51
|
Kong M, Chen H, Jiang Y, Xin Y, Han Y, Sheng H. Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: A retrospective case-control study. Surgery 2020; 169:767-773. [PMID: 33160636 DOI: 10.1016/j.surg.2020.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of the study was to evaluate the association between microfibrillar collagen hemostat and anastomotic leakage after anterior resection. METHOD Between March 2015 and December 2019, a total of 203 consecutive rectal cancer patients who underwent elective anterior resection were included. Patient parameters were analyzed. The relevant risk factors were identified by univariate and multivariate analysis. Propensity score matching was performed to reduce the selection bias. RESULTS In total, 26 (12.8%) of the 203 study patients developed clinical anastomotic leakage. The length of hospital stay was significantly prolonged by anastomotic leakage. In univariate analysis and multivariate analysis, male sex, low tumor location, and intraoperative application of microfibrillar collagen hemostat significantly increased the risk of anastomotic leakage. Furthermore, analysis after propensity score matching confirmed the independent role of microfibrillar collagen hemostat in anastomotic leakage. In addition, the median time of anastomotic leakage occurrence from the initial operation in patients with microfibrillar collagen hemostat was 9.00 days, which was significantly later than that in patients without microfibrillar collagen hemostat. CONCLUSION In addition to male sex and low tumor location, intraoperative application of microfibrillar collagen hemostat was demonstrated to be a significant risk factor for anastomotic leakage. This finding suggested that surgeons should be fully aware of this potential risk in anterior resection. Because of the limitation of retrospective study, however, randomized controlled trials are needed to confirm this association in the future.
Collapse
Affiliation(s)
- Meng Kong
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Hongyuan Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Yugang Jiang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Yingying Xin
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Yue Han
- Department of Gastrointestinal Surgery, Shandong Provincial Third Hospital, Shandong University, Jinan, Shandong, PR China
| | - Hongguang Sheng
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China.
| |
Collapse
|
52
|
Ben-Eliyahu S. Tumor Excision as a Metastatic Russian Roulette: Perioperative Interventions to Improve Long-Term Survival of Cancer Patients. Trends Cancer 2020; 6:951-959. [DOI: 10.1016/j.trecan.2020.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/09/2020] [Accepted: 06/19/2020] [Indexed: 01/27/2023]
|
53
|
Kryzauskas M, Degutyte AE, Abeciunas V, Lukenaite B, Jasiunas E, Poskus E, Strupas K, Poskus T. Experimental Study of Mechanical Integrity Testing in Stapled Large Bowel: Methylene Blue Leak Test Is Not Inferior to Air Leak Test. Visc Med 2020; 37:189-197. [PMID: 34250076 DOI: 10.1159/000510660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
Background/Objectives Anastomotic leakage remains the most devastating postoperative complication in colorectal surgery. The mechanical integrity of the newly formed colorectal anastomosis can be evaluated by visual inspection intraoperatively; both air leak and liquid leak tests are also used to evaluate the integrity of stapled colorectal anastomoses. It is not clear whether double-stapled anastomoses are more prone to leaks than single-stapled anastomoses. The aim of our study was to compare the methylene blue and the air leak test in the experimental setting of single-stapled and double-stapled porcine bowels. Methods Twenty-four distal colons were excised from slaughtered pigs without delay. The proximal bowel end was closed with a linear stapler using blue cartridges. The bowels were randomly divided into single-stapled or double-stapled groups. Air leak and methylene blue leak tests were performed. A digital pressure monitor with a gradual pressure increase function was used to both gradually increase pressure within the bowel and to determine the pressure at which the stapler line disintegrated. Results Air leakage occurred at a mean pressure of 51.62 (±16.60) mm Hg and methylene blue leakage occurred at 46.54 (±16.78) mm Hg (p = 0.31). The air and methylene blue leaks occurred at comparable pressures in single-stapled bowels and in double-stapled bowels (47.21 [±14.02] mm Hg vs. 50.96 [±19.15] mm Hg, p = 0.6). Conclusions The methylene blue solution leak test is not inferior to the air leak test. There is no significant difference in bursting pressure between single-stapled and double-stapled anastomoses.
Collapse
Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | | | - Eugenijus Jasiunas
- Center of Informatics and Development, Vilnius University Hospital "Santaros Klinikos", Vilnius, Lithuania
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephro-Urology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| |
Collapse
|
54
|
Mirnezami R, Mirnezami A. Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation. Clin Colon Rectal Surg 2020; 33:268-278. [PMID: 32968362 DOI: 10.1055/s-0040-1713744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.
Collapse
Affiliation(s)
- R Mirnezami
- Department of Colorectal Surgery, Royal Free Hospital, Hampstead, London
| | - A Mirnezami
- Division of Cancer Sciences, Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom.,Southampton Complex Cancer and Exenterative Unit, University Hospital Southampton, Southampton, United Kingdom
| |
Collapse
|
55
|
Ma L, Pang X, Ji G, Sun H, Fan Q, Ma C. The impact of anastomotic leakage on oncology after curative anterior resection for rectal cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22139. [PMID: 32925766 PMCID: PMC7489661 DOI: 10.1097/md.0000000000022139] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a serious clinical complication after anterior resection for rectal cancer and will lead to an increase in postoperative mortality. However, the effect on long-term oncology outcomes remains controversial. METHODS We searched the PubMed, Embase, and Cochrane library databases for related articles. The included studies assessed local recurrence, distant recurrence, overall survival, cancer-specific survival and disease-free survival. The systematic reviews and meta-analyses was conducted in accordance with the PRISMA guidelines. The combined RRs with 95% CI were then calculated using a fixed effects model or a randomized effect model. RESULTS A total of 18 cohort studies included 34,487 patients who met the inclusion criteria. The meta-analysis demonstrated that AL was associated with increased local recurrence (RR 1.47, 95% CI 1.14-1.90, I = 57.8%). Anastomotic leakage decreased overall survival (RR 0.92, 95% CI 0.88-0.96, I = 58.1%), cancer-specific survival (RR 0.96, 95% CI 0.92-1.00, I = 30.4%), and disease-free survival (RR 0.85, 95% CI 0.77-0.94, I = 80.4%). Distant recurrence may had no significant effects of AL (RR 1.16, 95% CI 0.91-1.46, I = 58.4%). CONCLUSION AL has a negative effect on local recurrence and long-term survival (including overall survival, cancer-specific survival, and disease-free survival) after anterior resection for rectal cancer, but not related to distant recurrence.
