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Sharabiany S, Joosten JJ, Musters GD, Talboom K, Tanis PJ, Bemelman WA, Hompes R. Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre. Colorectal Dis 2024; 26:650-659. [PMID: 38418896 DOI: 10.1111/codi.16863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024]
Abstract
AIM Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre. METHOD Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome. RESULTS In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567). CONCLUSION High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.
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Affiliation(s)
- Sarah Sharabiany
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna J Joosten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kim HJ, Choi GS, Park JS, Park SY, Song SH, Lee SM, Jeong MH, Cho SH. Long-term Complications of Laparoscopic or Robotic Lateral Pelvic Node Dissection After Preoperative Chemoradiotherapy for Locally Advanced Rectal Cancer. Dis Colon Rectum 2024; 67:505-513. [PMID: 38164944 DOI: 10.1097/dcr.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with rectal cancer who underwent lateral pelvic node dissection might be at a higher risk of postoperative complications derived from technical complexity. However, little is known regarding the long-term complications after lateral pelvic node dissection. OBJECTIVES The study aimed to investigate the long-term complications of preoperative chemoradiotherapy, followed by total mesorectal excision with lateral pelvic node dissection for locally advanced rectal cancers. DESIGN A retrospective analysis of a prospectively collected database. SETTINGS This study was conducted in a tertiary cancer center. PATIENTS Patients with rectal cancer who underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy between 2011 and 2019 were analyzed. All operations were performed via a laparoscopic or robotic approach. MAIN OUTCOME MEASURES Long-term complications were defined as adverse events that persisted or newly appeared ≥90 days after surgery and could be related to the surgery. RESULTS A total of 164 patients underwent total mesorectal excision with lateral pelvic node dissection after preoperative chemoradiotherapy. Short-term and long-term complication rates were 36.0% and 36.6%, respectively. Lymphocele was the most common long-term complication (17.7% of patients), and 11.6% had anastomotic leakage with chronic sinus. Of the patients with long-term complications, 20.7% of patients needed readmission for treatment. Of the 29 patients with lymphocele, 13 (41.0%) experienced spontaneous absorption and 11 (37.9%) required surgical or percutaneous catheter drainage or antibiotics use. Multivariate analysis showed pathologic pelvic node metastases ( p = 0.008), and a higher number of unilateral harvested pelvic nodes ( p = 0.001) were significantly associated with long-term complications. At the last follow-up (median duration of 43 months), 15.9% of patients had unresolved complications. LIMITATIONS The retrospective design. CONCLUSIONS Patients undergoing lateral pelvic node dissection experienced a higher frequency of long-term complications, but half of them had asymptomatic lymphoceles, most of which resolved spontaneously. However, further efforts should be paid to reduce anticipated complications related to lateral pelvic node dissection. See Video Abstract . COMPLICACIONES A LARGO PLAZO DE LA DISECCIN DE LOS GANGLIOS LIFTICOS PLVICOS LATERALES LAPAROSCPICA O ROBTICA DESPUS DE LA QUIMIORRADIOTERAPIA PREOPERATORIA CONTRA EL CNCER DEL RECTO LOCALMENTE AVANZADO ANTECEDENTES:Los pacientes con cáncer del recto sometidos a disección ganglionar linfática pélvica lateral podrían tener mayor riesgo de complicaciones postoperatorias derivadas de la complejidad técnica. Sin embargo, se sabe poco sobre las complicaciones a largo plazo después de la disección de los ganglios linfáticos pélvicos laterales.OBJETIVOS:Investigar las complicaciones a largo plazo de la quimiorradioterapia preoperatoria, seguida de escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales contra el cáncer de recto localmente avanzado.DISEÑO:Un análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTES:Este estudio se llevó a cabo en un centro oncológico terciario.PACIENTES:Se analizaron pacientes con cáncer de recto que se sometieron a escisión mesorrectal total con disección de ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria entre 2011 y 2019. Todas las operaciones se realizaron mediante abordaje laparoscópico o robótico.PRINCIPALES MEDIDAS DE RESULTADO:Las complicaciones a largo plazo se definieron como eventos adversos que persistieron o aparecieron recientemente ≥ 90 días después de la cirugía y podrían estar relacionados con la cirugía.RESULTADOS:Un total de 164 pacientes se sometieron a escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales después de quimiorradioterapia preoperatoria. Las tasas de complicaciones a corto y largo plazo fueron del 36,0% y 36,6%, respectivamente. El linfocele fue la complicación a largo plazo más común (17,7% de los pacientes) y el 11,6% tuvo fuga anastomótica con seno crónico. De los pacientes con complicaciones a largo plazo, el 20,7% de los pacientes necesitaron reingreso para recibir tratamiento. De 29 pacientes con linfocele, 13 (41,0%) experimentaron absorción espontánea y 11 (37,9%) requirieron drenaje quirúrgico o percutáneo con catéter o uso de antibióticos. El análisis multivariado mostró metástasis patológicas en los ganglios linfáticos pélvicos ( p = 0,008) y un mayor número de ganglios pélvicos extraídos unilateralmente ( p = 0,001) se asociaron significativamente con complicaciones a largo plazo. En el último seguimiento (mediana de 43 meses), el 15,9% de los pacientes tuvieron complicaciones no resueltas.LIMITACIÓN:El diseño retrospectivo.CONCLUSIONES:Los pacientes sometidos a disección de ganglios pélvicos linfáticos laterales experimentaron una mayor frecuencia de complicaciones a largo plazo, pero la mitad de ellos tuvieron linfoceles asintomáticos, la mayoría de los cuales se resolvieron espontáneamente. Sin embargo, se deben realizar mayores esfuerzos para reducir las complicaciones previstas relacionadas con la disección de los ganglios linfáticos pélvicos laterales. (Traducción-Dr. Aurian Garcia Gonzalez ).
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Ho Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung Min Lee
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min Hye Jeong
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Hyun Cho
- Department of Radiology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Liu J, Wang X, Chen H, Mei S, Qiu W, Tang J. Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection. J Gastroenterol Hepatol 2023; 38:1934-1941. [PMID: 37394244 DOI: 10.1111/jgh.16270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 05/28/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND AND AIM Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR). METHODS A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three-year disease-free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non-RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires. RESULTS The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non-left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3-year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05). CONCLUSIONS Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL.
