Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery

Short- and long-term outcome differences between patients undergoing left and right colon cancer surgery: cohort study

PURPOSE

Since the literature currently provides controversial data on the postoperative outcomes following right and left hemicolectomies, we carried out this study to examine the short- and long-term treatment outcomes.

METHODS

This study included consecutive patients who underwent right or left-sided colonic resections from year 2014 to 2018 and then they were followed up. The short-term outcomes such as postoperative morbidity and mortality according to Clavien-Dindo score, duration of hospital stay, and 90-day readmission rate were evaluated as well as long-term outcomes of overall survival and disease-free survival. Multivariable Cox regression analysis was performed of overall and progression-free survival.

RESULTS

In total, 1107 patients with colon tumors were included in the study, 525 patients with right-sided tumors (RCC) and 582 cases with tumors in the left part of the colon (LCC). RCC group patients were older (P < 0.001), with a higher ASA score (P < 0.001), and with more cardiovascular comorbidities (P < 0.001). No differences were observed between groups in terms of postoperative outcomes such as morbidity and mortality, except 90-day readmission which was more frequent in the RCC group. Upon histopathological analysis, the RCC group's patients had more removed lymph nodes (29 ± 14 vs 20 ± 11, P = 0.001) and more locally progressed (pT3-4) tumors (85.4% versus 73.4%, P = 0.001). Significantly greater 5-year overall survival and disease-free survival (P = 0.001) were observed for patients in the LCC group, according to univariate Kaplan-Meier analysis.

CONCLUSIONS

Patients with right-sided colon cancer were older and had more advanced disease. Short-term surgical outcomes were similar, but patients in the LCC group resulted in better long-term outcomes.

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy

BACKGROUND

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy.

METHODS

In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance.

RESULTS

Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model.

CONCLUSIONS

This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Two-row, three-row or powered circular stapler, which to choose when performing colorectal anastomosis? A systematic review and meta-analysis

PURPOSE

Three types of circular staplers can be used to perform a colorectal anastomosis: two-row (MCS), three-row (TRCS) and powered (PCS) devices. The objective of this meta-analysis has been to provide the existing evidence on which of these circular staplers would have a lower risk of presenting a leak (AL) and/or anastomotic bleeding (AB).

METHODS

An in-depth search was carried out in the electronic bibliographic databases Embase, PubMed and SCOPUS. Observational studies were included, since randomized clinical trials comparing circular staplers were not found.

RESULTS

In the case of AL, seven studies met the inclusion criteria in the PCS group and four in the TRCS group. In the case of AB, only four studies could be included in the analysis in the PCS group. The AL OR reported for PCS was 0.402 (95%-confidence interval (95%-CI): 0.266-0.608) and for AB: 0.2 (95% CI: 0.08-0.52). The OR obtained for AL in TRCS was 0.446 (95%-CI: 0.217 to 0.916). Risk difference for AL in PCS was - 0.06 (95% CI: - 0.07 to - 0.04) and in TRCS was - 0.04 (95%-CI: - 0.08 to - 0.01). Subgroup analysis did not report significant differences between groups. On the other hand, the AB OR obtained for PCS was 0.2 (95% CI: 0.08-0.52). In this case, no significant differences were observed in subgroup analysis.

CONCLUSION

PCS presented a significantly lower risk of leakage and anastomotic bleeding while TRCS only demonstrated a risk reduction in AL. Risk difference of AL was superior in the PCS than in TRCS.

Modulating Gut Microbiota Prevents Anastomotic Leak to Reduce Local Implantation and Dissemination of Colorectal Cancer Cells after Surgery

PURPOSE

Anastomotic leak (AL) is a major complication in colorectal cancer surgery and consists of the leakage of intestinal content through a poorly healed colonic wound. Colorectal cancer recurrence after surgery is a major determinant of survival. We hypothesize that AL may allow cancer cells to escape the gut and lead to cancer recurrence and that improving anastomotic healing may prevent local implantation and metastatic dissemination of cancer cells.

EXPERIMENTAL DESIGN

We investigated the association between AL and postoperative outcomes in patients with colorectal cancer. Using mouse models of poor anastomotic healing, we assessed the processes of local implantation and dissemination of cancer cells. The effect of dietary supplementation with inulin and 5-aminosalicylate (5-ASA), which activate PPAR-γ in the gut, on local anastomotic tumors was assessed in mice undergoing colonic surgery. Inulin and 5-ASA were also assessed in a mouse model of liver metastasis.

RESULTS

Patients experiencing AL displayed lower overall and oncologic survival than non-AL patients. Poor anastomotic healing in mice led to larger anastomotic and peritoneal tumors. The microbiota of patients with AL displays a lower capacity to activate the antineoplastic PPAR-γ in the gut. Modulation of gut microbiota using dietary inulin and 5-ASA reinforced the gut barrier and prevented anastomotic tumors and metastatic spread in mice.

CONCLUSIONS

Our findings reinforce the hypothesis that preventing AL is paramount to improving oncologic outcomes after colorectal cancer surgery. Furthermore, they pave the way toward dietary targeting of PPAR-γ as a novel way to enhance healing and diminish cancer recurrence.

Diet-induced shifts in the gut microbiota influence anastomotic healing in a murine model of colonic surgery

Host diet and gut microbiota interact to contribute to perioperative complications, including anastomotic leak (AL). Using a murine surgical model of colonic anastomosis, we investigated how diet and fecal microbial transplantation (FMT) impacted the intestinal microbiota and if a predictive signature for AL could be determined. We hypothesized that a Western diet (WD) would impact gut microbial composition and that the resulting dysbiosis would correlate with increased rates of AL, while FMT from healthy, lean diet (LD) donors would reduce the risk of AL. Furthermore, we predicted that surgical outcomes would allow for the development of a microbial preclinical translational tool to identify AL. Here, we show that AL is associated with a dysbiotic microbial community characterized by increased levels of Bacteroides and Akkermansia. We identified several key taxa that were associated with leak formation, and developed an index based on the ratio of bacteria associated with the absence and presence of leak. We also highlight a modifiable connection between diet, microbiota, and anastomotic healing, potentially paving the way for perioperative modulation by microbiota-targeted therapeutics to reduce AL.

