the MEDLINE database (2000 to December 5, 2012) to perform a systematic review of the studies that described AL, grade AL according to the grading system, pool data, and determine the average rate of AL for each grade after anterior resection (AR) for rectal cancer.

RESULTS

A total of 930 abstracts were retrieved; 40 articles on AR, 25 articles on low AR (LAR), and 5 articles on ultralow AR (ULAR) were included in the review and analysis. The pooled overall AL rate of AR was 8.58% (2,085/24,288); the rate of the asymptomatic leakage (Grade A) was 2.57%, that of AL that required active intervention without relaparotomy (Grade B) was 2.37%, and that of AL that required relaparotomy (Grade C) was 5.40%. The pooled rate of AL that required relaparotomy was higher in AR (5.40%) than in LAR (4.70%) and in ULAR (1.81%), which could be attributed to the higher rate of protective defunctioning stoma in LAR (40.72%) and ULAR (63.44%) compared with that in AR (30.11%).

CONCLUSIONS

The new grading system is simple that the ALs of each grade can be easily extracted from past publications, therefore likely to be accepted and applied in future studies.