Collapse
Affiliation(s)
- Lushun Ma
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University
| | - Xinyuan Pang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Guofeng Ji
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University
| | - Haojie Sun
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University
| | - Qihao Fan
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University
| | - Chong Ma
- Department of Gastrointestinal and Colorectal Surgery, China-Japan Union Hospital of Jilin University
| |
Collapse
|
56
|
Lawler J, Choynowski M, Bailey K, Bucholc M, Johnston A, Sugrue M. Meta-analysis of the impact of postoperative infective complications on oncological outcomes in colorectal cancer surgery. BJS Open 2020; 4:737-747. [PMID: 32525280 PMCID: PMC7528523 DOI: 10.1002/bjs5.50302] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/26/2020] [Accepted: 05/02/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cancer outcomes are complex, involving prevention, early detection and optimal multidisciplinary care. Postoperative infection and surgical site-infection (SSI) are not only uncomfortable for patients and costly, but may also be associated with poor oncological outcomes. A meta-analysis was undertaken to assess the oncological effects of SSI in patients with colorectal cancer. METHODS An ethically approved PROSPERO-registered meta-analysis was conducted following PRISMA guidelines. PubMed and Scopus databases were searched for studies published between 2007 and 2017 reporting the effects of postoperative infective complications on oncological survival in colorectal cancer. Results were separated into those for SSI and those concerning anastomotic leakage. Articles with a Methodological Index for Non-Randomized Studies score of at least 18 were included. Hazard ratios (HRs) with 95 per cent confidence intervals were computed for risk factors using an observed to expected and variance fixed-effect model. RESULTS Of 5027 articles were reviewed, 43 met the inclusion criteria, with a total of 154 981 patients. Infective complications had significant negative effects on overall survival (HR 1·37, 95 per cent c.i. 1·28 to 1·46) and cancer-specific survival (HR 2·58, 2·15 to 3·10). Anastomotic leakage occurred in 7·4 per cent and had a significant negative impact on disease-free survival (HR 1·14, 1·09 to 1·20), overall survival (HR 1·34, 1·28 to 1·39), cancer-specific survival (HR 1·43, 1·31 to 1·55), local recurrence (HR 1·18, 1·06 to 1·32) and overall recurrence (HR 1·46, 1·27 to 1·68). CONCLUSION This meta-analysis identified a significant negative impact of postoperative infective complications on overall and cancer-specific survival in patients undergoing colorectal surgery.
Collapse
Affiliation(s)
- J Lawler
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - K Bailey
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Bucholc
- EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry, /Londonderry, UK
| | - A Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland
| | - M Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Donegal, Ireland.,EU INTERREG Centre for Personalized Medicine, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Derry, /Londonderry, UK
| |
Collapse
|
57
|
Kverneng Hultberg D, Svensson J, Jutesten H, Rutegård J, Matthiessen P, Lydrup ML, Rutegård M. The Impact of Anastomotic Leakage on Long-term Function After Anterior Resection for Rectal Cancer. Dis Colon Rectum 2020; 63:619-628. [PMID: 32032197 DOI: 10.1097/dcr.0000000000001613] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is still not clear whether anastomotic leakage after anterior resection for rectal cancer affects long-term functional outcome. OBJECTIVE This study aimed to evaluate how anastomotic leakage following anterior resection for rectal cancer influences defecatory, urinary, and sexual function. DESIGN In this retrospective population-based cohort study, patients were identified through the Swedish Colorectal Cancer Registry, which was also used for information on the exposure variable anastomotic leakage and covariates. SETTINGS A nationwide register was used for including patients. PATIENTS All patients undergoing anterior resection for rectal cancer in Sweden from April 2011 to June 2013 were included. MAIN OUTCOME MEASURES Outcome was any defecatory, sexual, or urinary dysfunction, assessed 2 years after surgery by a postal questionnaire. The association between anastomotic leakage and function was assessed in multivariable logistic and linear regression models, with adjustment for confounding. RESULTS Response rate was 82%, resulting in 1180 included patients. Anastomotic leakage occurred in 7.5%. A permanent stoma was more common among patients with leakage (44% vs 9%; p < 0.001). Patients with leakage had an increased risk of aid use for fecal incontinence (OR, 2.27; 95% CI, 1.20-4.30) and reduced sexual activity (90% vs 82%; p = 0.003), whereas the risk of urinary incontinence was decreased (OR, 0.53; 95% CI, 0.31-0.90). A sensitivity analysis assuming that a permanent stoma was created because of anorectal dysfunction strengthened the negative impact of leakage on defecatory dysfunction. LIMITATIONS Limitations include the use of a questionnaire that had not been previously validated, underreporting of anastomotic leakage in the register, and small patient numbers in the analysis of sexual symptoms. CONCLUSIONS Anastomotic leakage was found to statistically significantly increase the risk of aid use due to fecal incontinence and reduced sexual activity, although the impact on defecatory dysfunction might be underestimated, because permanent stomas are sometimes fashioned because of anorectal dysfunction. Further research is warranted, especially regarding urogenital function. See Video Abstract at http://links.lww.com/DCR/B157. EL IMPACTO DE LA FUGA ANASTOMÓTICA EN LA FUNCIÓN A LARGO PLAZO DESPUÉS DE LA RESECCIÓN ANTERIOR POR CÁNCER RECTAL: Todavía no está claro si la fuga anastomótica después de la resección anterior por cáncer rectal afecta el resultado funcional a largo plazo.Evaluar cómo la fuga anastomótica después de la resección anterior para el cáncer rectal influye en la función defecatoria, urinaria y sexual.En este estudio de cohorte retrospectivo basado en la población, los pacientes fueron identificados a través del Registro Sueco de cáncer colorrectal, que también se utilizó para obtener información sobre la variable de exposición de fuga anastomótica y las covariables.Se utilizó un registro nacional para incluir pacientes.Se incluyeron todos los pacientes sometidos a resección anterior por cáncer de recto en Suecia desde abril de 2011 hasta junio de 2013.El resultado fue cualquier disfunción defecatoria, sexual o urinaria, evaluada dos años después de la cirugía mediante un cuestionario postal. La asociación entre la fuga anastomótica y la función se evaluó en modelos logísticos multivariables y de regresión lineal, con ajuste por confusión.La tasa de respuesta fue del 82%, lo que resultó en 1180 pacientes incluidos. La fuga anastomótica ocurrió en el 7,5%. Un estoma permanente fue más común entre los pacientes con fugas (44% vs. 9%; p <0.001). Los pacientes con fugas tenían un mayor riesgo de uso de ayuda para la incontinencia fecal (OR 2.27; IC 95% 1.20-4.30) y una menor actividad sexual (90% vs. 82%; p = 0.003), mientras que el riesgo de incontinencia urinaria disminuyó (OR 0.53; IC 95% 0.31-0.90). Un análisis de sensibilidad que supone que se creaba un estoma permanente debido a una disfunción anorrectal fortaleció el impacto negativo de la fuga en la disfunción defecatoria.Las limitaciones incluyen el cuestionario utilizado que no ha sido validado previamente, el subregistro de fugas anastomóticas en el registro y el pequeño número de pacientes en el análisis de síntomas sexuales.Se descubrió que la fuga anastomótica aumentaba estadísticamente de manera significativa el riesgo de uso de ayuda debido a la incontinencia fecal y la actividad sexual reducida, aunque el impacto en la disfunción defecatoria podría estar subestimada, ya que a veces los estomas permanentes se forman debido a la disfunción anorrectal. Se justifica la investigación adicional, especialmente con respecto a la función urogenital. Consulte Video Resumen en http://links.lww.com/DCR/B157. (Traducción-Dr. Gonzalo Hagerman).