The effects of enhanced recovery after surgery on wound infection, complications, and postoperative hospital stay in patients undergoing colorectal surgery: A systematic review and meta-analysis

This study aimed to systematically evaluate the effects of enhanced recovery after surgery (ERAS) on surgical site infections, postoperative complications, and length of hospital stay in patients undergoing colorectal surgery. A comprehensive search was conducted of PubMed, Web of Science, Ovid, EMBASE, The Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data from database inception to April 2023 to identify relevant studies on the application of ERAS in colorectal surgery. Studies were screened, and data were extracted based on predetermined inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.4 software. A total of 22 studies, including 3702 patients (ERAS group: 1906; control group: 1796), were included in the final analysis. ERAS significantly reduced the incidence of surgical site infection (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.34-0.69, p < 0.001), postoperative complications (OR: 0.33, 95% CI: 0.27-0.41, p < 0.001), and length of hospital stay (standardised mean difference: -1.22 days, 95% CI: -1.66 to -0.77 days, p < 0.001). These findings suggest that ERAS reduces the incidence of surgical site infections and postoperative complications and shortens the length of hospital stay in patients undergoing colorectal surgery. Therefore, ERAS should be promoted and applied in clinical practice.

Peritoneal and Systemic Interleukin-10 as Early Biomarkers for Colorectal Anastomotic Leakage Following Surgery in Colorectal Cancer Patients: A Systematic Review and Meta-Analysis

<b><br>Introduction:</b> Despite advancements in diagnostic methods, the early detection of colorectal anastomotic leakage (CAL) continues to pose challenges. The identification of reliable markers is crucial to reduce patient morbidity and mortality. Cytokines present in drain fluid and systemic cytokine levels have shown promise as predictive markers for CAL; however, additional high-quality evidence is warranted to enhance the reliability and validity of the findings in this field.</br> <b><br>Aim:</b> This systematic review and meta-analysis aimed to assess the significance of peritoneal and serum/plasma interleukin-10 (IL-10) levels in the early detection of CAL in patients undergoing colorectal surgery for colorectal cancer.</br> <b><br>Methods:</b> A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science databases, covering studies published until July 2023. The search aimed to identify relevant studies investigating the levels of plasma/serum and peritoneal IL-10 (or both) in colorectal cancer patients undergoing colorectal surgery, specifically focusing on the presence of CAL. Data on the mean and standard deviation of IL-10 levels in both CAL and non-CAL patients were extracted from the selected studies. Mean differences in IL-10 levels were analyzed for each postoperative day (POD) using the OpenMeta [analyst] software.</br> <b><br>Results:</b> 11 articles were selected for inclusion in this systematic review. Among them, nine articles reported data on peritoneal IL-10 levels, while four articles focused on circulating IL-10 levels. The statistical analysis included four eligible articles that assessed peritoneal IL-10 levels, and the results indicated no significant increase in CAL patients compared to non-CAL patients on any postoperative day (POD). Meta-analysis for circulating IL-10 levels was not feasible.</br> <b><br>Conclusions:</b> Up to now, peritoneal and systemic IL-10 levels cannot be considered as early markers for CAL after colorectal surgery in colorectal cancer patients. More high-quality studies are needed to establish the potential of IL-10 as a reliable marker for detecting anastomotic leakage after colorectal surgery.</br>.

Surgical considerations for the "perfect" colorectal anastomosis

A technically sound colorectal anastomosis is paramount in optimising outcomes and reducing complications such as anastomotic leak which can lead to prolonged hospital stay, repeated operations, stoma formation, anastomotic stricture formation and even mortality in patients. Therefore, thorough consideration should be given to all aspects of its construct, from its basic mechanical configuration to subsequent evaluation of anastomosis integrity and perfusion. Risk factors for anastomotic leakage are well established and are usually classified into modifiable and non-modifiable risk factors. In this review article, we will focus on and discuss the modifiable surgical risk factors and how the authors incorporate latest evidence and surgical principles in creating a "perfect" colorectal anastomosis. We review the latest evidence on the proper mechanical construct of a colorectal anastomosis, enhanced recovery after surgery (ERAS), high versus low ligation of inferior mesenteric artery (IMA), routine splenic flexure mobilisation (SFM), the use of indocyanine green (ICG), as well as methods used for the evaluation of the anastomosis integrity. New adjuncts described in the literature to reinforce anastomoses are also discussed. In summary, meticulous technique with nuanced refinements based on our understanding of surgical principles, together with the adoption of relevant new technologies, are essential in our strive towards the "perfect" colorectal anastomosis.

Influence of splenic flexure mobilization on postoperative and oncological outcomes following anterior resection

BACKGROUND

Splenic flexure mobilization (SFM) during anterior resection is often debated given its increased operative complexity and lack of clear data suggesting oncological benefit. This study aimed to compare postoperative complications and 3-year oncological outcomes in patients undergoing anterior resection with and without SFM.

METHODS

A retrospective single center observational study was performed. Notes review was performed for all patients undergoing anterior resection over a one-year period at a high-volume institution for sigmoid and rectal cancers. Anterior resections performed for benign disease or non-colorectal cancers were excluded.

RESULTS

One hundred seventeen patients were included and 49 (41.9%) underwent SFM. 75 (64.1%) cases were completed laparoscopically and 48 (41%) resulted in stoma formation. SFM significantly increased the risk of minor Clavien Dindo Grade 1 postoperative complications (18.4% vs. 5.9%, P=0.03), however, it had no impact on more major postoperative complications, including anastomotic leaks (4.2% vs. 7.1%, P=0.52). There were no significant differences in median total lymph node yield (21.0% vs. 21.1, P=0.57) or R0 resection margin (93.9% vs. 94.1%, P=0.96). There was a non-significant trend towards lower overall recurrence rates in the SFM group (10.2% vs. 19.1%, P=0.19).

CONCLUSIONS

In patients undergoing anterior resection for colorectal cancer, SFM provides no clear oncological benefit, but does increase the likelihood of minor postoperative complications. Whilst a trend towards lower overall recurrence rates was observed in the SFM group, this was not statistically significant. Therefore, SFM should be carefully considered on a case-by-case basis.

