Low Incidence of Pelvic Sepsis after Hartmann's Procedure: Radiation Therapy May Be a Risk Factor

Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR)

Objective

The primary outcome was to compare overall postoperative surgical complications within 30 days after Hartmann's procedure (HP) compared with intersphincteric abdominoperineal excision (iAPE). The secondary outcome was major surgical complications (Clavien-Dindo ≥ III).

Background

There is uncertainty regarding the optimal surgical method in patients with rectal cancer when an anastomosis is unsuitable.

Methods

Rectal cancer patients with a tumor height >5 cm, registered in the Swedish Colorectal Cancer Registry who received HP or iAPE electively in 2017-2020 were included, (HP, n = 696; iAPE, n = 314). Logistic regression analysis adjusting for body mass index, American Society of Anesthesiologists classification, sex, age, preoperative radiotherapy, tumor height, cancer stage, operating hospital, and type of operation was performed.

Results

Patients in the HP group were older and had higher American Society of Anesthesiologists scores. The mean operating time was less for HP (290 vs 377 min). Intraoperative bowel perforations were less frequent in the HP group, 3.6% versus 10.2%. Overall surgical complication rates were 20.3% after HP and 15.9% after iAPE (P = 0.118). Major surgical complications were 7.5% after HP and 5.7% and after iAPE (P = 0.351). Multiple regression analysis indicated a higher risk of overall surgical complications after HP (odds ratio: 1.63; 95% confidence interval = 1.09-2.45).

Conclusions

HP was associated with a higher risk of surgical complications compared with iAPE. In patients unfit for anastomosis, iAPE may be preferable. However, the lack of statistical power regarding major surgical complications, prolonged operating time, increased risk of bowel perforation, and lack of long-term outcomes, raises uncertainty regarding recommending intersphincteric abdominoperineal excision as the preferred surgical approach.

Risk Factors for Rectal Stump Leakage After Discontinuity Resection: Stump Length Matters Most

BACKGROUND

Discontinuity resection is commonly conducted to avoid anastomotic leakage in high-risk patients but potentially results in rectal stump leakage. Although risk factors for anastomotic leakage have been widely studied, data on rectal stump leakage rates and underlying risk factors are scarce.

OBJECTIVE

To determine rectal stump leakage rates following Hartmann's procedure and to identify patient-and surgery-associated risk factors.

DESIGN

A retrospective study with univariate and multivariate analyses was performed to identify risk factors of rectal stump leakage. A subgroup analysis of scheduled operations was performed.

SETTINGS

The study was conducted at Heidelberg University Hospital, Germany.

PATIENTS

Patients were included who underwent discontinuity resection with rectal stump formation between 2010 and 2020.

MAIN OUTCOME MEASURES

The main outcome measures included rectal stump leakage rates, 30-day mortality, length of hospitalization, and necessity for further invasive treatment.

RESULTS

Rectal stump leakage occurred in 11.78% of patients. Rectal stump leakage rates varied considerably depending on the surgical procedure performed and were highest following subtotal pelvic exenteration (34%). Diagnosis of rectal stump leakage peaked on postoperative day 7. A short rectal stump ( p = 0.001), previous pelvic radiotherapy ( p = 0.04), chemotherapy ( p = 0.004), and previous laparotomy ( p = 0.03) were independent risk factors for rectal stump leakage in the entire patient collective. In patients undergoing scheduled surgery, a short rectal stump was the only independent risk factor ( p = 0.003). Rectal stump leakage was not associated with increased 30-day mortality but prolonged length of hospitalization and frequently necessitated further invasive treatment.

LIMITATIONS

Study results are limited by the retrospective design, a high number of emergency operations, and the mere inclusion of symptomatic leakages.

CONCLUSIONS

Rectal stump leakage is a relevant complication after discontinuity resection. Risk factors should be considered during surgical decision-making when both discontinuity resection and abdominoperineal resection are feasible. See Video Abstract.

FACTORES DE RIESGO PARA LA FUGA DEL MUN RECTAL DESPUS DE UNA RESECCIN POR DISCONTINUIDAD LA LONGITUD DEL MUN ES LO MS IMPORTANTE