Collapse
Affiliation(s)
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Henrik Jutesten
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå
| |
Collapse
|
58
|
Yang J, Chen Q, Jindou L, Cheng Y. The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis. J Surg Oncol 2020; 121:1283-1297. [PMID: 32243581 DOI: 10.1002/jso.25921] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage. METHODS The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I2 , and bias was evaluated by funnel plot and Begg's test. RESULTS A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12). CONCLUSIONS The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.
Collapse
Affiliation(s)
- Jianguo Yang
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingwei Chen
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Jindou
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong Cheng
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
59
|
Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
| |
Collapse
|
60
|
Du CZ, Fan ZH, Yang YF, Yuan P, Gu J. Value of intra-operative Doppler sonographic measurements in predicting post-operative anastomotic leakage in rectal cancer: a prospective pilot study. Chin Med J (Engl) 2020; 132:2168-2176. [PMID: 31461731 PMCID: PMC6797145 DOI: 10.1097/cm9.0000000000000410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anastomotic leakage is a serious surgical complication in rectal cancer; however, effective evaluation methods for predicting anastomotic leakage individual risk in patients are not currently available. This study aimed to develop a method to evaluate the risk of leakage during surgery. METHODS The 163 patients with rectal cancer, who had undergone anterior resection and low-ligation procedures for Doppler sonographic hemodynamic measurement from April 2011 to January 2015 in Peking University Cancer Hospital, were prospectively recruited. A predictive model was constructed based on the associations between anastomotic leakage and alterations in the anastomotic blood supply in the patients, using both univariate and multivariate statistical analyses, as well as diagnostic methodology evaluation, including Chi-square test, logistic regression model, and receiver operating characteristic curve. RESULTS The overall anastomotic leakage incidence was 9.2% (15/163). Doppler hemodynamic parameters whose reduction was significantly associated with anastomotic leakage were peak systolic velocity, pulsatility index, and resistance index. The areas under the receiver operating characteristic curve of residual rates of peak systolic velocity, pulsatility index, and resistance index in predicting anastomotic leakage were 0.703 (95% confidence interval [CI]: 0.552-0.854), 0.729 (95% CI: 0.579-0.879), and 0.689 (95% CI: 0.522-0.856), respectively. The predictive model revealed that the patients with severely reduced blood-flow signal exhibited a significantly higher incidence rate of anastomotic leakage than those with sufficient blood supply (19.6% vs. 3.7%, P = 0.003), particularly the patients with low rectal cancer (25.9% vs. 3.9%, P = 0.007) and those receiving neoadjuvant chemoradiotherapy (32.1% vs. 3.7%, P = 0.001), independent of prophylactic ileostoma. Multivariate analysis revealed that insufficient blood supply of the anastomotic bowel was an independent risk factor for anastomotic leakage (odds ratio: 10.37, 95% CI: 2.703-42.735, P = 0.001). CONCLUSION Based on this explorative study, Doppler sonographic hemodynamic measurement of the anastomotic bowel presented potential value in predicting anastomotic leakage.
Collapse
Affiliation(s)
- Chang-Zheng Du
- Gastrointestinal Cancer Center, Peking University Cancer Hospital, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China.,Department of Pathology, Duke University Medical School, Durham, NC, USA
| | - Zhi-Hui Fan
- Department of Sonography, Peking University Cancer Hospital, Beijing 100142, China
| | - Yuan-Fan Yang
- Department of Pathology, Duke University Medical School, Durham, NC, USA
| | - Ping Yuan
- Peking University Shougang Hospital, Beijing 100144, China
| | - Jin Gu
- Gastrointestinal Cancer Center, Peking University Cancer Hospital, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China.,Peking University Shougang Hospital, Beijing 100144, China.,Peking-Tsinghua Joint Center for Life Sciences, Beijing 100871, China
| |
Collapse
|
61
|
Sueda T, Tei M, Yoshikawa Y, Furukawa H, Matsumura T, Koga C, Wakasugi M, Miyagaki H, Kawabata R, Tsujie M, Hasegawa J. Prognostic impact of postoperative intra-abdominal infections after elective colorectal cancer resection on survival and local recurrence: a propensity score-matched analysis. Int J Colorectal Dis 2020; 35:413-422. [PMID: 31897647 DOI: 10.1007/s00384-019-03493-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Several authors have reported an association between anastomotic leak and/or intra-abdominal abscess and oncological survival and recurrence. However, no reports have investigated whether combining anastomotic leak/intra-abdominal abscess and positive drainage culture influences long-term oncological outcomes. Therefore, we defined these complications as postoperative intra-abdominal infections. The present study aimed to evaluate the prognostic impact of postoperative intra-abdominal infections on long-term oncological outcomes after curative stage I-III colorectal cancer surgery. METHODS We performed a retrospective analysis of 755 consecutive patients with stage I-III colorectal cancer undergoing curative surgery between 2010 and 2015 by performing a propensity score-matched analysis to reduce selection bias. RESULTS Of the 755 patients, 62 were matched for postoperative intra-abdominal infections analyses. The median follow-up was 48 months. Compared with the non-infections group, the postoperative intra-abdominal infections group had a significantly shorter local recurrence-free survival (P = 0.01 prior to matching, and P = 0.05 after matching). No significant difference was found between the groups in terms of overall, cancer-specific free, recurrence-free, or distant recurrence-free survival. However, multivariate analyses identified postoperative intra-abdominal infections as an independent prognostic factor for local recurrence-free survival (P = 0.04 prior to matching, and P = 0.03 after matching). CONCLUSIONS In this matched-pair analysis comparing stage I-III colorectal cancer patients with and without postoperative intra-abdominal infections, postoperative intra-abdominal infections were associated with poor local recurrence-free survival, but not overall, cancer-specific free, recurrence-free, or distant recurrence-free survival.