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Affiliation(s)
- Junguang Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiaolin Wang
- Department of General Surgery, The Second Hospital of Yulin, Yulin, China
| | - Hekai Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenlong Qiu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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5
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JH. Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort. Ann Surg 2023; 278:772-780. [PMID: 37498208 PMCID: PMC10549897 DOI: 10.1097/sla.0000000000006043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL). BACKGROUND AL after RC resection often results in a permanent stoma. METHODS This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated. RESULTS This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76). CONCLUSIONS The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.
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Affiliation(s)
- Nynke G. Greijdanus
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - Francisco B. de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H. Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O. Perez
- Department of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yves Panis
- Department of Colorectal Surgery, Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Department of Surgery, Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Johannes H.W. de Wilt
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Denost Q, Sylla D, Fleming C, Maillou-Martinaud H, Preaubert-Hayes N, Benard A. A phase III randomized trial evaluating the quality of life impact of a tailored versus systematic use of defunctioning ileostomy following total mesorectal excision for rectal cancer-GRECCAR 17 trial protocol. Colorectal Dis 2023; 25:443-452. [PMID: 36413078 DOI: 10.1111/codi.16428] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/23/2022]
Abstract
AIM The systematic use of a defunctioning ileostomy for 2-3 months postoperatively to protect low colorectal anastomosis (<7 cm from the anal verge) has been the standard practice after total mesorectal excision (TME). However, stoma-related complications can occur in 20%-60% of cases, which may lead to prolonged inpatient care, urgent reoperation and long-term definitive stoma. A negative impact on quality of life (QoL) and increased healthcare expenses are also observed. Conversely, it has been reported that patients without a defunctioning stoma or following early stoma closure (days 8-12 after TME) have a better functional outcome than patients with systematic defunctioning stoma in situ for 2-3 months. METHOD The main objective of this trial is to compare the QoL impact of a tailored versus systematic use of a defunctioning stoma after TME for rectal cancer. The primary outcome is QoL at 12 months postoperatively using the European Organization for. Research and Treatment of Cancer QoL questionnaire QLQ-C30. Among 29 centres of the French GRECCAR network, 200 patients will be recruited over 18 months, with follow-up at 1, 4, 8 and 12 months postoperatively, in an open-label, randomized, two-parallel arm, phase III superiority clinical trial. The experimental arm (arm A) will undergo a tailored use of defunctioning stoma after TME based on a two-step process: (i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leak (defunctioning stoma only if modified anastomotic failure observed risk score ≥2) and (ii) if a stoma is fashioned, whether to perform an early stoma closure at days 8-12, according to clinical (fever), biochemical (C-reactive protein level on days 2 and 4 postoperatively) and radiological postoperative assessment (CT scan with retrograde contrast enema at days 7-8 postoperatively). The control arm (arm B) will undergo systematic use of a defunctioning stoma for 2-3 months after TME for all patients, in keeping with French national and international guidelines. Secondary outcomes will include comprehensive analysis of functional outcomes (including bowel, urinary and sexual function) again up to 12 months postoperatively and a cost analysis. Regular assessments of anastomotic leak rates in both arms (every 50 randomized patients) will be performed and an independent data monitoring committee will recommend trial cessation if this rate is excessive in arm A compared to arm B. CONCLUSION The GRECCAR 17 trial is the first randomized trial to assess a tailored, patient-specific approach to decisions regarding defunctioning stoma use and closure after TME according to personalized risk of anastomotic leak. The results of this trial will describe, for the first time, the QoL and morbidity impact of selective use of a defunctioning ileostomy and the potential health economic effect of such an approach.
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Affiliation(s)
- Quentin Denost
- Department of Colorectal Surgery, Hôpital Haut-Lévèque CHU, Bordeaux, France
| | - Dienabou Sylla
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale CHU, Bordeaux, France
| | - Christina Fleming
- Department of Colorectal Surgery, Hôpital Haut-Lévèque CHU, Bordeaux, France
| | | | | | - Antoine Benard
- Inserm, CIC1401-EC, Bordeaux, Service D'information Médicale CHU, Bordeaux, France
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Jang HB, Kang SB, Lee H, Choi BJ, Lee SC. Anastomotic leakage and chronic presacral sinus after transanal total mesorectal excision (taTME) for rectal cancer: A comparative study to laparoscopic TME. Asian J Surg 2022; 45:2197-2202. [PMID: 34801358 DOI: 10.1016/j.asjsur.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/31/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Several studies have shown that there are no significant differences in anastomotic leakage associated with Transanal total mesorectal excision (taTME) versus laparoscopic TME (lapTME) for rectal cancer; however, little is known about late anastomotic leakage, such as that primarily found in the chronic presacral sinus. We aimed to compare the occurrence of anastomotic leakage and chronic presacral sinus in rectal cancer for taTME and lapTME. METHODS In this retrospective cohort study, data were collected for patients with rectal cancer who underwent surgery between January 2009 and September 2019. Of the 220 patients included in this study, 182 were in the lapTME group and 38 in the taTME group. We compared factors associated with anastomotic leakage and chronic presacral sinus formation between the two groups. A binary-logistic model was used to determine the risk factors for chronic presacral sinus. RESULTS Anastomotic leakage occurred in six patients (15.8%) in the taTME group and 36 patients (19.7%) in the lapTME group. Chronic presacral sinus occurred in three patients (7.9%) in the taTME group and 15 patients (8.2%) in the lapTME group. There was no significant difference in anastomotic leakage or chronic presacral sinus between groups (P = 0.569 and P = 1.000, respectively). Pathologic stage III or higher was significantly associated with chronic presacral sinus formation (P = 0.006). CONCLUSION There were no significant differences between taTME and lapTME regarding the incidence of anastomotic leakage or chronic presacral sinus. Almost one-third of anastomotic leakages developed into chronic presacral sinus.