ANTECEDENTES:La resección de discontinuidad se realiza comúnmente para evitar la fuga anastomótica en pacientes de alto riesgo, pero potencialmente da como resultado una fuga del muñón rectal. Si bien los factores de riesgo de fuga anastomótica se han estudiado ampliamente, los datos sobre las tasas de fuga del muñón rectal y los factores de riesgo subyacentes son escasos.OBJETIVO:Determinar las tasas de fuga del muñón rectal después del procedimiento de Hartmann e identificar los factores de riesgo asociados con el paciente y la cirugía.DISEÑO:Se realizó un estudio retrospectivo con análisis univariado y multivariado para identificar los factores de riesgo de fuga del muñón rectal. Se llevó a cabo un análisis de subgrupos de las operaciones programadas.AJUSTES:El estudio se realizó en el Hospital Universitario de Heidelberg, Alemania.PACIENTES:Se incluyeron pacientes que se sometieron a resección de discontinuidad con formación de muñón rectal entre 2010 y 2020.MEDIDAS DE RESULTADO PRINCIPALES:Las principales medidas de resultado incluyeron las tasas de fuga del muñón rectal, la mortalidad a los 30 días, la duración de la hospitalización y la necesidad de un tratamiento invasivo adicional.RESULTADOS:La fuga del muñón rectal ocurrió en el 11,78% de los pacientes. Las tasas de fuga del muñón rectal variaron considerablemente según el procedimiento quirúrgico realizado y fueron más altas después de la exenteración pélvica subtotal (34%). El diagnóstico de fuga del muñón rectal alcanzó su punto máximo en el día 7 del postoperatorio. Un muñón rectal corto (p = 0,001), radioterapia pélvica previa (p = 0,04), quimioterapia (p = 0,004) y laparotomía previa (p = 0,03) fueron factores de riesgo independientes de fuga rectal. Fuga del muñón en todo el colectivo de pacientes. En los pacientes sometidos a cirugía programada, el muñón rectal corto fue el único factor de riesgo independiente (p = 0,003). La fuga del muñón rectal no se asoció con un aumento de la mortalidad a los 30 días, pero con una duración prolongada de la hospitalización y con frecuencia requirió un tratamiento invasivo adicional.LIMITACIONES:Los resultados del estudio están limitados por el diseño retrospectivo, un alto número de operaciones de emergencia y la mera inclusión de fugas sintomáticas.CONCLUSIONES:La fuga del muñón rectal es una complicación relevante tras la resección por discontinuidad. Se deben considerar los factores de riesgo durante la toma de decisiones quirúrgicas cuando son factibles tanto la resección por discontinuidad como la resección abdominoperineal. (Traducción-Yesenia Rojas-Khalil ).

Gluteal Fasciocutaneous Flap Reconstruction After Salvage Surgery for Pelvic Sepsis

BACKGROUND

Chronic pelvic sepsis mostly originates from complicated pelvic surgery and failed interventions. This is a challenging condition that often requires extensive salvage surgery consisting of complete debridement with source control and filling of the dead space with well-vascularized tissue.

OBJECTIVE

This study aimed to describe the outcomes of gluteal fasciocutaneous flaps for the treatment of secondary pelvic sepsis.

DESIGN

Retrospective single-center cohort study.

SETTINGS

Tertiary referral center.

PATIENTS

Patients who underwent salvage surgery for secondary pelvic sepsis between 2012 and 2020 using a gluteal flap were included in this study.

MAIN OUTCOME MEASURES

Percentage of complete wound healing.

RESULTS

In total, 27 patients were included, of whom 22 underwent index rectal resection for cancer and 21 had undergone (chemo)radiotherapy. A median of 3 (interquartile range, 1-5) surgical and 1 (interquartile range, 1-4) radiological interventions preceded salvage surgery during a median period of 62 (interquartile range, 20-124) months. Salvage surgery included partial sacrectomy in 20 patients. The gluteal flap consisted of a V-Y flap in 16 patients, superior gluteal artery perforator flap in 8 patients, and a gluteal turnover flap in 3 patients. Median hospital stay was 9 (interquartile range, 6-18) days. During a median follow-up of 18 (interquartile range, 6-34) months, wound complications occurred in 41%, with a reintervention rate of 30%. The median time to wound healing was 69 (interquartile range, 33-154) days, with a complete healing rate of 89% at the end of follow-up.

LIMITATIONS

Retrospective design and heterogeneous patient population.

CONCLUSIONS

In patients undergoing major salvage surgery for chronic pelvic sepsis, the use of gluteal fasciocutaneous flaps is a promising solution because of the high success rate, limited risks, and relatively simple technique. See Video Abstract at http://links.lww.com/DCR/C160 .