Outcome of Completion Surgery after Endoscopic Submucosal Dissection in Early-Stage Colorectal Cancer Patients

T1 colorectal cancers (T1CRC) are increasingly being treated by endoscopic submucosal dissection (ESD). After ESD of a T1CRC, completion surgery is indicated in a subgroup of patients. Currently, the influence of ESD on surgical morbidity and mortality is unknown. The aim of this study was to compare 90-day morbidity and mortality of completion surgery after ESD to primary surgery. The completion surgery group consisted of suspected T1CRC patients from a multicenter prospective ESD database (2014-2020). The primary surgery group consisted of pT1CRC patients from a nationwide surgical registry (2017-2019). Patients with rectal or sigmoidal cancers were selected. Patients receiving neoadjuvant therapy were excluded. Propensity score adjustment was used to correct for confounders. In total, 411 patients were included: 54 in the completion surgery group (39 pT1, 15 pT2) and 357 in the primary surgery group with pT1CRC. Adverse event rate was 24.1% after completion surgery and 21.3% after primary surgery. After completion surgery 90-day mortality did not occur, though one patient died in the primary surgery group. After propensity score adjustment, lymph node yield did not differ significantly between the groups. Among other morbidity-related outcomes, stoma rate (OR 1.298 95%-CI 0.587-2.872, p = 0.519) and adverse event rate (OR 1.162; 95%-CI 0.570-2.370, p = 0.679) also did not differ significantly. A subgroup analysis was performed in patients undergoing rectal surgery. In this subgroup (37 completion and 136 primary surgery), these morbidity outcomes also did not differ significantly. In conclusion, this study suggests that ESD does not compromise morbidity or 90-day mortality of completion surgery.

Factors Influencing Postoperative Complications Following Minimally Invasive Ivor Lewis Esophagectomy: A Retrospective Cohort Study

BACKGROUND

Complications arising following minimally invasive Ivor Lewis esophagectomy often result from inadequate enteral nutrition, highlighting the need for proactive measures to prevent such issues. One approach involves identifying high-risk cases prone to complications and implementing percutaneous endoscopic jejunostomy (PEJ) tube placement during esophageal resection to ensure timely enteral nutrition.

METHODS

In this single-center, retrospective cohort study, we examined patients who underwent minimally invasive esophagectomy for esophageal cancer at a high-volume center. The dataset encompassed demographic information, comorbidities, laboratory parameters, and intraoperative details. Our center utilized the EndoVac system pre-emptively to safeguard the anastomosis from harmful secretions and to enhance local oxygen partial pressure. All patients received pre-emptive EndoVac therapy and underwent esophagogastroduodenoscopy in the early postoperative days. The need for multiple postoperative EndoVac cycles indicated complications, including anastomotic insufficiency and subsequent requirement for a PEJ. The primary objectives were identifying predictive factors for anastomotic insufficiency and the need for multi-cycle EndoVac therapy, quantifying their effects, and assessing the likelihood of postoperative complications.

RESULTS

149 patients who underwent minimally invasive or hybrid Ivor Lewis esophagectomy were analyzed and 21 perioperative and demographic features were evaluated. Postoperative complications were associated with the body mass index (BMI) category, the use of blood pressure medication, and surgery duration. Anastomotic insufficiency as a specific complication was correlated with BMI and the Charlson comorbidity index. The odds ratio of being in the high-risk group significantly increased with higher BMI (OR = 1.074, p = 0.048) and longer surgery duration (OR = 1.005, p = 0.004).

CONCLUSIONS

Based on our findings, high BMI and longer surgery duration are potential risk factors for postoperative complications following minimally invasive esophagectomy. Identifying such factors can aid in pre-emptively addressing nutritional challenges and reducing the incidence of complications in high-risk patients.

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts

BACKGROUND

Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections.

MATERIALS AND METHODS

A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026).

CONCLUSION

The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.

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.

Anastomotic leak risk factors following colon cancer resection: a systematic review and meta-analysis

BACKGROUND

Despite improved surgical techniques, anastomotic leakage is still a serious complication that can occur after colon cancer resection, resulting in increased morbidity and mortality. The aim of this study was to evaluate the risk factors for anastomotic leakage after colon cancer surgery, provide a theoretical basis for reducing its occurrence, and guide the practice of clinicians.

METHODS

A systematic review of PubMed, Ovid, Web of Science and Cochrane Central Register of Controlled Trials databases was conducted by using a combination of subject terms and free words for online searches. The databases were searched from their inception to 31 March 2022, and all cross-sectional, cohort or case‒control studies examining the risk factors for the development of anastomotic fistula after surgery for colon cancer were identified.

RESULT

A total of 2133 articles were searched for this study, and 16 publications were ultimately included, all of which were cohort studies. A total of 115,462 subjects were included, and a total of 3959 cases of anastomotic leakage occurred postoperatively, with an incidence of 3.4%. The odds ratio (OR) and 95% confidence interval (CI) were used for evaluation. Male sex (OR = 1.37, 95% CI: 1.29-1.46, P < 0.00001), BMI (OR = 1.04, 95% CI: 1.00-1.08, P = 0.03), diabetes (OR = 2.80, 95% CI: 1.81-4.33, P < 0.00001), combined lung disease (OR = 1.28, 95% CI: 1.15-1.42, P < 0.00001), anaesthesia ASA score (OR = 1.35, 95% CI: 1.24-1.46, P < 0.00001), ASA class ≥ III (OR = 1.34, 95% CI: 1.22-1.47, P < 0.00001), emergency surgery (OR = 1.31, 95% CI: 1.11-1.55, P = 0.001), open surgery (OR = 1.94, 95% CI: 1.69-2.24, P < 0.00001) and type of surgical resection (OR = 1.34, 95% CI: 1.12-1.61, P = 0.002) are risk factors for anastomotic leakage after colon cancer surgery. There is still a lack of strong evidence on whether age (OR = 1.00, 95% CI: 0.99-1.01, P = 0.36) and cardiovascular disease (OR = 1.18, 95% CI: 0.94-1.47, P = 0.16) are factors influencing the occurrence of anastomotic leakage after colon cancer surgery.

CONCLUSIONS

Male sex, BMI, obesity, coexisting pulmonary disease, anaesthesia ASA score, emergency surgery, open surgery and type of resection were risk factors for anastomotic leakage after colon cancer surgery. The effect of age and cardiovascular disease on postoperative anastomotic leakage in patients with colon cancer needs further study.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.

Indocyanine green fluorescence angiography decreases the risk of anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis

Background

Anastomotic leakage is a serious complication after rectal cancer resection. Intraoperative use of indocyanine green fluorescence angiography (ICGFA) can help prevent anastomotic leakage, but its use is controversial. We conducted a systematic review and meta-analysis to determine the efficacy of ICGFA in reducing anastomotic leakage.

Methods

Relevant data and research published until September 30, 2022, was retrieved from the PubMed, Embase, and Cochrane Library databases, and the difference in the incidence of anastomotic leakage after rectal cancer resection between ICGFA and standard treatment was compared.