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Affiliation(s)
- Han Beol Jang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Bum Kang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyein Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Jo Choi
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Sang Chul Lee
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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8
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de Lacy FB, Talboom K, Roodbeen SX, Blok R, Curell A, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates. Br J Surg 2022; 109:822-831. [PMID: 35640282 PMCID: PMC10364759 DOI: 10.1093/bjs/znac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/10/2022] [Accepted: 04/21/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. METHODS A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. RESULTS Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. CONCLUSION EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.
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Affiliation(s)
- F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Robin Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Anna Curell
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Oncological and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Roel Hompes
- Correspondence to: Roel Hompes, Department of Surgery, Amsterdam UMC, University of Amsterdam, Location AMC, J1A-216, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (e-mail: )
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9
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Vignali A, De Nardi P. Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis. World J Gastroenterol 2022; 28:1394-1404. [PMID: 35582677 PMCID: PMC9048477 DOI: 10.3748/wjg.v28.i14.1394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/07/2021] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.
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Affiliation(s)
- Andrea Vignali
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
- Department of Surgery, Vita-Salute University, Milano 20132, Italy
| | - Paola De Nardi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
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10
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Talboom K, Tanis PJ, Bemelman WA, Hompes R. Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How? Clin Colon Rectal Surg 2022; 35:155-164. [PMID: 35237112 PMCID: PMC8885159 DOI: 10.1055/s-0041-1742117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.
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Affiliation(s)
- K. Talboom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands,Address for correspondence P. J. Tanis, MD, PhD Department of Surgery, Amsterdam UMCDe Boelelaan 1117, 1081 HV AmsterdamThe Netherlands
| | - W. A. Bemelman
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - R. Hompes
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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11
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Chen YC, Tsai YY, Ke TW, Fingerhut A, Chen WTL. Transanal endoluminal repair for anastomotic leakage after low anterior resection. BMC Surg 2022; 22:24. [PMID: 35081948 PMCID: PMC8793212 DOI: 10.1186/s12893-022-01484-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is still no consensus on the management of colorectal anastomotic leakage after low anterior resection. The goal was to evaluate the outcomes of patients who underwent transanal endoluminal repair + laparoscopic drainage ± stoma vs. drainage only ± stoma. METHODS Retrospective chart review of patients sustaining anastomotic leakage after laparoscopic low anterior resection between January 2013 and September 2020 who required laparoscopic reoperation. RESULTS Forty-nine patients were included, 22 patients underwent combined laparoscopy and transanal endoluminal repair and 27 patients had drainage with a stoma (n = 16) or drainage alone (n = 11), without direct anastomotic repair. The overall morbidity rate was 30.6% and the mortality rate was 2%. Combined laparoscopic lavage/drainage and transanal endoluminal repair of anastomotic leakage was associated with a lower complication rate (13.6% vs. 44.4%, p = 0.03) and fewer intraabdominal infections (4.5% vs. 29.6%, p = 0.03) compared with no repair. CONCLUSIONS Combined laparoscopic lavage/drainage and transanal endoluminal repair is effective in the management of colorectal anastomosis leakage and was associated with lower morbidity-in particular intraabdominal infection-compared with no repair. However, our results need to be confirmed in larger, and ideally randomized, studies.
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Affiliation(s)
- Yi-Chang Chen
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yuan-Yao Tsai
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tao-Wei Ke
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, People's Republic of China.,Medical University Hospital of Graz, Graz, Austria
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12
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Friel CM, Kin CJ. Anastomotic Complications. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:189-206. [DOI: 10.1007/978-3-030-66049-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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13
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Chandan S, Shen B, Kochhar GS. Therapeutic Endoscopy in Postoperative Pouch Complications. Clin Colon Rectal Surg 2022; 35:78-88. [PMID: 35069034 PMCID: PMC8763469 DOI: 10.1055/s-0041-1740032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ileal pouch-anal anastomosis (IPAA) or "J"-pouch as it is commonly referred to, is the treatment of choice in patients with medically refractory ulcerative colitis. IPAA can have infectious, inflammatory, and mechanical complications. Currently, there are no Food and Drug Administration-approved medical therapies for these complications. Surgery that may be eventually required can have significant morbidities due to the complexity of IPAA. Endoscopy is fast emerging as a leading modality of treatment for some of these pouch complications. Endoscopy in adjunct with medical treatment can help manage the majority of pouch-related disorders and improve the outcome.
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Affiliation(s)
- Saurabh Chandan
- Gastroenterology and Hepatology, CHI Health Creighton University Medical Center, Omaha, Nebraska
| | - Bo Shen
- Center for Ileal Pouch Disorders, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, New York
| | - Gursimran S. Kochhar
- Gastroenterology and Hepatology, Allegheny Health Network, Pittsburgh, Pennsylvania
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14
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Ponholzer F, Klingler CP, Gasser E, Gehwolf P, Ninkovic M, Bellotti R, Kafka-Ritsch R, Öfner D. Long-term outcome after chronic anastomotic leakage following surgery for low rectal cancer. Int J Colorectal Dis 2022; 37:1807-1816. [PMID: 35819487 PMCID: PMC9388432 DOI: 10.1007/s00384-022-04213-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE This study analyzed the prevalence and factors influencing the history of chronic anastomotic leakage following low anterior resection for rectal cancer. Furthermore, the treatment of a persisting presacral sinus and the impact of stoma reversal on outcome were evaluated. METHODS The institutional database was scanned for all patients with anastomotic leakage, who were primarily treated for low rectal cancer between January 1995 and December 2019. Patients with rectovaginal and rectovesical fistula or an inadequate follow-up were excluded (n = 5). After applying the exclusion criteria, 71 patients remained for analysis. RESULTS A total of 39 patients out of 71 patients with anastomotic leakage (54.9%) developed a persisting presacral sinus. Neoadjuvant radiochemotherapy or chemotherapy showed a significant impact on the formation of a chronic anastomotic leakage (radiochemotherapy: p = 0.034; chemotherapy: p = 0.050), while initial surgical treatment showed no difference for anastomotic healing (p = 0.502), but a significantly better overall survival (p = 0.042). Multiple therapies and surgical revision had a negative impact on patients' rate of natural bowel continuity (p = 0.006/ < 0.001). In addition, the stoma reversal cohort showed improved overall 10-year survival (p = 0.004) and functional results (bowel continuity: p = 0.026; pain: p = 0.031). CONCLUSION Primary surgical therapy for chronic anastomotic leakage should consist of surgical treatment. Furthermore, the reversal of a protective stoma should be considered a viable option in treating chronic presacral sinus to improve pain symptoms and bowel continuity.