Collapse
Affiliation(s)
- Toshinori Sueda
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan.
| | - Mitsuyoshi Tei
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Yukihiro Yoshikawa
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Haruna Furukawa
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Tae Matsumura
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Chikato Koga
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Masaki Wakasugi
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Hiromichi Miyagaki
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Ryohei Kawabata
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Masanori Tsujie
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| | - Junichi Hasegawa
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-kitaku, Sakai, Osaka, 591-8025, Japan
| |
Collapse
|
62
|
Guo Y, Luo Y, Zhao H, Bai L, Li J, Li L. Early Versus Routine Stoma Closure in Patients With Colorectal Resection: A Meta-Analysis of 7 Randomized Controlled Trials. Surg Innov 2020; 27:291-298. [PMID: 32100636 DOI: 10.1177/1553350620907812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background. A substantial proportion of patients undergoing colorectal surgery receive a temporary stoma, and the timing for stoma closure remains unclear. The aim of this study was to evaluate the safety and feasibility of early stoma closure (ESC) compared with routine stoma closure (RSC) after colorectal surgery. Methods. We comprehensively searched PubMed, Embase, and the Cochrane Library for randomized controlled trials that compared ESC and RSC after colorectal surgery. Results. A total of 7 randomized controlled trials with 814 enrolled patients were identified for this meta-analysis. There were no significant differences between the ESC and RSC groups regarding the complications of stoma closure (26.8% and 16.6%, respectively; odds ratio [OR]: 1.30; 95% confidence interval [CI]: 0.89-1.90; P = .17). A subgroup analysis was conducted by Clavien-Dindo grade of complication, and no significant difference was observed in any subgroup ( P > .05). However, the ESC group had a significantly higher risk of wound complications than the RSC group (17.6% and 7.8%, respectively; OR: 2.61; 95% CI: 1.43-4.76; P = .002), and the RSC group had more cases of small bowel obstruction than the ESC group (3.1% and 8.4%, respectively; OR: 0.37; 95% CI: 0.15-0.87; P = .02). Conclusions. ESC is a safe and effective therapeutic approach in patients who have undergone colorectal surgery; it is associated with a reduced risk of bowel obstruction but a higher risk of wound complications.
Collapse
Affiliation(s)
- Yinyin Guo
- Lanzhou University Second Hospital, Lanzhou, China
| | - Yanxin Luo
- The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Zhao
- Lanzhou University Second Hospital, Lanzhou, China
| | - Liangliang Bai
- The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Juan Li
- The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Laiyuan Li
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| |
Collapse
|
63
|
Foppa C, Ng SC, Montorsi M, Spinelli A. Anastomotic leak in colorectal cancer patients: New insights and perspectives. Eur J Surg Oncol 2020; 46:943-954. [PMID: 32139117 DOI: 10.1016/j.ejso.2020.02.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 02/09/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
Anastomotic leak (AL) remains a potentially life-threatening sequela of colorectal surgery impacting on mortality, short- and long-term morbidity, quality of life, local recurrence (LR) and disease-free survival. Despite technical improvements and the identification of several surgery- and patient-related factors associated to the risk of AL, its incidence has not significantly changed over time. In this context, the clarification of the mechanisms underlying anastomotic healing remains an important unmet need, crucial for improving patients' outcomes. This review concentrates on novel key findings in the etiopathogenesis of AL, how they can contribute in determining LR, and measures which may contribute to reducing its incidence. AL results from a complex, dynamic interplay of several factors and biological processes, including host genetics, gut microbiome, inflammation and the immune system. Many of these factors seem to act in concert to drive both AL and LR, even if the exact mechanisms remain to be elucidated. The next generation sequencing technology, including the microbial metagenomics, could lead to tailored bowel preparations targeting only those pathogens that can cause AL. Significant progress is being made in each of the reviewed areas, moving toward translational and targeted therapeutic strategies to prevent the difficult complication of AL.
Collapse
Affiliation(s)
- Caterina Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy.
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Division of Gastroenterology and Hepatology, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
| | - Marco Montorsi
- Division of General and Digestive Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
| | - Antonino Spinelli
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi) - Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy.
| |
Collapse
|
64
|
Raskov H, Orhan A, Salanti A, Gögenur I. Premetastatic niches, exosomes and circulating tumor cells: Early mechanisms of tumor dissemination and the relation to surgery. Int J Cancer 2020; 146:3244-3255. [PMID: 31808150 DOI: 10.1002/ijc.32820] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/15/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022]
Abstract
The physiological stress response to surgery promotes wound healing and functional recovery and includes the activation of neural, inflammatory and proangiogenic signaling pathways. Paradoxically, the same pathways also promote metastatic spread and growth of residual cancer. Human and animal studies show that cancer surgery can increase survival, migration and proliferation of residual tumor cells. To secure the survival and growth of disseminated tumor cells, the formation of premetastatic niches in target organs involves a complex interplay between microenvironment, immune system, circulating tumor cells, as well as chemical mediators and exosomes secreted by the primary tumor. This review describes the current understanding of the early mechanisms of dissemination, as well as how surgery may facilitate disease progression.
Collapse
Affiliation(s)
- Hans Raskov
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Adile Orhan
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ali Salanti
- Centre for Medical Parasitology at Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
65
|
Tsai YY, Chen WTL. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019; 10:1229-1237. [PMID: 31949944 DOI: 10.21037/jgo.2019.07.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.
Collapse
Affiliation(s)
- Yuan-Yao Tsai
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - William Tzu-Liang Chen
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| |
Collapse
|
66
|
Kim JC, Lee JL, Kim CW, Lim SB, Alsaleem HA, Park SH. Mechanotechnical faults and particular issues of anastomotic complications following robot-assisted anterior resection in 968 rectal cancer patients. J Surg Oncol 2019; 120:1436-1445. [PMID: 31721221 DOI: 10.1002/jso.25765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine-green fluorescence imaging (IFI) and robot-stapled anastomosis have yet been undetermined. METHODS This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot-assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed. RESULTS AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease-free survival (P = .02) and local recurrence (P = .03), respectively. CONCLUSIONS AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.