Results

This meta-analysis included 22 studies with a total of 4,738 patients. The results showed that ICGFA use during surgery decreased the incidence of anastomotic leakage after rectal cancer surgery [risk ratio (RR) = 0.46; 95% confidence interval (95% CI), 0.39-0.56; p < 0.001]. Simultaneously, in subgroup analyses for different regions, ICGFA was found to be used to reduce the incidence of anastomotic leakage after rectal cancer surgery in Asia (RR = 0.33; 95% CI, 0.23-0.48; p < 0.00001) and Europe (RR = 0.38; 95% CI, 0.27-0.53; p < 0.00001) but not in North America (RR = 0.72; 95% CI, 0.40-1.29; p = 0.27). Regarding different levels of anastomotic leakage, ICGFA reduced the incidence of postoperative type A anastomotic leakage (RR = 0.25; 95% CI, 0.14-0.44; p < 0.00001) but did not reduce the incidence of type B (RR = 0.70; 95% CI, 0.38-1.31; p = 0.27) and type C (RR = 0.97; 95% CI, 0.51-1.97; p = 0.93) anastomotic leakages.

Conclusion

ICGFA has been linked to a reduction in anastomotic leakage after rectal cancer resection. However, multicenter randomized controlled trials with larger sample sizes are required for further validation.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis

BACKGROUND

Whether to ligate the inferior mesenteric artery at its root during anterior resection for sigmoid colon or rectal cancer is still under debate. This study compared the surgical outcomes, postoperative recovery, and anastomotic leakage between high and low ligation of the inferior mesenteric artery through a subgroup analysis.

METHODS

This was a retrospective analysis of prospectively collected data. All patients who underwent colorectal resection for rectosigmoid cancer between December 2016 and December 2019 were enrolled. According to the surgical ligation level of the inferior mesenteric artery, the patients were categorized into either the high or low ligation group. The investigated population was matched using the propensity score method.

RESULTS

Overall, 894 patients with sigmoid or rectal cancer underwent elective anterior resection with high (577 patients) or low (317 patients) ligation of the inferior mesenteric artery. After the propensity score matching, 245 patients in each group were compared. High ligation of the inferior mesenteric artery was associated with higher incidence of anastomotic leakage (14.9% vs. 5.6%, P = 0.041) for mid- to low-rectum tumors and a higher incidence of complications (8.6% vs. 3.3%, P = 0.013) of grades 1-2 according to the Clavien-Dindo classification system.

CONCLUSION

Compared with high ligation, low ligation of the inferior mesenteric artery resulted in lower likelihood of morbidity and mortality in rectal and sigmoid cancers. Moreover, low ligation was less likely to result in anastomosis leakage in mid- to low-rectal cancers.

Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection

AIM

The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy.

METHOD

Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis.

RESULTS

A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01).

CONCLUSION

LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.

Clinical anastomosis leakage and associated factors among patients who had intestinal anastomosis in northwest referral hospitals, Ethiopia

BACKGROUND

Clinical anastomosis leakage leads to increased hospital costs, lengths of stay, readmissions, reoperations, and death. Therefore, this study aimed to assess clinical anastomotic leakage and associated factors among patients who had intestinal anastomosis in Northwest referral Hospitals, Ethiopia.

METHOD

A retrospective cross-sectional study design was conducted among 411 randomly selected patients. The patient's medical records from February 2017 to February 2020 were used. The date range during which patients' medical records were extracted was from March 1 to June 2020. Patient medical record charts and data extraction sheets were used to collect the data. Data was entered into EPI-DATA version 3.1 and exported into SPSS version 25 for analysis. Binary and multiple logistic regression analysis was used to assess the association between dependent and independent variables. P-value of less than 0.05 and odds ratio with 95% CI were used to declare the presence of association.

RESULTS

The response rate of the study was 99.8%. Of 411 patients, 38 (9.2%) patients developed clinical anastomotic leakage. Age group 0-10 years (AOR = 6.85 95% CI: 1.742-26.97), emergency presentation (AOR = 3.196 95% CI: 1.132-9.025), and pre-operative comorbid disease (AOR = 7.62 95% CI: 2.804-20.68) were significantly associated with anastomotic leak.

CONCLUSIONS

Clinical anastomotic leakage is higher than the expected rate (4.9%-7.2%). Age, emergency presentation, and comorbidities were associated with clinical anastomotic leak. Hence, attention to early identification of risk factors and providing optimal pre-operative, operative, and post-operative care is necessary.

Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model

INTRODUCTION

In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS.

MATERIALS AND METHODS

Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T₀) and after resection, in patients having a stoma in situ (T₁). These risk factors were used to construct a web-based prediction tool.

RESULTS

Of 2099 patients included in the study (T₀), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T₁), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T₀ and T₁ population. Other predictors at T₀ were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T₁, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T₀ and an AUC of 0.81 for T₁.

CONCLUSIONS

PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.

Anastomotic Leak in Colorectal Surgery: Predictive Factors and Survival

<br><b>Introduction:</b> Anastomotic leak (AL) is a serious complication following colorectal surgery.</br> <br><b>Aim:</b> The aim of this study was to identify factors associated with the development of AL and to analyze its impact on survival.</br> <br><b>Materials and methods:</b> All consecutive adult colorectal cancer resections performed between 2007 and 2020 with curative intent and anastomosis formation were included from a prospectively maintained database. The primary outcome measure was the rate of AL. The secondary outcome measure was 5-year overall survival (OS).</br> <br><b>Results:</b> There were 6837 eligible patients. The rate of AL was 2.2% and 4.0% in patients with colon and rectal cancer, respectively. AL was a significant independent predictor of reduced 5-year OS in patients who underwent curative surgery for rectal cancer (odds ratio 2.293, p = 0.009). Emergency surgery (p = 0.015), surgery at a public hospital (p = 0.002), and an open surgical approach (p = 0.021) were all associated with a significantly higher risk of AL in patients with colon cancer, with higher rates of AL noted in left colectomies as compared to right hemicolectomies (4.4% <i>vs.</i> 1.3%, p < 0.001). In rectal cancer patients, AL was associated with neoadjuvant chemoradiotherapy (p = 0.038) and male gender (p = 0.002). The anastomosis formation technique (hand-sewn <i>vs.</i> stapled) did not impact the rate of AL (p = 0.116 and p = 0.198 with colon and rectal cancer, respectively).</br> <br><b>Discussion:</b> Clinicians should be cognizant of the predictive factors for AL and should consider early intervention for at-risk patients.</br>.

Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis

INTRODUCTION

anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy.

METHODS

the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05.

RESULTS

cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35).

CONCLUSIONS

important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.

The Significance of Blood and Peritoneal Fluid Biochemical Markers in Identifying Early Anastomotic Leak following Colorectal Resection-Findings from a Single-Center Study

Background and Objectives: The aim of our study was to evaluate the value of leukocyte, C reactive protein (CRP), procalcitonin, lactate, and carcinoembryonic antigen (CEA) in blood and peritoneal fluid in early recognition of anastomotic leak (AL) after colorectal resections. Materials and Methods: Our pilot prospective cohort study was conducted at the abdominal surgery department at University Medical Center Ljubljana. A total of 43 patients who underwent open or laparoscopic colorectal resection because of benign or malignant etiology were enrolled. All of the patients had primary anastomosis without stoma formation. Results: Three patients in our patient group developed AL (7%). We found a statistically significant elevation of serum lactate levels in patients that developed AL compared to those who did not but noted no statistically relevant difference in the blood or peritoneal fluid levels of other biochemical markers. Conclusions: Elevated lactate levels may be considered a promising biomarker for the early diagnosis of AL, but more research on bigger patient groups is warranted.

Anastomotic Leak Impact on Long-Term Survival after Right Colectomy for Cancer: A Propensity-Score-Matched Analysis

Our goal was to assess the impact of anastomotic leaks (ALs) on oncologic outcomes using a case-matched analysis. Patients undergoing right hemicolectomy for cancer between 2014 and 2018 were included. The main variables were the risk factor of anastomotic leak, overall survival and disease-free survival. Propensity score matching was performed according to the patient’s age, co-morbidities and TNM staging as well as the type of procedure. Oncologic outcomes were analyzed. We included 488 patients and performed final analysis on 69 patients. The AL rate was 4.71% (23 patients). Intrahospital mortality was significantly higher in the AL group, at 1.3% (6 of 465) vs. 8.7% (2 of 23), p = 0.05. Three-year overall survival (OS) in the non-AL group was higher, although the difference could not be considered significant (71.5% vs. 37.3%, p = 0.082); similarly, the likelihood for impaired 3-year progression-free survival (PFS) was lower, but the difference here could also not be considered significant (69.3% vs. 37.3%, p = 0.106). Age, advanced tumor stage, lymph node metastases and distant metastases were associated with higher probability of death or recurrence of disease. In contrast, minimally invasive surgery was associated with lower probability of death (HR (95% CI): 0.99 (0.14–0.72); p = 0.023) and recurrence of disease (HR (95% CI): 0.94 (0.13–0.68); p = 0.020). In an adjusted Cox regression analysis, AL, age and distant metastases were associated with poor long-term survival. Moreover, AL, age and distant metastases were associated with higher probability of recurrence of disease. Based on our results, AL is a significant factor for worse oncologic outcomes. Simple summary: we aimed to assess patients with anastomotic leaks following right hemicolectomy for cancer. These patients were matched to patients without leaks. Propensity score analysis demonstrated that anastomotic leak was a marker of worse oncologic outcomes.

Side-to-end reanastomosis after low-anterior resection (STELAR): Outcomes, feasibility, and description of procedure performed by a gynecologic oncology service

BACKGROUND AND OBJECTIVES

Low anterior rectosigmoid resection for a gynecologic disease is usually performed in concert with other procedures and can result in significant morbidity should anastomotic complication occur. This study examined surgical outcomes of side-to-end reanastomosis after low anterior resection (STELAR) performed by gynecologic oncology service.

METHODS

This is a case series examining consecutive patients who underwent STELAR for gynecologic indications by a single gynecologic oncology group from 2009 to 2018. Prospectively collected institutional surgical database was searched for STELAR, and standard descriptive statistics were used to describe intraoperative and postoperative complications specific to reanastomosis.

RESULTS

A total of 69 women underwent STELAR, with median age and body mass index of 54 years and 24 kg/m² , respectively. 63.8% of patients had ovarian cancer and 84.4% had stage III-IV disease. The median estimated blood loss was 875 ml. Four (5.8%) women underwent protective loop colostomy at the time of STELAR. Postoperatively, there was 1 (1.4%) case of abscess formation within 30 days and 1 (1.4%) case of anastomotic leak 5 weeks after STELAR that required reoperation and diversion. No cases of fistula were clinically identified.

CONCLUSION

Side-to-end reanastomosis may be a safe and feasible procedure to accomplish low rectosigmoid anastomosis in women with gynecologic disease.

Predictors of Quality of Life Six Years after Curative Colorectal Cancer Surgery: Results of the Prospective Multicenter Study

Background and objectives: Improving early diagnosis and advances in colorectal cancer (CRC) treatment leads to longer survival of these patients. The purpose of this study was to identify the main surgical factors affecting long-term Quality of life (QoL) among colorectal cancer patients after surgery. Materials and Methods: QoL was prospectively evaluated in patients undergoing elective colorectal cancer resection operations in three CRC surgery centers of Lithuania using EORTC generic (QLQC-30) and disease-specific (QLQ-CR29) questionnaires at the time of preoperative admission and 1, 24, and 72 months after surgery. QoL was evaluated among different patient groups, diagnostic and treatment modalities, disease, and postoperative complications. Non-parametric tests and multivariate logistic regression models were used for statistical analysis. Results: Eighty-eight consecutive CRC patients from three institutions were included in the study over a three-month inclusion period, 42 (47.73%) women and 46 (52.27%) men, mean age 64.2 ± 11.5 years. Most tumors were localized in the sigmoid colon and rectum. The largest number of patients had stage III cancer. Twenty-nine patients died—a 6-year survival rate was 67%. 50 of 59 live patients (84.8%) responded to the questionnaire 6 years after their operation. Evaluating changes in quality of life 72 months after surgery with assessments before surgery, both questionnaire responses revealed good long-term CRC surgical treatment results: improved general and functional scale estimates and decreased symptom scale ratings. The multivariate analysis found that age, stoma formation, and rectal cancer were independent risk factors for having worse QoL six years after surgical intervention. Conclusions: Six years after surgery, QoL returns to preoperative levels. Age, stoma formation, adjuvant treatment, and rectal cancer reduce long-term QoL.