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Affiliation(s)
- Florian Ponholzer
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Clemens Paul Klingler
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Elisabeth Gasser
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Philipp Gehwolf
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Marijana Ninkovic
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ruben Bellotti
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Reinhold Kafka-Ritsch
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Dietmar Öfner
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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15
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Zhao S, Zhang L, Gao F, Wu M, Zheng J, Bai L, Li F, Liu B, Pan Z, Liu J, Du K, Zhou X, Li C, Zhang A, Pu Z, Li Y, Feng B, Tong W. Transanal Drainage Tube Use for Preventing Anastomotic Leakage After Laparoscopic Low Anterior Resection in Patients With Rectal Cancer: A Randomized Clinical Trial. JAMA Surg 2021; 156:1151-1158. [PMID: 34613330 PMCID: PMC8495603 DOI: 10.1001/jamasurg.2021.4568] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Preventing anastomotic leakage (AL) is crucial for colorectal surgery. Some studies have suggested a positive role of transanal drainage tubes (TDTs) in AL prevention after low anterior resection, but this finding is controversial. OBJECTIVE To assess the effect of TDTs in AL prevention after laparoscopic low anterior resection for rectal cancer. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial with parallel groups (TDT vs non-TDT) was performed from February 26, 2016, to September 30, 2020. Participants included patients from 7 different hospitals in China who were undergoing laparoscopic low anterior resection with the double-stapling technique for mid-low rectal cancer; 576 patients were initially enrolled in this study, and 16 were later excluded. Ultimately, 560 patients were randomly divided between the TDT and non-TDT groups. INTERVENTIONS A silicone tube was inserted through the anus, and the tip of the tube was placed approximately 5 cm above the anastomosis under laparoscopy at the conclusion of surgery. The tube was fixed with a skin suture and connected to a drainage bag. The TDT was scheduled for removal 3 to 7 days after surgery. MAIN OUTCOMES AND MEASURES The primary end point was the postoperative AL rate within 30 days. RESULTS In total, 576 patients were initially enrolled in this study; 16 of these patients were excluded. Ultimately, 560 patients were randomly divided between the TDT group (n = 280; median age, 61.5 years [IQR, 54.0-68.8 years]; 177 men [63.2%]) and the non-TDT group (n = 280; median age, 62.0 years [IQR, 52.0-69.0 years]; 169 men [60.4%]). Intention-to-treat analysis showed no significant difference between the TDT and non-TDT groups in AL rates (18 [6.4%] vs 19 [6.8%]; relative risk, 0.947; 95% CI, 0.508-1.766; P = .87) or AL grades (grade B, 14 [5.0%] and grade C, 4 [1.4%] vs grade B, 11 [3.9%] and grade C, 8 [2.9%]; P = .43). In the stratified analysis based on diverting stomas, there was no significant difference in the AL rate between the groups, regardless of whether a diverting stoma was present (without stoma, 12 [5.8%] vs 15 [7.9%], P = .41; and with stoma, 6 [8.3%] vs 4 [4.5%], P = .50). Anal pain was the most common complaint from patients in the TDT group (130 of 280, 46.4%). Accidental early TDT removal occurred in 20 patients (7.1%), and no bleeding or iatrogenic colonic perforations were detected. CONCLUSIONS AND RELEVANCE The results from this randomized clinical trial indicated that TDTs may not confer any benefit for AL prevention in patients who undergo laparoscopic low anterior resection for mid-low rectal cancer without preoperative radiotherapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02686567.
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Affiliation(s)
- Song Zhao
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Luyang Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Gao
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Gansu, China
| | - Miao Wu
- Department of Gastrointestinal and Hernia Surgery, Second People’s Hospital of Yibin, Yibin, China
| | - Jianyong Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi’an, China
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Li
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Baohua Liu
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Zehui Pan
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Gansu, China
| | - Jian Liu
- Department of Gastrointestinal and Hernia Surgery, Second People’s Hospital of Yibin, Yibin, China
| | - Kunli Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi’an, China
| | - Xiong Zhou
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Chunxue Li
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Anping Zhang
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Zhizhong Pu
- Department of Gastrointestinal and Breast Surgery, The People's Hospital of Kaizhou District, Chongqing, China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University, Chongqing, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weidong Tong
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
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16
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van Workum F, Talboom K, Hannink G, Wolthuis A, de Lacy BF, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rosman C, Hompes R, Tanis PJ, de Wilt JHW. Treatment of anastomotic leakage after rectal cancer resection: The TENTACLE-Rectum study. Colorectal Dis 2021; 23:982-988. [PMID: 33169512 PMCID: PMC8246753 DOI: 10.1111/codi.15435] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/25/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
AIM Anastomotic leakage is a severe complication after low anterior resection (LAR) for rectal cancer and occurs in up to 20% of patients. Most research focuses on reducing its incidence and finding predictive factors for anastomotic leakage. There are no robust data on severity and treatment strategies with associated outcomes. The aims of this work were (1) to investigate the factors that contribute to severity of anastomotic leakage and to compose an anastomotic leakage severity score and (2) to evaluate the effects of different treatment approaches on prespecified outcome parameters, stratified for severity score and other leakage characteristics. METHOD TENTACLE-Rectum is an international multicentre retrospective cohort study. Patients with anastomotic leakage after LAR for primary rectal cancer between 1 January 2014 and 31 December 2018 will be included by each centre. We aim to include 1246 patients in this study. The primary outcome is 1-year stoma-free survival (i.e. patients alive at 1 year without a stoma). Secondary outcomes include number of reinterventions and unplanned readmissions within 1 year, total length of hospital stay, total time with a stoma, the type of stoma present at 1 year (defunctioning, permanent), complications related to secondary leakage and mortality. For aim (1) regression models will be used to create an anastomotic leakage severity score. For aim (2) the effectiveness of different treatment strategies for leakage will be tested after correction for severity score and leakage characteristics, in addition to other potential related confounders. CONCLUSION TENTACLE-Rectum will be an important step towards drawing up evidence-based recommendations and improving outcomes for patients who experience severe treatment-related morbidity.