Collapse
Affiliation(s)
- Jin C Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Jong L Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Chan W Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Hassan A Alsaleem
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| | - Seong H Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea
| |
Collapse
|
67
|
Bashir Mohamed K, Hansen CH, Krarup PM, Fransgård T, Madsen MT, Gögenur I. The impact of anastomotic leakage on recurrence and long-term survival in patients with colonic cancer: A systematic review and meta-analysis. Eur J Surg Oncol 2019; 46:439-447. [PMID: 31727475 DOI: 10.1016/j.ejso.2019.10.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/OBJECTIVE Anastomotic leakage (AL) is one of the most severe complications following colorectal cancer surgery and is associated with increased short and long term mortality. The literature is conflicting regarding increased risk of recurrence after AL. The aim of this study was to systematically review the impact of anastomotic leakage on the risk of local or distant recurrence and overall survival, cancer specific survival, and disease-free survival. METHODS A systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. A systematic search in PubMed, EMBASE, CINHAL, and The Cochrane Library was performed and meta-analyses were performed on all outcomes including analysis based on time-to-event data. RESULTS A total of eighteen cohort studies, including 69,047 patients whereof 2,555 patients had anastomotic leakage, were included. Meta-analysis demonstrated no significant effects of anastomotic leakage on local recurrence (RR 1.16, 95% CI 0.84-1.59) or distant recurrence (RR 1.44, 95% CI 0.52-3.96). Anastomotic leakage decreased overall survival (RR 0.85, 95% CI 0.77-0.94), disease free survival (RR 0.80, 95% CI 0.72-0.89), and cancer specific survival (RR 0.90, 95% CI 0.83-0.97). A time-to-event analysis was conducted on available data and the results were congruent with the frequency analyses. CONCLUSION Anastomotic leakage following colonic resections is significantly associated with impaired overall survival, disease free survival and cancer specific survival. The study did not show any statistically significant association between anastomotic leakage and recurrence.
Collapse
Affiliation(s)
- Khadra Bashir Mohamed
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark.
| | - Christine Haangard Hansen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Peter-Martin Krarup
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Tina Fransgård
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Michael Tvilling Madsen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark; Institute of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| |
Collapse
|
68
|
Zimmermann M, Merkel S, Weber K, Bruch HP, Hohenberger W, Keck T, Grützmann R. Laparoscopic surgery for rectal cancer reveals comparable oncological outcome even in context of worse short-term results-long-term analysis of nearly 500 patients from two high-volume centers. Int J Colorectal Dis 2019; 34:1541-1550. [PMID: 31309324 DOI: 10.1007/s00384-019-03350-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Large randomized controlled trials have investigated the oncological value of the laparoscopic approach to colorectal cancer. Mainly, non-inferiority for the laparoscopic approach regarding long-term survival could be shown. Nevertheless, some recent trials revealed inferiority especially due to histopathological quality of specimen or location of the tumor in the rectum. The main objective of this study was to compare two historical patient collectives of specialized centers for either the laparoscopic or the open resection approach, regarding long-term survival and disease progression of rectal cancer according to tumor localization in a retrospective propensity score-matched analysis. METHODS A retrospective analysis, based on two prospectively maintained institutional colorectal cancer databases, was performed. The database of the reference center in Erlangen maintained almost exclusively open operations whereas the database in Lübeck maintained to a vast majority laparoscopic operations. To adjust risk profiles, a 1:1 propensity score matching was performed. RESULTS Seven hundred fifty-five patients of both centers (Erlangen, n = 507, Lübeck n = 248) were included. Propensity score matching resulted in two equalized groups with 248 patients. Regarding the postoperative complications, advantages for the open approach were seen. Analyzing the survival data, no differences in disease-free as well as overall survival were shown. Also, no differences in the overall loco-regional recurrence and distant metastasis rate were detected. CONCLUSION In centers with adequate expertise, open and laparoscopic procedures result in equivalent oncologic long-term outcomes. Advantages for the open resected group concerning short-term results and complications were detected, due to remarkably low rates of anastomotic leakage.
Collapse
Affiliation(s)
- Markus Zimmermann
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Hans-Peter Bruch
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Werner Hohenberger
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Tobias Keck
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Robert Grützmann
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| |
Collapse
|
69
|
Brown PJ, Hyland R, Quyn AJ, West NP, Sebag-Montefiore D, Jayne D, Sagar P, Tolan DJ. Current concepts in imaging for local staging of advanced rectal cancer. Clin Radiol 2019; 74:623-636. [PMID: 31036310 DOI: 10.1016/j.crad.2019.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022]
Abstract
Imaging of rectal cancer has an increasingly pivotal role in the diagnosis, staging, and treatment stratification of patients with the disease. This is particularly true for advanced rectal cancers where magnetic resonance imaging (MRI) findings provide essential information that can change treatment. In this review we describe the rationale for the current imaging standards in advanced rectal cancer for both morphological and functional imaging on the baseline staging and reassessment studies. In addition the clinical implications and future methods by which radiologists may improve these are outlined relative to TNM8.
Collapse
Affiliation(s)
- P J Brown
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - R Hyland
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - A J Quyn
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - N P West
- Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Welcome Trust Brenner Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - D Sebag-Montefiore
- Department of Clinical Oncology, Bexley Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D Jayne
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - P Sagar
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D J Tolan
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| |
Collapse
|
70
|
Schack A, Fransgaard T, Klein MF, Gögenur I. Perioperative Use of Nonsteroidal Anti-inflammatory Drugs Decreases the Risk of Recurrence of Cancer After Colorectal Resection: A Cohort Study Based on Prospective Data. Ann Surg Oncol 2019; 26:3826-3837. [DOI: 10.1245/s10434-019-07600-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Indexed: 02/06/2023]
|
71
|
Spinelli A, Carvello M, D'Hoore A, Foppa C. Integration of transanal techniques for precise rectal transection and single-stapled anastomosis: a proof of concept study. Colorectal Dis 2019; 21:841-846. [PMID: 30943327 DOI: 10.1111/codi.14631] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/16/2019] [Indexed: 02/08/2023]
Abstract
AIM Transection of the distal rectum and subsequent anastomosis differ between the open, minimally invasive and transanal approaches. With the transanal technique, there is direct control of the transection level and the single-stapled anastomosis, thus overcoming two crucial limitations of rectal surgery. This study describes a technique for precise a transanal rectal transection with a single-stapled (TTSS) colorectal, coloanal or ileoanal anastomosis in 20 consecutive patients undergoing low rectal surgery. METHODS After completing rectal dissection by the preferred technique (open or minimally invasive), TTSS was created. The detailed video describes this technique. RESULTS TTSS was feasible in all patients: 13 underwent total mesorectal excision + TTSS for low rectal cancer and seven underwent ileoanal pouch + TTSS for benign disease. Complications included one Grade IIIa and three Grade I, according to the Clavien-Dindo classification (median follow-up 6 months). CONCLUSION TTSS represents a technique which can be applied regardless of the preferred approach (open, minimally invasive or transanal) for low rectal dissection. The adoption of TTSS could well allow for a more consistent comparison of the outcomes following the differing approaches to rectal surgery.