RECONSTRUCCIN CON COLGAJO FASCIOCUTNEO GLTEO DESPUS DE UNA CIRUGA DE RESCATE POR SEPSIS PLVICA

ANTECEDENTES:La sepsis pélvica crónica esta causada principalmente por cirugías pélvicas complicadas e intervenciones fallidas. Esta es una condición desafiante que a menudo requiere una cirugía de rescate extensa que consiste en un desbridamiento completo controlando el orígen infeccioso y rellenando el espacio muerto con tejido bien vascularizado, como por ejemplo un colgajo de tejido autólogo. La pared abdominal (colgajo de recto abdominal) o la pierna (colgajo de gracilis) se utilizan principalmente como sitios donantes para esta indicación, mientras que los colgajos glúteos pueden ser alternativas atractivas.OBJETIVO:Describir los resultados de los colgajos fasciocutáneos glúteos en el tratamiento de la sepsis pélvica secundaria.DISEÑO:Estudio de cohortes retrospectivo en un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Todos aquellos que se sometieron a cirugía de rescate por sepsis pélvica secundaria entre 2012 y 2020 utilizando un colgajo fasciocutáneo glúteo.PRINCIPALES MEDIDAS DE RESULTADO:El porcentaje de cicatrización completa de la herida.RESULTADOS:En total, se incluyeron 27 pacientes, de los cuales 22 fueron sometidos a resección rectal por cáncer indicada y 21 pacientes que habían recibido (quimio)radioterapia. Una mediana de tres (RIC 1-5) intervenciones quirúrgicas y una (RIC 1-4) intervenciones radiológicas precedieron a la cirugía de rescate durante una mediana de 62 (RIC 20-124) meses.La cirugía de rescate incluyó una resección parcial del sacro en 20 pacientes. El colgajo fasciocutáneo glúteo consistió en la confección de un colgajo en V-Y en 16 pacientes, un colgajo incluyendo la perforante de la arteria glútea superior en 8 y un colgajo de rotación de músculo glúteo en 3 pacientes.La mediana de estancia hospitalaria fue de nueve (RIC 6-18) días. Durante una mediana de seguimiento de 18 (IQR 6-34) meses, se produjeron complicaciones de la herida en el 41%, con una tasa de reintervención del 30%.La mediana de tiempo hasta la cicatrización de la herida fue de 69 (IQR 33-154) días con una tasa de cicatrización completa del 89 % al final del seguimiento cicatricial.LIMITACIONES:Diseño retrospectivo y población heterogénea de pacientes.CONCLUSIONES:En pacientes sometidos a cirugía mayor de rescate por sepsis pélvica crónica, el uso de colgajos fasciocutáneos glúteos es una solución prometedora debido a la alta tasa de éxito, los riesgos limitados y la técnica relativamente simple. Video Resumen en http://links.lww.com/DCR/C160 . (Traducción-Dr. Xavier Delgadillo ).

Incidence and risk factors of blowout within 90 days after a primary Hartmann's procedure: a retrospective cohort study

PURPOSE

The literature reports a varying occurrence (3-33%) of blowout of the rectal remnant after Hartmann's procedure, and there is a lack of multivariate analyses on potential risk factors for blowout following Hartmann's procedure. We aimed to estimate the incidence of blowout within 90 days after a primary Hartmann's procedure and to identify potential risk factors for blowout through multivariate analysis.

METHODS

A retrospective cohort study was conducted at the Department of Surgery, Aarhus University Hospital, a Danish primary and tertiary hospital. Patients who underwent primary surgery with Hartmann's procedure irrespective of surgical setting and indications between September 2016 and August 2021 were included. Blowout was defined as a defective closure line of the rectal stump or a pelvic abscess.

RESULTS

A total of 178 patients were included, and blowout occurred in 30 patients (16.9%) within 90 days after a primary Hartmann's procedure. Multivariate analysis showed increased risk of blowout among patients with Hinchey IV diverticulitis (relative risk 6.32 (95% CI 4.09-9.75)), previous radiotherapy (relative risk 3.35 (95% CI 1.67-6.74)), and alcohol overconsumption (relative risk 1.69 (95% CI 1.05-2.72)). Intraoperative insertion of a Foley catheter in the rectal remnant significantly reduced the risk of blowout within 90 days after a primary Hartmann's procedure (relative risk 0.18 (95% CI 0.05-0.65)).

CONCLUSION

Blowout remains a severe and common complication within 90 days after a primary Hartmann's procedure. Hinchey IV diverticulitis, pelvic radiotherapy, and alcohol overconsumption are risk factors. An intraoperatively inserted rectal Foley catheter is a protective factor and can be considered used in all patients undergoing Hartmann's procedure.

Low incidence of pelvic sepsis following Hartmann's procedure for rectal cancer: a retrospective multicentre study

BACKGROUND

Results of previous studies regarding pelvic sepsis after Hartmann's procedure (HP) for rectal cancer have been inconsistent and few studies report the risk factors. This study aimed to investigate the incidence of pelvic sepsis after HP, identify risk factors and describe when as well as how pelvic sepsis was diagnosed and treated.