Effect of Indocyanine Green Fluorescence Angiography on Anastomotic Leakage in Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies

Background

Meta-analyses have demonstrated that indocyanine green (ICG) can effectively prevent anastomotic leakage (AL) after colorectal surgery. However, recent evidence from large randomized controlled trial (RCT) has suggested that ICG fluorescence angiography does not reduce the incidence of AL in colorectal surgery. This study was conducted to evaluate the value of ICG for the prevention of AL following colorectal surgery.

Methods

Up to September 16, 2021, PubMed, Embase, China National Knowledge Infrastructure, Web of Science, Scopus, Cochrane Library, and VIP databases were searched for RCTs and propensity-score matched (PSM) studies evaluating the use of ICG for prevention of AL after colorectal surgery. Mean differences (MDs) or odds ratios (ORs) and 95% confidence intervals (CI) were calculated.

Results

Twenty studies (5 RCTs and 15 PSM studies) with a total of 5,125 patients were included. ICG did not reduce the reoperation rate (OR, 0.71; 95% CI, 0.38, 1.30), conversion rates (OR, 1.34; 95% CI, 0.65, 2.78), or mortality (OR, 0.50; 95% CI, 0.13, 1.85), but ICG did reduce the incidence of AL (OR, 0.46; 95% CI, 0.36, 0.59) and symptomatic AL (OR, 0.48; 95% CI, 0.33, 0.71), and reduced the length of hospital stay (MD,-1.21; 95% CI,-2.06,-0.35) and intraoperative blood loss (MD,-9.13; 95% CI,-17.52,-0.74). In addition, ICG use did not increase the incidence of total postoperative complications (OR, 0.93; 95% CI, 0.64, 1.35), postoperative ileus (OR, 1.26; 95% CI, 0.53, 2.97), wound infection (OR, 0.76; 95% CI, 0.44, 1.32), urinary tract infection (OR, 0.87; 95% CI, 0.30, 2.59), pulmonary infection (OR, 0.23; 95% CI, 0.04, 1.45), urinary retention (OR, 1.08; 95% CI, 0.23, 5.04), anastomotic bleeding (OR, 1.53; 95% CI, 0.27, 8.60), anastomotic stricture (OR, 0.74; 95% CI, 0.24, 2.29), or operative time (MD,-9.64; 95% CI,-20.28, 1.01).

Conclusions

ICG can effectively reduce the incidence of AL, without prolonging the operation time or increasing postoperative complications in colorectal surgery.

Systematic Review Registration

www.crd.york.ac.uk/prospero/#recordDetails, identifier: CRD42021279064.

Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections

Purpose

The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery.

Method

Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation.

Results

This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively).

Conclusion

The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.

Comprehensive testing of colorectal anastomosis: results of prospective observational cohort study

BACKGROUND

Anastomotic leakage remains one of the most threatening complications in colorectal surgery. Intraoperative testing of anastomosis may reduce the postoperative anastomotic leakage rates. This study aimed to investigate a novel comprehensive intraoperative colorectal anastomosis testing technique to detect the failure of the anastomosis construction and to reduce the risk of postoperative leak.

METHODS

This multi-centre prospective cohort pilot study included 60 patients who underwent colorectal resection with an anastomosis at or below 15 cm from the anal verge. Comprehensive trimodal testing consisted of indocyanine green fluorescence angiography, tension testing, air-leak, and methylene blue leak tests to evaluate the perfusion, tension, and mechanical integrity of the anastomosis.

RESULTS

Ten (16.7%) patients developed an anastomotic leakage. Trimodal test was positive in 16 (26.6%) patients and the operative plan was changed for all of them. Diverting ileostomy was performed in 14 (87.5%) patients. However, two (12.5%) patients still developed clinically significant anastomotic leakage (Grade B). Forty-four (73.4%) patients had a negative trimodal test, preventive ileostomy was performed in 19 (43.2%), and five (11.4%) patients had clinically significant anastomotic leakage (Grade B and C).

CONCLUSION

Trimodal testing identifies anastomoses with initial technical failure where reinforcement of anastomosis or diversion can lead to an acceptable rate of anastomotic leakage. Identification of well-performed anastomosis could allow a reduction of ileostomy rate by two-fold. However, anastomotic leakage rate remains high in technically well-performed anastomoses.

Fatores de risco pré-operatórios associados à fístula anastomótica após colectomia para câncer colorretal: revisão sistemática e metanálise

RESUMO Objetivo: fístula anastomótica (FA) após colectomia para câncer colorretal (CCR) é complicação grave. Esta revisão sistemática e meta-análise avaliou os fatores de risco pré-operatórios para FA em pacientes submetidos à colectomia. Métodos: a pesquisa bibliográfica abrangeu 15 anos e 9 meses (1 de janeiro de 2005 - 19 de outubro de 2020), sendo utilizadas as plataformas PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC e Web of Science. O critério de inclusão foram estudos transversais, coorte e caso-controle em fatores de risco pré-operatórios para FA (desfecho). A escala Newcastle-Ottawa foi usada para avaliação de viés dos estudos. A metanálise envolveu o cálculo dos efeitos de tratamento para cada estudo individualmente incluindo odds ratio (OR), risco relativo (RR) e intervalo de confiança de 95% (IC95%) com construção de modelo de efeitos aleatórios, para avaliar o impacto de cada variável (p<0,05). Resultados: foram selecionados 39 estudos transversais, 21 coortes e quatro casos-controle. A metanálise identificou 14 fatores de risco para FA em pacientes com CCR após colectomia, que são sexo masculino (RR=1,56; IC 95%=1,40-1,75), tabagismo (RR=1,48; IC 95%=1,30-1,69), alcoolismo (RR=1,35; IC 95%=1,21-1,52), diabetes mellitus (RR=1,97; IC 95%=1,44-2,70), doenças pulmonares (RR=2,14; IC 95%=1,21-3,78), doença pulmonar obstrutiva crônica (RR=1,10; IC 95%=1,04-1,16), doença coronariana (RR=1,61; IC 95%=1,07-2,41), doença renal crônica (RR=1,34; IC 95%=1,22-1,47), altas notas na escala ASA (RR=1,70; IC 95%=1,37-2,09), cirurgia abdominal prévia (RR=1,30; IC 95%=1,04-1,64), cirurgia de emergência (RR=1,61; IC 95%=1,26-2,07), quimioterapia neoadjuvante (RR=2,16; IC 95%=1,17-4,02), radioterapia (RR=2,36; IC 95%=1,33-4,19) e quimiorradioterapia (RR=1,58; IC 95%=1,06-2,35). Conclusões: importantes fatores de risco pré-operatórios para FA colorretais em pacientes com CCR foram identificados com base nas melhores pesquisas baseadas em evidências e esse conhecimento deve influenciar decisões relacionadas ao tratamento.