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Affiliation(s)
- Frans van Workum
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands,Department of Surgery and cancerImperial CollegeLondonUK
| | - Kevin Talboom
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Gerjon Hannink
- Department of Operating RoomsRadboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Jeremie H. Lefevre
- Department of Digestive SurgerySorbonne Université, AP‐HPHôpital Saint AntoineParisFrance
| | - Michael Solomon
- Department of SurgeryUniversity of Sydney Central Clinical SchoolCamperdownNew South WalesAustralia
| | - Matteo Frasson
- Department of SurgeryValencia University Hospital La FeValenciaSpain
| | | | - Quentin Denost
- Department of SurgeryBordeaux University HospitalBordeauxFrance
| | | | - Tsuyoshi Konishi
- Department of Gastroenterological SurgeryCancer Institute Hospital of the Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yves Panis
- Colorectal DepartmentBeaujon Hospital, Clichy, and University of ParisClichyFrance
| | - Camiel Rosman
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
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17
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Slooter MD, Blok RD, de Krom MA, Buskens CJ, Bemelman WA, Tanis PJ, Hompes R. Optimizing omentoplasty for management of chronic pelvic sepsis by intra-operative fluorescence angiography: a comparative cohort study. Colorectal Dis 2020; 22:2252-2259. [PMID: 32683788 PMCID: PMC7818129 DOI: 10.1111/codi.15276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/09/2020] [Indexed: 12/17/2022]
Abstract
AIM Pelviperineal wound complications frequently occur after salvage surgery for chronic pelvic sepsis despite using an omentoplasty. Sufficient perfusion of the omentoplasty following mobilization is essential for proper healing. This study investigated the impact on short-term clinical outcomes of fluorescence angiography (FA) using indocyanine green for assessment of omental perfusion in patients undergoing salvage surgery. METHOD This was a comparative cohort study including consecutive patients who underwent combined abdominal and transanal minimally invasive salvage surgery with omentoplasty at a national referral centre for chronic pelvic sepsis between December 2014 and August 2019. The historical and interventional cohorts were defined based on the date of introduction of FA in April 2018. The primary outcome was pelviperineal non-healing, defined by the presence of any degree of pelviperineal infection at the final postoperative evaluation. RESULTS Eighty-eight patients underwent salvage surgery with omentoplasty for chronic pelvic sepsis, of whom 52 did not have FA and 36 did have FA. The underlying primary disease was Crohn's disease (n = 50) or rectal cancer (n = 38), with even distribution among the cohorts (P = 0.811). FA led to a change in management in 28/36 (78%) patients. After a median of 89 days, pelviperineal non-healing was observed in 22/52 (42%) patients in the cohort without FA and in 8/36 (22%) patients in the cohort with FA (P = 0.051). Omental necrosis was found during reoperation in 3/52 and 0/36 patients, respectively (P = 0.266). CONCLUSION After introduction of FA to assess perfusion of the omentoplasty, halving of the pelviperineal non-healing rate was observed in patients undergoing salvage surgery for chronic pelvic sepsis.
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Affiliation(s)
- M. D. Slooter
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - R. D. Blok
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands,LEXORCentre for Experimental and Molecular MedicineOncode InstituteCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - M. A. de Krom
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - C. J. Buskens
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - W. A. Bemelman
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - P. J. Tanis
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - R. Hompes
- Department of SurgeryCancer Centre AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
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Chi S, Guo J, Zhang X, Li K, Xu P, Cao G, Li S, Tang ST. Resuturing Without Enterostomy for the Treatment of Early-Stage Anastomotic Leaks After Laparoscopic Soave Procedure in Hirschsprung's Disease. J Laparoendosc Adv Surg Tech A 2020; 30:1295-1300. [PMID: 33181061 DOI: 10.1089/lap.2020.0640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Anastomotic leak (AL) rates gradually decreased with surgical skills and perioperative management progression, but it is still inevitable. As the traditional management of AL after the pull-through procedure of Hirschsprung's disease (HD), enterostomy could lead to multiple surgeries, repeated hospitalizations, increased costs, and enterostomy-associated complications. This study aimed to explore the safety and feasibility of resuturing without enterostomy treating early AL after the laparoscopic Soave procedure. Methods: From October 2014 to June 2019, 10 patients who had AL after the laparoscopic Soave procedure were included. Six patients underwent simply resuturing with presacral drainage; the reoperation time was 1-5 days after primary surgery. Four patients who had diffused peritonitis or severe inflammations received resuturing with an ileostomy, and the reoperation time was 6-11 days. Results: Common early symptoms of AL included persistent fever, sacrococcygeal pain, and abdominal pain. The median delay to reoperation was 1.0 (0-2.25) day. Five patients had leaks at the 3-6 o'clock position, two had leaks at the 6-9 o'clock, and the other three had leaks at the 6 o'clock. The median postoperative fever durations were similar in patients without or with an ileostomy, and the median length of intensive care unit (ICU) stays, duration of antibiotic use, and postoperative length of stay were significantly longer in patients with ileostomy. The mean follow-up time was 38.5 ± 16.7 months (15-69 m). As of the time of writing, no reoccurrence was identified. Conclusion: For patients without diffuse peritonitis, severe inflammations, early diagnosis and timely resuturing of AL within 5 days after the laparoscopic Soave procedure of HD could be a safe, effective, and pleasing treatment.
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Affiliation(s)
- Shuiqing Chi
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jialing Guo
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kang Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peipei Xu
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Computed Tomography Findings at 6th Month Related to Chronic Anastomotic Complications After Rectal Surgery. Int Surg 2020. [DOI: 10.9738/intsurg-d-20-00006.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
This study aimed to assess a radiologic test and clinical findings as risk factors of chronic complications after anastomotic leakage (CCAL) in rectal surgery.
Summary of Background Data
Anastomotic leakage (AL) is the most important complication that is related to chronic complications like unhealed chronic sinuses, strictures, and infections.