Collapse
Affiliation(s)
- A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - M Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg Leuven, Leuven, Belgium
| | - C Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milan, Italy
| |
Collapse
|
72
|
Pucciarelli S, Del Bianco P, Pace U, Bianco F, Restivo A, Maretto I, Selvaggi F, Zorcolo L, De Franciscis S, Asteria C, Urso EDL, Cuicchi D, Pellino G, Morpurgo E, La Torre G, Jovine E, Belluco C, La Torre F, Amato A, Chiappa A, Infantino A, Barina A, Spolverato G, Rega D, Kilmartin D, De Salvo GL, Delrio P. Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer. Br J Surg 2019; 106:1147-1155. [PMID: 31233220 DOI: 10.1002/bjs.11222] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/30/2019] [Accepted: 04/02/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. METHODS This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. RESULTS Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. CONCLUSION Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- S Pucciarelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - P Del Bianco
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - U Pace
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - F Bianco
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - A Restivo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - I Maretto
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - F Selvaggi
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - L Zorcolo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - S De Franciscis
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - C Asteria
- Department of General Surgery, Ospedale Carlo Poma, Mantua, Italy
| | - E D L Urso
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - D Cuicchi
- General Surgery Unit, Department of Alimentary Tract, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - G Pellino
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - E Morpurgo
- Department of Surgery, Regional Centre for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - G La Torre
- Abdominal Surgical Oncology, Department of Surgery, IRCCS, Centro di Riferimento oncologico della Basilicata, Rionero in Vulture, Italy
| | - E Jovine
- General Surgery and Emergency, Maggiore Hospital, Azienda Sanitaria Locale di Bologna, Bologna, Italy
| | - C Belluco
- Department of Surgical Oncology, Centro di Riferimento Oncologico -IRCCS, National Cancer Institute, Aviano, Italy
| | - F La Torre
- Division of Emergency and Trauma Surgery, Emergency Department, Policlinico Umberto I, College of Medicine and Dentistry, Sapienza University, Rome, Italy
| | - A Amato
- Department of Coloproctology, Sanremo Hospital, Sanremo, Italy
| | - A Chiappa
- Innovative Techniques in Surgery Unit, European Institute of Oncology, University of Milan, Milan, Italy
| | - A Infantino
- Surgical Unit, Department of General Surgery, Santa Maria dei Battuti Hospital, San Vito al Tagliamento, Italy
| | - A Barina
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - G Spolverato
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - D Rega
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - D Kilmartin
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - G L De Salvo
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - P Delrio
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| |
Collapse
|
73
|
Keane C, Park J, Öberg S, Wedin A, Bock D, O'Grady G, Bissett I, Rosenberg J, Angenete E. Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer. Br J Surg 2019; 106:645-652. [PMID: 30706439 PMCID: PMC6590150 DOI: 10.1002/bjs.11092] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/07/2018] [Accepted: 11/17/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer. METHODS Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI). RESULTS Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054). CONCLUSION Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.
Collapse
Affiliation(s)
- C. Keane
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - J. Park
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - S. Öberg
- Centre for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of CopenhagenCopenhagenDenmark
| | - A. Wedin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - D. Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - G. O'Grady
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - I. Bissett
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - J. Rosenberg
- Centre for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of CopenhagenCopenhagenDenmark
| | - E. Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| |
Collapse
|
74
|
Sint A, Lutz R, Assenmacher M, Küchenhoff H, Kühn F, Faist E, Bazhin AV, Rentsch M, Werner J, Schiergens TS. Monocytic HLA-DR Expression for Prediction of Anastomotic Leak after Colorectal Surgery. J Am Coll Surg 2019; 229:200-209. [PMID: 30905855 DOI: 10.1016/j.jamcollsurg.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/26/2019] [Accepted: 03/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Earlier detection of anastomotic leakage (AL) after colorectal procedures could minimize the detrimental clinical impact of AL and thereby reduce morbidity and mortality. STUDY DESIGN We conducted a prospective study with assessment of the diagnostic accuracy of monocytic HLA-DR (mHLA-DR) expression compared with WBCs, C-reactive protein (CRP), and procalcitonin (PCT) in predicting AL in patients undergoing elective colorectal operation with anastomosis. RESULTS Comparison of the blood marker values on postoperative day (POD) 4 revealed significant differences for all markers, but the difference for mHLA-DR was highly significant (15% expression of monocytes in AL patients vs 34% in patients without AL; p = 0.001). Together with WBC (p = 0.026), mHLA-DR expression was the only test to show significance on day 3 (14% vs 31%; p < 0.001). Receiver operating characteristic analysis revealed that mHLA-DR expression had superior diagnostic accuracy compared with all other diagnostic markers both on POD 3 (mHLA-DR area under the curve [AUC] 0.928; WBC AUC 0.734; CRP AUC 0.707; PCT AUC 0.672) and POD 4 (mHLA-DR AUC 0.887; WBC AUC 0.738; CRP AUC 0.709; PCT AUC 0.696). Monocytic HLA-DR had a negative predictive value of at least 94% on PODs 3 and 4, as well as specificity and positive predictive values of 100% at a threshold of 23% on POD 3 and 24% on POD 4, respectively. CONCLUSIONS Expression of mHLA-DR appears to be a more accurate predictor for AL after colorectal operation compared with WBC, CRP, and PCT. It represents a promising test to precisely monitor the perioperative course of high-risk patients and contribute to safer discharge.
Collapse
Affiliation(s)
- Alena Sint
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rebecca Lutz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Helmut Küchenhoff
- Department of Statistics, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Eugen Faist
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tobias S Schiergens
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
| |
Collapse
|
75
|
Michalik T, Matkowski R, Biecek P, Forgacz J, Szynglarewicz B. Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse. Radiol Oncol 2019; 53:77-84. [PMID: 30840588 PMCID: PMC6411029 DOI: 10.2478/raon-2019-0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/10/2019] [Indexed: 12/17/2022] Open
Abstract
Background Anterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR). Patients and methods A series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed. Results AL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively. Conclusions Anastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.