METHODS

Data were collected from the Swedish Colorectal Cancer Registry on all patients undergoing HP for rectal cancer in the county of Skåne from 2007-2017. Patients diagnosed with pelvic sepsis were compared with patients without pelvic sepsis and risk factors for developing pelvic sepsis were analysed in a multivariable model.

RESULTS

A total of 252 patients were included in the study, with 149 (59%) males, and a median age of 75 years (range 20-92). Altogether, 27 patients (11%) were diagnosed with pelvic sepsis. Risk factors for developing pelvic sepsis were neoadjuvant radiotherapy (OR 7.96, 95% CI 2.54-35.36) and BMI over 25 kg/m² (OR 5.26, 95% CI 1.80-19.50). Median time from operation to diagnosis was 21 days (range 5-355) with 11 (40%) patients diagnosed beyond 30 days postoperatively. The majority of cases 19 (70%) were treated conservatively and none needed major surgery.

CONCLUSION

Pelvic sepsis occurred in 11% of patients. Neoadjuvant radiotherapy and higher BMI were significant risk factors for developing pelvic sepsis. Forty percent of patients were diagnosed later than 30 days postoperatively and most patients were successfully treated conservatively. Our findings suggest that HP is a valid treatment option for rectal cancer when anastomosis is inappropriate, even in patients receiving neoadjuvant radiotherapy.

The complication profile of low Hartmann's in rectal cancer: a systematic review and meta-analysis

BACKGROUND

Non-restorative options for low rectal cancer not invading the sphincter includes low Hartmann's procedure (LH) and inter-sphincteric abdominoperineal resection (ISAPR). There is currently little comparative data to differentiate these options.

OBJECTIVES

The aim of this review was to assess the peri-operative morbidity of LH, and then to compare it to that of ISAPR.

DATA SOURCES

An up-to-date systematic review was performed on the available literature between 2000-2020 on PubMed, EMBASE, Medline, and Cochrane Library databases.

STUDY SELECTION

All studies reporting on non-restorative surgeries for rectal cancer were analysed. Outcomes were firstly analysed between LH and non-LH groups, with further sub-analysis comparing the LH and ISAPR groups.

MAIN OUTCOME MEASURE

The main outcome measures were the rates of pelvic sepsis, rates of overall post-operative complication rates, oncological outcomes, and survival.

RESULTS

A total of 12 observational studies were included. There were 3526 patients (61.1%) in the LH group, and 2238 patients (38.9%) in the non-LH group, which included 461 patients who underwent ISAPR. The LH group had a higher rate of pelvic sepsis as compared to the non-LH group (OR: 1.79, 95% CI: 1.39-2.29, P < 0.001). The difference is more marked in the sub-analysis comparing LH and ISAPR alone (OR: 3.94, 95% CI: 1.88-7.84, P < 0.01) corresponding to a higher rate of unplanned re-intervention. LH was associated with a higher rate of short-term post-operative mortality as compared to the non-LH group.

CONCLUSION

ISAPR is the preferred option for non-restorative rectal surgery, with a more favourable peri-operative morbidity and short-term mortality profile as compared to LH.

Sepsis in surgical inpatients: under-recognised but with significant consequences

BACKGROUND

The true incidence of sepsis in surgical cohorts in Ireland remains unclear. According to inpatient audits, patients in surgical diagnostic groups (DRG) who developed sepsis had a longer length of stay and higher mortality rate compared with medical DRG patients who developed sepsis.

AIMS

We investigated sepsis incidence on a general surgical ward to identify risk factors and strategies to improve management.

METHODS

Demographics, admission and discharge details, infection risk factors, infection, and sepsis were studied prospectively on a surgical ward in July 2018.

RESULTS

The mean age of 164 patients was 60.5 years (range 18-93 years), 107 (65.2%) were admitted electively, 16 (9.8%) were colonised with a multidrug-resistant organism (MDRO), and 30 (18.3%) were classified as frail on admission. Twelve (7.3%) developed sepsis (ward sepsis rate 118.2/10,000 bed days used). 'Sepsis' was documented in six cases and the national sepsis screening form used in four patients. Patients with sepsis were three times as likely to be MDRO-colonised (OR 3.56; 95% CI = 0.86-14.82; p = 0.065) or frail (OR 3.63; 95% CI = 1.07-12.35; p = 0.03), four times as likely to be an inpatient at the end of the study (OR 4.22, 96% CI 1.23-14.49; p = 0.01), and three times as likely to be readmitted (OR 3.46, 95% CI 1.02-11.76; p = 0.03).

CONCLUSION

Sepsis was under-documented, and barriers exist with use of the national sepsis screening form. Frailty, which is a sepsis risk factor, should be assessed pre-operatively to maximise prevention.