Diverting stomas reduce reoperation rates for anastomotic leak but not overall reoperation rates within 30 days after anterior rectal resection: a national cohort study

PURPOSE

A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma.

METHODS

A 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located < 15 cm from the anal verge. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry. Primary end point was relaparotomy or relaparoscopy for anastomotic leak within 30 days from index surgery. Secondary endpoints were postoperative complications including reoperation for any cause.

RESULTS

Some 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p > 0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97-7.24, p < 0.001) was associated with increased risk for anastomotic leak. However, there were no differences in overall reoperation rates following anterior resection with or without diverting stoma (9.3% vs 10.9%, p = 0.423), and overall complication rates were similar. Reoperation was associated with increased mortality irrespective of the main intraoperative finding.

CONCLUSION

Diverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not affect overall rates of reoperation or complications within 30 days.

An evaluation of short-term outcomes after reoperations for anastomotic leakage in colon cancer patients

PURPOSE

Scarce data are available on differences among index colectomies for colon cancer regarding reoperation for anastomotic leakage (AL) and clinical consequences. Therefore, this nationwide observational study aimed to evaluate reoperations for AL after colon cancer surgery and short-term postoperative outcomes for the different index colectomies.

METHODS

Patients who underwent resection with anastomosis for a first primary colon carcinoma between 2013 and 2019 and were registered in the Dutch ColoRectal Audit were included. Primary outcomes were mortality, ICU admission, and stoma creation.

RESULTS

Among 39,565 patients, the overall AL rate was 4.8% and ranged between 4.0% (right hemicolectomy) and 15.4% (subtotal colectomy). AL was predominantly managed with reoperation, ranging from 81.2% after transversectomy to 92.4% after sigmoid resection (p < 0.001). Median time to reoperation differed significantly between index colectomies (range 4-8 days, p < 0.001), with longer and comparable intervals for non-surgical reinterventions (range 13-18 days, p = 0.747). After reoperation, the highest mortality rates were observed for index transversectomy (15.4%) and right hemicolectomy (14.4%) and lowest for index sigmoid resection (5.6%) and subtotal colectomy (5.9%) (p < 0.001). Reoperation with stoma construction was associated with a higher mortality risk than without stoma construction after index right hemicolectomy (17.7% vs. 8.5%, p = 0.001). ICU admission rate was 62.6% overall (range 56.7-69.2%), and stoma construction rate ranged between 65.5% (right hemicolectomy) and 93.0% (sigmoid resection).

CONCLUSION

Significant differences in AL rate, reoperation rate, time to reoperation, postoperative mortality after reoperation, and stoma construction for AL were found among the different index colectomies for colon cancer, with relevance for patient counseling and perioperative management.

Oral and Parenteral vs. Parenteral Antibiotic Prophylaxis for Patients Undergoing Laparoscopic Colorectal Resection: An Intervention Review with Meta-Analysis

This study aims to systematically assess the efficacy of parenteral and oral antibiotic prophylaxis compared to parenteral-only prophylaxis for the prevention of surgical site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer resection. Published and unpublished randomized clinical trials comparing the use of oral and parenteral prophylactic antibiotics vs. parenteral-only antibiotics in patients undergoing laparoscopic colorectal surgery were collected searching electronic databases (MEDLINE, CENTRAL, EMBASE, SCIENCE CITATION INDEX EXPANDED) without limits of date, language, or any other search filter. The outcomes included SSIs and other infectious and noninfectious postoperative complications. Risk of bias was assessed using the Cochrane revised tool for assessing risk of bias in randomized trials (RoB 2). A total of six studies involving 2252 patients were finally included, with 1126 cases in the oral and parenteral group and 1126 cases in the parenteral-only group. Meta-analysis results showed a statistically significant reduction of SSIs (OR 0.54, 95% CI 0.40 to 0.72; p < 0.0001) and anastomotic leakage (OR 0.55, 95% CI 0.33 to 0.91; p = 0.02) in the group of patients receiving oral antibiotics in addition to intravenous (IV) antibiotics compared to IV alone. Our meta-analysis shows that a combination of oral antibiotics and intravenous antibiotics significantly lowers the incidence of SSI compared with intravenous antibiotics alone.

Intracorporeal versus Extracorporeal Anastomosis for Laparoscopic Right Hemicolectomy: Short-Term Outcomes

Laparoscopic right hemicolectomy represents an effective therapeutic approach for right colon cancer (RCC). The primary aim of this study was to evaluate bowel function recovery, length of hospital stay, operative time, and the number of general and anastomosis-related postoperative complications from intracorporeal anastomosis (ICA) vs. extracorporeal anastomosis (ECA); the secondary outcome was the number of lymph nodes retrieved. This observational study was conducted on 108 patients who underwent right hemicolectomy for RCC; after surgical resection, 64 patients underwent ICA and 44 underwent ECA. The operative time was slightly longer in the ICA group than in the ECA group, even though the difference was not significant (199.31 ± 48.90 min vs. 183.64 ± 35.80 min; p = 0.109). The length of hospital stay (7.53 ± 1.91 days vs. 8.77 ± 3.66 days; p = 0.036) and bowel function recovery (2.21 ± 1.01 days vs. 3.45 ± 1.82 days; p < 0.0001) were significantly lower in the ICA group. There were no significant differences in postoperative complications (12% in ICA group vs. 9% in ECA group), wound infection (6% in ICA group vs. 7% in ECA group), or anastomotic leakage (6% in ICA group vs. 9% in ECA group). We did not observe a significant difference between the two groups in the number of lymph nodes collected (19.46 ± 7.06 in ICA group vs. 22.68 ± 8.79 in ECA group; p = 0.086). ICA following laparoscopic right hemicolectomy, compared to ECA, could lead to a significant improvement in bowel function recovery and a reduction in the length of hospital stay in RCC patients.

Short and long-term outcomes of elderly patients undergoing left-sided colorectal resection with primary anastomosis for cancer

BACKGROUND

The proportion of elderly colorectal cancer (CRC) patients requiring surgery is increasing. Colorectal resection for left-sided cancers is the most controversial as the primary anastomosis or end-colostomy and open or minimally invasive approaches are available. Therefore, this study was conducted to investigate the short- and long-term outcomes in elderly patients after resection with primary anastomosis for left-sided CRC.