Methods
This retrospective study included patients who developed anastomotic leakage (AL) after undergoing extraperitoneal anastomosis. Patients with the following characteristics were excluded: (1) patients with no anastomoses, (2) patients undergoing multiple resections due to synchronous colorectal lesions, (3) patients with no curative resections of the primary lesions, and (4) patients experiencing immediate postoperative mortality. Finally, 72 patients were analyzed in this study. The patients were divided into the no chronic complication (NCC) group and the chronic complication (CC) group.
Results
Of the 72 included patients, 17 (23.6%) had CCAL. The patients in the CC group more frequently had radiotherapy and lower tumor compared to the patients in the NCC group. A total of 52 (52/55 [94.5%]) and 4 patients (4/17 [23.5%]) in the NCC group and the CC group achieved bowel continuity 3 years after the primary surgery, respectively (P < 0.0001). According to the multivariate analysis, CT findings at the sixth postoperative month and tumor height were associated with CCAL (P < 0.0001 and P = 0.046, respectively).
Conclusion
This study showed that CT findings at the 6th postoperative month and tumor height were possibly associated with CCAL.
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Presacral Anastomotic Sinus After Low Anterior Resection Mimicking Recurrent Rectal Cancer. Clin Nucl Med 2020; 45:e171-e173. [PMID: 31977488 DOI: 10.1097/rlu.0000000000002934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Presacral anastomotic sinus is recognized as a complication of anastomotic leakage in patients with rectal cancer. Active inflammation in the anastomotic sinus can masquerade as pelvic recurrence of rectal cancer. We present a case of progressive inflammation in anastomotic sinus demonstrated by serial FDG PET/CT scans. Despite its benign nature, increased FDG uptake in this nonnegligible condition, which could lead to further detrimental complications including secondary cancer, may have clinical implications.
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Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection. Dis Colon Rectum 2019; 62:1458-1466. [PMID: 31567923 DOI: 10.1097/dcr.0000000000001483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted in a tertiary referral center. PATIENTS All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES Primary end points were procedural characteristics and 90-day major complications. RESULTS In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS A limitation of this study is the relatively small sample size. CONCLUSIONS This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis.El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica.Este es un estudio de cohorte retrospectiva.Este estudio se realizó en un centro de referencia terciario.Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018.La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional.Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días.En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente.La limitación de este estudio es el tamaño relativamente pequeño de la muestra.Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.
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CT assessment of the quality of omentoplasty and its implications for perineal wound healing. Int J Colorectal Dis 2019; 34:1963-1970. [PMID: 31686200 DOI: 10.1007/s00384-019-03412-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE This study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer. METHODS This was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia. RESULTS This study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149-2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty. CONCLUSION This relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.
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Slooter MD, Blok RD, Wisselink DD, Buskens CJ, Bemelman WA, Tanis PJ, Hompes R. Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study. Tech Coloproctol 2019; 23:723-728. [PMID: 31432336 PMCID: PMC6736781 DOI: 10.1007/s10151-019-02048-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND During creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion. METHODS All consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018-October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification). RESULTS Fifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12-198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3-39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9-37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2-29.7) in well perfused and 2.5 (interquartile range 1.7-4.0) in poorly perfused tissue. CONCLUSIONS FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.
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Affiliation(s)
- M D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,LEXOR, Center for Experimental and Molecular Medicine, Oncode Institute, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D D Wisselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Surgery, Amsterdam UMC, University of Amsterdam, G4, Post box 22660, 1100 DD, Amsterdam, The Netherlands.
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Kim CH. Anastomotic Sinus Developed From Leakage in Rectal Cancer Resection: When Can We Reverse the Defunctioning Stoma? Ann Coloproctol 2019; 35:1-2. [PMID: 30879277 PMCID: PMC6425244 DOI: 10.3393/ac.2018.12.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Gwangju, Korea
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25
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Lan N, Hull TL, Shen B. Endoscopic sinusotomy versus redo surgery for the treatment of chronic pouch anastomotic sinus in ulcerative colitis patients. Gastrointest Endosc 2019; 89:144-156. [PMID: 30107182 DOI: 10.1016/j.gie.2018.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 08/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Pouch sinus may be a serious adverse event in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic sinusotomy (ESi) and redo pouch surgery in the management of pouch sinus. METHODS All consecutive ulcerative colitis patients with chronic pouch sinuses treated with ESi versus redo surgery from 2006 to 2016 were identified. The primary outcomes were recurrence-free and surgery-free survivals. The secondary outcome was postprocedural adverse events. RESULTS This historical cohort study included 226 patients (ESi, n = 141; redo surgery, n = 85). Complete healing of the sinus was achieved in 75 patients (53.2%) and partial healing in 23 patients (16.3%) with ESi, and an initial complete healing (ie, no anastomotic leak before ileostomy closure) was obtained in 80 patients (94.1%) receiving redo surgery. Sinus recurrence after complete healing was seen in 17 patients (22.7%) treated with ESi and 28 patients (32.9%) treated with surgery (P = .15). Subsequent surgery was needed in 34 patients (24.1%) with ESi therapy and 18 patients (21.2%) with initial redo surgery (P = .70). Kaplan-Meier recurrence-free and surgery-free survivals after initial procedures showed no statistical difference between the 2 groups (P = .42 and P = .65, respectively). The rate of adverse events in the ESi group was significantly lower than that in the surgery group (2.5% vs 43.5%, P < .0001). CONCLUSIONS Recurrence-free and surgery-free survivals were comparable between patients treated with ESi and redo surgery, whereas pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy L Hull
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Shen
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Olsen BC, Sakkestad ST, Pfeffer F, Karliczek A. Rate of Anastomotic Leakage After Rectal Anastomosis Depends on the Definition: Pelvic Abscesses are Significant. Scand J Surg 2018; 108:241-249. [PMID: 30474492 DOI: 10.1177/1457496918812223] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The International Study Group of Rectal Cancer has proposed that a pelvic abscess in the proximity of the anastomosis is considered an anastomotic leak, whether or not its point of origin is detectable. This study describes how the inclusion of pelvic abscesses alters the leakage rate. MATERIAL AND METHODS Risk factors and postoperative complications in patients with visible anastomotic leakage ("direct leakage"), pelvic abscesses alone in the vicinity of a visibly intact anastomosis ("abscess leakage"), and no leakage were retrospectively evaluated. RESULTS In total, 341 patients operated with anterior resections and who received an anastomosis within 15 cm as measured from the anal verge were included. A total of 37 patients (10.9%) had direct leakage, 13 (3.8%) had abscess leakage, and 291 (85.3%) had no leakage. The overall anastomotic leakage rate was 14.7% (50 patients). In accordance with the grading system outlined by International Study Group of Rectal Cancer, 7 patients (2.1%) experienced Grade A leakage, 19 (5.6%) Grade B, and 24 (7.0%) Grade C. Direct leak patients had more often a reoperation due to anastomotic complications (odds ratio = 19.7, p = 0.001), a permanent stoma (odds ratio = 28.5, p = 0.001), and a longer hospital stay than abscess leak patients (29.0 vs 15.5 days, p = 0.030). CONCLUSION Abscess leakage accounted for over one-fourth of the overall leakage rate, raising the leakage rate. Direct leak patients were at a higher risk of requiring a reoperation, permanent stoma, and longer hospital stay than abscess leak patients. Abscess leak patients were at a greater risk for a urinary tract infection, wound infection, and postoperative intestinal obstruction than non-leak patients.