Collapse
Affiliation(s)
- Tomasz Michalik
- Department of Surgical Oncology, Lower Silesian Oncology Centre – Regional Comprehensive Cancer Centre, Wroclaw, Poland
| | - Rafał Matkowski
- Department of Surgical Oncology, Lower Silesian Oncology Centre – Regional Comprehensive Cancer Centre, Wroclaw, Poland
- Department of Oncology, Faculty of Postgraduate Medical Training, Wroclaw Medical University, Wroclaw, Poland
| | - Przemyslaw Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Jozef Forgacz
- Department of Surgical Oncology, Lower Silesian Oncology Centre – Regional Comprehensive Cancer Centre, Wroclaw, Poland
| | - Bartlomiej Szynglarewicz
- Department of Surgical Oncology, Lower Silesian Oncology Centre – Regional Comprehensive Cancer Centre, Wroclaw, Poland
- Department of Oncology, Faculty of Postgraduate Medical Training, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
76
|
Influence of Anastomotic Leak After Elective Colorectal Cancer Resection on Survival and Local Recurrence: A Propensity Score Analysis. Dis Colon Rectum 2019; 62:286-293. [PMID: 30540662 DOI: 10.1097/dcr.0000000000001287] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The occurrence of anastomotic leakage is still a life-threatening complication for patients after colorectal surgery. In literature not only an impact on the short-term outcome but also on long-term survival and local recurrence of colorectal cancer patients is discussed. OBJECTIVE This study aimed to investigate the impact of anastomotic leakage on long-term survival and local recurrence. DESIGN A total of 1122 patients with resections for colorectal cancer were analyzed. In 94 patients (8.4%) there was clinical proof of anastomotic leakage. A reference group was defined as the 1028 patients without anastomotic leakage using 1:1 propensity score-matching according to the following criteria: age, sex, International Union Against Cancer stage, Karnofsky index, tumor site, and grading, as well as adjuvant chemotherapy. A calculation of overall survival, disease-free survival, and local recurrence rate was performed for both groups. SETTINGS The study was conducted using a retrospective matched-pairs analysis, based on a prospectively maintained institutional colorectal cancer database. PATIENTS Ninety-four patients with anastomotic leakage and 94 matched control subjects from a total of 1122 patients with resections for colorectal cancer were studied. MAIN OUTCOME MEASURES Overall survival, disease-free survival, and local recurrence rate for patients with colorectal cancer with and without anastomotic leakage were measured. RESULTS The propensity score matching successfully created 2 groups with no significant differences in the matching criteria. Survival analysis disclosed no significant differences between the groups in terms of overall survival, disease-free survival, and local recurrence rate. Univariate analysis identified age, Karnofsky index, International Union Against Cancer stage, and lymph node metastasis as significant prognostic factors. Multivariable analysis of these variates revealed age and positive lymph nodes as independent predictors of overall survival and disease-free survival. LIMITATIONS The study was limited by nature of being a retrospective analysis and monocentric study. CONCLUSIONS This matched-pairs analysis, comparing patients with colorectal cancer with and without anastomotic leakage, revealed no significant differences in overall survival, disease-free survival, and local recurrence rate. Contrary results in the literature might be caused by nonbalanced settings in nonmatched collectives. See Video Abstract at http://links.lww.com/DCR/A811.
Collapse
|
77
|
Laparoscopic surgery may decrease the risk of clinical anastomotic leakage and a nomogram to predict anastomotic leakage after anterior resection for rectal cancer. Int J Colorectal Dis 2019; 34:319-328. [PMID: 30470941 PMCID: PMC6331738 DOI: 10.1007/s00384-018-3199-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Anastomotic leakage is still one of the most dreaded complications after anterior resection for rectal cancer. This study aimed to identify risk factors for anastomotic leakage and to create a nomogram for precise prediction of anastomotic leakage after anterior resection for rectal cancer. METHODS Two thousand six hundred eighteen consecutive patients who underwent anterior resection for rectal cancer with primary anastomosis, with or without diverting stoma, were retrospectively analyzed as a training dataset. Univariate and multivariable Cox regression analyses were used to determine independent risk factors associated with anastomotic leakage. A nomogram was constructed to predict anastomotic leakage. Data containing 611 patients were prospectively collected as a test dataset. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots. RESULTS The rate of clinical anastomotic leakage was 9.3% in the training dataset. Multivariate analysis identifies the following variables as independent risk factors for anastomotic leakage: gender (male) (odds ratio (OR) = 2.286), distance of tumor to anal verge (OR = 0.791), tumor size (OR = 1.175), operating time (OR = 1.009), diabetes mellitus (OR = 1.704), laparoscopic surgery (OR = 0.445), anastomotic bleeding (OR = 13.46), and diverting stoma (OR = 0.386). We created a nomogram with high discriminative ability (concordance index, 0.722). The area under the curve value, which evaluated the predictive performance of external validation, was 0.723. CONCLUSIONS A protective diverting stoma and laparoscopic surgery significantly decrease the risk of anastomotic leakage. Our nomogram was a useful tool for precise prediction of anastomotic leakage after anterior resection for rectal cancer.
Collapse
|
78
|
Influence of Conversion and Anastomotic Leakage on Survival in Rectal Cancer Surgery; Retrospective Cross-sectional Study. J Gastrointest Surg 2019; 23:2007-2018. [PMID: 30187334 PMCID: PMC6773666 DOI: 10.1007/s11605-018-3931-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Conversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery. METHODS Patients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage. RESULTS Out of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (p = 0.025 and p = 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (p = 0.002 and p = 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322-3.551) and DFS (1.592, 1077-2.353). Conversion was an independent predictor of DFS (1.525, 1.071-2.172), but not of OS. CONCLUSION Technical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.
Collapse
|
79
|
Bailón-Cuadrado M, Pérez-Saborido B, Sánchez-González J, Rodríguez-López M, Velasco-López R, C Sarmentero-Prieto J, I Blanco-Álvarez J, Pacheco-Sánchez D. Prognostic Nutritional Index predicts morbidity after curative surgery for colorectal cancer. Cir Esp 2018; 97:71-80. [PMID: 30583791 DOI: 10.1016/j.ciresp.2018.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/12/2018] [Accepted: 08/30/2018] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is a major health concern and it is associated with significant morbidity and mortality. Over the last decades, the relationship between cancer and nutritional and inflammatory status in oncologic patients was studied thoroughly and multiple immunonutritional scores were developed. These scores have been mainly related to the prognosis of several cancers. An interaction between the tumour and the host is generated, triggering a systemic inflammatory reaction leading to several neuroendocrine changes. This situation favours a tendency towards anorexia and catabolism. Our hypothesis is that nutritional and inflammatory status of oncologic patients is correlated to postoperative morbidity. METHODS This is a prospective observational cohort study with those patients undergoing curative surgery for CRC at our institution between September 2015 and March 2017. Nutritional and inflammatory status was established using Onodera's Prognostic Nutritional Index (PNI). Complications (overall, severe, infectious and anastomotic leakage) were carefully collected during the first 30 days of the postoperative period. RESULTS After carrying out the multivariate analysis, PNI turned out to be a great predictive and protective factor for overall complications (RR: 0.279; 95% CI: 0.141-0.552), severe complications (RR: 0.355; 95% CI: 0.130-0.965), infectious complications (RR: 0.220; 95% CI: 0.099-0.489) and anastomotic leakage (RR: 0.151; 95% CI: 0.036-0.640). CONCLUSION Our work reports that PNI is an independent predictive factor for the development of postoperative complications following curative surgery for CRC.