METHODS

The cohort study included left-sided colorectal cancer patients who underwent resection with primary anastomosis. The participants were divided into non-elderly (≤75 years) and elderly (> 75 years) groups. Short- and long-term postoperative outcomes were investigated.

RESULTS

In total 738 (82%) and 162 (18%) patients were allocated to non-elderly and elderly groups, respectively. Minimally invasive surgery (MIS) was less prevalent in the elderly (42.6% vs 52.7%, p = 0.024) and a higher proportion of these suffered severe or lethal complications (15.4% vs 9.8%, p = 0.040). MIS decreased the odds for postoperative complications (OR: 0.41; 95% CI: 0.19-0.89, p = 0.038). The rate of anastomotic leakage was similar (8.5% vs 11.7%, p = 0.201), although, in the case of leakage 21.1% of elderly patients died within 90-days after surgery. Overall- and disease-free survival was impaired in the elderly. MIS increased the odds for long-term survival.

CONCLUSIONS

Elderly patients suffer more severe complications after resection with primary anastomosis for left-sided CRC. The risk of anastomotic leakage in the elderly and non-elderly is similar, although, leakages in the elderly seem to be associated with a higher 90-day mortality rate. Minimally invasive surgery is associated with decreased morbidity in the elderly.

Trends in risk factors of anastomotic leakage after colorectal cancer surgery (2011-2019): A Dutch population-based study

AIM

Anastomotic leakage (AL) after colon cancer (CC) and rectal cancer (RC) surgery often requires reintervention. Prevalence and morbidity may change over time with evolutions in treatment strategies and changes in patient characteristics. This nationwide study aimed to evaluate changes in the incidence, risk factors and mortality from AL during the past nine years.

METHODS

Data of CC and RC resections with primary anastomosis were extracted from the Dutch Colorectal Audit (2011-2019). AL was registered if requiring reintervention. Three consecutive cohorts were compared using logistic regression analysis.

RESULTS

Incidence of AL after CC surgery decreased from 6.6% in 2011-2013 to 4.8% in 2017-2019 and increased from 8.6% to 11.9% after RC surgery. In 2011-2013, male sex, ASA ≥3, (y)pT3-4, neoadjuvant therapy, emergency surgery and multivisceral resection were identified as risk factors for AL after CC surgery. In 2017-2019, only male sex and ASA ≥3 were risk factors for AL. For RC patients, male sex and neoadjuvant therapy were a risk factor for AL in 2011-2013. In 2017-2019, transanal approach was also a risk factor for AL. Postoperative mortality rate after AL was 12% (CC) and 2% (RC) in 2017-2019, without significant changes over time.

CONCLUSION

Contradictory trends in incidence and mortality for AL were observed among CC and RC surgery with changing risk factors over the past 9 years. High mortality after AL is only observed after CC surgery and remains unchanged. Continued efforts should be made to improve early detection and treatment of AL for these patients.

Does preoperative neoadjuvant chemotherapy impact short-term surgical outcomes in patients with locally advanced colon cancer?

BACKGROUND

Preoperative neoadjuvant chemotherapy (NAC) for colon cancer in advanced stages is associated with improved outcomes and tumor regression. The aim of our study was to identify outcomes in patients with colon cancer who received preoperative NAC.

METHODS

A 4-year analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was performed. We included patients with locally advanced colon cancer (non-metastatic T3, T4 with or without nodal involvement) who underwent colon cancer resection. Patients were stratified into two groups (NAC and No-NAC). Our outcome measures were anastomotic leaks, hospital length of stay (LOS), 30-day complications, 30-day mortality, and 30-day readmissions. We performed a multi-variable logistic regression analysis.

RESULTS

We analyzed 90,055 patients of which 7694 (NAC: 7.8 % (n = 599) and No-NAC: 92.2% (n = 7095)) met the inclusion criteria and included in the analysis. Mean age was 67 ± 13 years, 51% were males, and 72% were whites. Patients in the NAC group were more likely to be younger (60 ± 12 years vs. 68 ± 13 years, p < 0.01) and males (62% vs. 50%, p < 0.01) compared to No-NAC. On regression analysis, preoperative NAC was independently associated with higher odds of anastomotic leak (OR 1.35 [1.05-1.97], p = 0.03) and 30-day readmission (OR 1.54 [1.24-2.05], p < 0.01) in reference to No-NAC. However, no association was found between NAC and 30-day complications and 30-day mortality.

CONCLUSIONS

Preoperative NAC might be associated with adverse outcomes of anastomotic leaks and 30-day readmissions, however does not appear to impact 30-day complications nor 30-day mortality.

Risk factors of symptomatic anastomotic leakage and its impacts on a long-term survival after laparoscopic low anterior resection for rectal cancer: a retrospective single-center study

Background

Postoperative symptomatic anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) for rectal cancer. AL can potentially affect short-term patient outcomes and long-term prognosis. This study aimed to explore the risk factors and long-term survival of symptomatic AL after laparoscopic LAR for rectal cancer.

Methods

From May 2009 to May 2015, 298 consecutive patients who underwent laparoscopic LAR for rectal cancer with or without a defunctioning stoma were included in this study. Univariate and multivariate logistic regression analyses were used to explore independent risk factors for symptomatic AL. Survival analysis was performed using Kaplan–Meier curves, and log-rank tests were used for group comparisons.

Results

Among the 298 patients enrolled in this study, symptomatic AL occurred in eight (2.7%) patients. The univariate analysis showed that age of ≤65 years (P = 0.048), neoadjuvant therapy (P = 0.095), distance from the anal verge (P = 0.078), duration of operation (P = 0.001), and pathological tumor (T) category (P = 0.004) were associated with symptomatic AL. The multivariate analysis demonstrated that prolonged duration of operation (P = 0.010) was an independent risk factor for symptomatic AL after laparoscopic LAR for rectal cancer. No statistically significant differences were observed in the 3-year (P = 0.785) and 5-year (P = 0.979) overall survival rates.

Conclusions

A prolonged duration of operation increased the risk of symptomatic AL after laparoscopic LAR for rectal cancer. An impact of symptomatic AL on a long-term survival was not observed in this study; however, further studies are required.

Trial registration

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033413) on May 31, 2020.