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Affiliation(s)
- B C Olsen
- 1 Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - S T Sakkestad
- 1 Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - F Pfeffer
- 1 Department of Clinical Medicine, University of Bergen, Bergen, Norway.,2 Department of Surgery, Haukeland University Hospital, Bergen, Norway
| | - A Karliczek
- 1 Department of Clinical Medicine, University of Bergen, Bergen, Norway.,2 Department of Surgery, Haukeland University Hospital, Bergen, Norway
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Peng CH, Chen YJ, Pang WB, Zhang TC, Wang ZM, Wu DY, Wang K. STROBE-anastomotic leakage after pull-through procedure for Hirschsprung disease. Medicine (Baltimore) 2018; 97:e13140. [PMID: 30431584 PMCID: PMC6257430 DOI: 10.1097/md.0000000000013140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study was undertaken to explore the causes, diagnosis, and treatment of anastomotic leakage after pull-through (PT) procedure for Hirschsprung disease (HD).A retrospective analysis of patients with anastomotic leakage after a PT procedure in the General Surgery Department of Beijing Children's Hospital from July 2013 to June 2016 was undertaken. The surgical characteristics, diagnosis, and treatment were retrospectively analyzed.Among the 213 patients who underwent PT procedures, 5 patients had a documented anastomotic leakage. The median age of these 5 patients at the time of the PT procedure was 6.8 years old, and this was higher than those without anastomotic leakage (1.7 years old). In all patients, rectal examination in the lithotomy position revealed an anastomotic dehiscence at the 6 o'clock position. The abdominal ultrasonography demonstrated retrorectal pneumatosis with or without an abscess in 4 patients. All patients were treated with ileostomies and anastomotic resuturing. The median delay to management was 4 days (range: 1-29 days). Four patients (4/5, 80%) were cured, and 1 (delay, 29 days) of these 4 patients developed postoperative ileus. The remaining patient (delay, 9 days) was required to undergo a repeat PT procedure. For the 4 cured patients, the median follow-up time was 20 months (range: 15-37 months), and these patients defecated 3 times daily at most without soiling.Older children with HD might be prone to anastomotic leakage. The findings of the rectal examination and ultrasonography were distinctive and useful for the diagnosis. Early ileostomy and resuturing of the anastomosis could be used to treat anastomotic leakage.
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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Park IK. Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis. Ann Coloproctol 2018; 34:259-265. [PMID: 30419724 PMCID: PMC6238803 DOI: 10.3393/ac.2018.05.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. Methods Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. Results A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). Conclusion In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.
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Affiliation(s)
- In Teak Woo
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Kyu Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
BACKGROUND When a colorectal or coloanal anastomosis fails because of persistent leakage or stenosis, or the anastomosis has to be resected for recurrent cancer, constructing a new anastomosis might be an option in selected patients. This is a rare and complex type of redo surgery. OBJECTIVE The aim of this review was to evaluate the current literature on redo anastomosis for complicated colorectal or coloanal anastomosis. DATA SOURCES A systematic literature search of MEDLINE, EMBASE, the Cochrane Library, the PROSPERO register, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform database was performed. STUDY SELECTION Two reviewers independently screened the available literature. All studies reporting on redo surgery and aiming at reconstruction of a prior low colorectal or coloanal anastomosis for any indication were included. MAIN OUTCOME MEASURES Primary outcome was successful restoration of continuity. Secondary outcomes were postoperative morbidity, pelvic sepsis, incontinence, and mortality. RESULTS Nine studies were included, comprising 291 patients, of whom 76% had index surgery for colorectal cancer. Pooled proportions showed an overall success rate of 79% (95% CI, 69-86), with a pooled incidence of major postoperative morbidity of 16% (95% CI, 10-24). The pooled pelvic sepsis rate was 16% (95% CI, 9-27), and the pooled surgical reintervention and readmission rates were 11% (95% CI, 8-17) and 7% (95% CI, 3-15). Five studies reported on incontinence, with a pooled proportion of 17% (95% CI, 10-26). LIMITATIONS The limitations of this review are the lack of randomized controlled trials and high-quality studies, and the small sample sizes and heterogeneous patient populations in the included studies. CONCLUSIONS Redo surgery is a valuable treatment option for the complicated colorectal or coloanal anastomosis with 79% successful restoration of bowel continuity in the published literature from experienced tertiary centers.
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Abstract
BACKGROUND AND AIMS Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus. METHODS All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival. RESULTS A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases. CONCLUSIONS NKSi is an effective and safe procedure for treating pouch sinus.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bo Shen
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Chen WTL, Bansal S, Ke TW, Chang SC, Huang YC, Kato T, Wang HM, Fingerhut A. Combined repeat laparoscopy and transanal endolumenal repair (hybrid approach) in the early management of postoperative colorectal anastomotic leaks: technique and outcomes. Surg Endosc 2018; 32:4472-4480. [DOI: 10.1007/s00464-018-6193-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 04/20/2018] [Indexed: 12/18/2022]
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Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg 2017; 266:870-877. [PMID: 28746154 DOI: 10.1097/sla.0000000000002429] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Little is known about late detected anastomotic leakage after low anterior resection for rectal cancer, and the proportion of leakages that develops into a chronic presacral sinus. METHODS In this collaborative snapshot research project, data from registered rectal cancer resections in the Dutch Surgical Colorectal Audit in 2011 were extended with additional treatment and long-term outcome data. Independent predictors for anastomotic leakage were determined using a binary logistic model. RESULTS A total of 71 out of the potential 94 hospitals participated. From the 2095 registered patients, 998 underwent a low anterior resection, of whom 88.8% received any form of neoadjuvant therapy. Median follow-up was 43 months (interquartile range 35-47). Anastomotic leakage was diagnosed in 13.4% within 30 days, which increased to 20.0% (200/998) beyond 30 days. Nonhealing of the leakage at 12 months was 48%, resulting in an overall proportion of chronic presacral sinus of 9.5%. Independent predictors for anastomotic leakage at any time during follow-up were neoadjuvant therapy (odds ratio 2.85; 95% confidence interval 1.00-8.11) and a distal (≤3 cm from the anorectal junction on magnetic resonance imaging) tumor location (odds ratio 1.88; 95% confidence interval 1.02-3.46). CONCLUSIONS This cross-sectional study of low anterior resection for rectal cancer in the Netherlands in 2011, with almost routine use of neoadjuvant radiotherapy, shows that one third of anastomotic leakages is diagnosed beyond 30 days, and almost half of the leakages eventually do not heal. Chronic presacral sinus is a significant clinical problem that deserves more attention.
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Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database. Dis Colon Rectum 2017; 60:706-713. [PMID: 28594720 DOI: 10.1097/dcr.0000000000000800] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant. OBJECTIVE This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer. DESIGN All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit. SETTINGS Data were derived from the Dutch Surgical Colorectal Audit. MAIN OUTCOME MEASURES The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured. RESULTS Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage. LIMITATIONS Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database. CONCLUSIONS Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.
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Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, Festen S, van der Zaag EJ, Tanis PJ, Bemelman WA. Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc 2017; 32:315-327. [PMID: 28664443 PMCID: PMC5770507 DOI: 10.1007/s00464-017-5679-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/19/2017] [Indexed: 12/13/2022]
Abstract
Introduction Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of anastomotic leakage after pre-treatment with the Endosponge® therapy. Methods In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed. Results Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient. Conclusion Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
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Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - G D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - L P S Stassen
- Department of Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands
| | | | - D Hess
- Department of Surgery, Antonius Zorggroep, Sneek, The Netherlands
| | - S van Dieren
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - E J van der Zaag
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Musters GD, Borstlap WA, Bemelman WA, Buskens CJ, Tanis PJ. Intersphincteric completion proctectomy with omentoplasty for chronic presacral sinus after low anterior resection for rectal cancer. Colorectal Dis 2016; 18:147-54. [PMID: 26277690 DOI: 10.1111/codi.13086] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/20/2015] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to determine the clinical outcome of salvage surgery without restoring continuity for symptomatic chronic presacral sinus after low anterior resection (LAR) for rectal cancer. METHOD Out of a prospective cohort of 46 patients with chronic presacral sinus (> 1 year after LAR), 27 underwent completion proctectomy with omentoplasty between January 2005 and July 2014. RESULTS The initial treatment for rectal cancer included neoadjuvant radiotherapy in 26 (96%) patients. Besides a chronic presacral sinus, a secondary fistula was present in 15 (56%) patients. Definitive salvage surgery was performed after a median of 40 (12-350) months from the primary resection. The median hospital stay after single- and multiple-stage salvage surgery was 11 and 17 days. Postoperative complications occurred in 44% of patients. The re-intervention rate was 33% with a range of 1-10 interventions per patient. During a median follow-up of 20 (4-45) months from salvage surgery, healing of the chronic presacral sinus occurred in 78% of patients, with a healing rate after single- and multiple-stage procedures of 88% and 64% respectively (P = 0.19). CONCLUSION Patients with a symptomatic chronic presacral sinus after LAR for rectal cancer, in whom restoration of continuity is not intended, can be effectively managed by completion proctectomy with complete debridement of the sinus and fistula tracts followed by an omentoplasty to fill the presacral cavity, preferably as a single-stage procedure.
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Affiliation(s)
- G D Musters
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Borstlap
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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López V, Abrisqueta J, Luján J, Serrano A, Parrilla P. Endoscopic treatment with biologic glue of chronic presacral sinus after low anterior resection. Cir Esp 2014; 93:197-9. [PMID: 25458550 DOI: 10.1016/j.ciresp.2014.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 09/22/2014] [Accepted: 09/24/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Víctor López
- Departamento de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España.
| | - Jesús Abrisqueta
- Departamento de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - Juan Luján
- Departamento de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - Andrés Serrano
- Departamento de Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - Pascual Parrilla
- Departamento de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
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Henneman D, ten Berge MG, Snijders HS, van Leersum NJ, Fiocco M, Wiggers T, Tollenaar RA, Wouters MW. Safety of elective colorectal cancer surgery: Non-surgical complications and colectomies are targets for quality improvement. J Surg Oncol 2013; 109:567-73. [DOI: 10.1002/jso.23532] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 11/22/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Daniel Henneman
- Department of Surgery; Leiden University Medical Center; Leiden The Netherlands
| | | | - Heleen S. Snijders
- Department of Surgery; Leiden University Medical Center; Leiden The Netherlands
| | | | - Marta Fiocco
- Department of Medical Statistics and Bioinformatics; Leiden University Medical Center; Leiden The Netherlands
| | - Theo Wiggers
- Department of Surgery; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | | | - Michel W.J.M. Wouters
- Department of Surgery; Leiden University Medical Center; Leiden The Netherlands
- Department of Surgical Oncology; Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
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