Collapse
Affiliation(s)
- Martín Bailón-Cuadrado
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España.
| | - Baltasar Pérez-Saborido
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Javier Sánchez-González
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Mario Rodríguez-López
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - Rosalía Velasco-López
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José C Sarmentero-Prieto
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - José I Blanco-Álvarez
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| | - David Pacheco-Sánchez
- Departamento de Cirugía General y Digestiva, Hospital Universitario Río Hortega, Valladolid, España
| |
Collapse
|
80
|
Klaver CE, Wasmann KA, Verstegen M, van der Bilt JD, Nagtegaal ID, van Ramshorst B, Tanis PJ, Wolthuis AM, van Santvoort HC, de Wilt JH, D'Hoore A. Postoperative abdominal infections after resection of T4 colon cancer increase the risk of intra-abdominal recurrence. Eur J Surg Oncol 2018; 44:1880-1888. [DOI: 10.1016/j.ejso.2018.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/24/2018] [Accepted: 09/23/2018] [Indexed: 01/09/2023] Open
|
81
|
The application of defunctioning stomas after low anterior resection of rectal cancer. Surg Today 2018; 49:451-459. [DOI: 10.1007/s00595-018-1736-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/29/2018] [Indexed: 02/07/2023]
|
82
|
The effects of intraoperative ICG fluorescence angiography in laparoscopic low anterior resection: a propensity score-matched study. Int J Clin Oncol 2018; 24:394-402. [DOI: 10.1007/s10147-018-1365-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/31/2018] [Indexed: 12/22/2022]
|
83
|
Ramphal W, Boeding JRE, Gobardhan PD, Rutten HJT, de Winter LJMB, Crolla RMPH, Schreinemakers JMJ. Oncologic outcome and recurrence rate following anastomotic leakage after curative resection for colorectal cancer. Surg Oncol 2018; 27:730-736. [PMID: 30449500 DOI: 10.1016/j.suronc.2018.10.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/31/2018] [Accepted: 10/01/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Anastomotic leakage is one of the most severe early complications after colorectal surgery, and it is associated with a high reoperation rate-, and increased in short-term morbidity and mortality rates. It remains unclear whether anastomotic leakage is associated with poor oncologic outcomes. The aim of this study was to determine the impacts of anastomotic leakage on long-term oncologic outcomes, disease-free survival and overall mortality in patients who underwent curative surgery for colorectal cancer. METHODS This single-centre, retrospective, observational cohort study included patients who underwent curative surgery for colorectal cancer between 2005 and 2015 and who had a primary anastomosis. Survival- and multivariate cox regression analyses were performed to adjust for confounding. RESULTS A total of 1984 patients had a primary anastomosis after surgery. The overall incidence of anastomotic leakage was 7.5%; 19 patients were excluded because they were lost to follow-up. Of the remaining 1965 patients, 41 (2.1%) developed local recurrence associated with anastomotic leakage [adjusted hazard ratio (HR) = 2.25; 95% confidence interval (CI) 1.14-5.29; P = 0.03]. Distant recurrence developed in 291(14.8%) patients with no association with anastomotic leakage [adjusted HR = 1.30 (95% CI: 0.85-1.97) P = 0.23]. Anastomotic leakage was associated with increased long-term mortality [adjusted HR = 1.69 (95% CI 1.32-2.18) P < 0.01]. Five year disease-free survival was significantly decreased in patients with anastomotic leakage, (log rank test P < 0.01). CONCLUSION Anastomotic leakage was significantly associated with increased rates of local recurrence, disease free-survival and overall mortality. Associations of anastomotic leakage with distant recurrence was not found.
Collapse
Affiliation(s)
- Winesh Ramphal
- Department of Surgery, Amphia Hospital Breda, the Netherlands.
| | | | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | | | | | | |
Collapse
|
84
|
Numata M, Yamaguchi T, Kinugasa Y, Shiomi A, Kagawa H, Yamakawa Y, Furuatni A, Manabe S, Yamaoka Y, Torii K, Kato S. Safety and feasibility of laparoscopic reoperation for treatment of anastomotic leakage after laparoscopic colorectal cancer surgery. Asian J Endosc Surg 2018; 11:227-232. [PMID: 29322627 DOI: 10.1111/ases.12452] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/10/2017] [Accepted: 11/26/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The safety and feasibility of laparoscopic reoperation for anastomotic leakage remain unclear. METHODS A total of 3321 patients underwent laparoscopic surgery for primary colorectal cancer at a tertiary referral center from September 2002 to May 2016. Of these, 31 patients who underwent reoperation for treatment of anastomotic leakage were enrolled in this study and divided into two reoperation groups: laparoscopic (n = 15) and open (n = 16). Data regarding patient demographics, operative outcomes, morbidity, length of hospital stay, mortality, and stoma closure after reoperation in the two groups were compared. RESULTS No significant difference was observed in the primary surgery procedure between the two groups. Estimated blood loss (1 vs 9 mL, P = 0.020), total postoperative complications (26.7% vs 68.8%, P = 0.032), wound infection (0.0% vs 31.2%, P = 0.043), and postoperative hospital stay (18 vs 31 days, P = 0.017) were significantly better in the laparoscopic group than in the open group. Although the rate of stoma closure after reoperation was higher in the laparoscopic group, the difference was not significant (86.7% vs 62.5%, P = 0.220). CONCLUSIONS Laparoscopic reoperation exhibited better short-term outcomes than open reoperation for selected patients with anastomotic leakage.
Collapse
Affiliation(s)
- Masakatsu Numata
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Tomohiro Yamaguchi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yusuke Kinugasa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hiroyasu Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yushi Yamakawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Akinobu Furuatni
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Shoichi Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yusuke Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Kakeru Torii
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Shunichiro Kato
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| |
Collapse
|
85
|
Armstrong G, Croft J, Corrigan N, Brown JM, Goh V, Quirke P, Hulme C, Tolan D, Kirby A, Cahill R, O'Connell PR, Miskovic D, Coleman M, Jayne D. IntAct: intra-operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial. Colorectal Dis 2018; 20:O226-O234. [PMID: 29751360 PMCID: PMC6099475 DOI: 10.1111/codi.14257] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 05/02/2018] [Indexed: 02/06/2023]
Abstract
AIM Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10-15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near-infrared laparoscopy can minimize the rate of AL leak compared with conventional white-light laparoscopy. Two mechanistic sub-studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies. METHOD IntAct is a prospective, unblinded, parallel-group, multicentre, European, randomized controlled trial comparing surgery with intra-operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end-point is rate of clinical AL at 90 days following surgery. Secondary end-points include all AL (clinical and radiological), change in planned anastomosis, complications and re-interventions, use of stoma, cost-effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days. DISCUSSION IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning.
Collapse
Affiliation(s)
| | - J. Croft
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - N. Corrigan
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - J. M. Brown
- Clinical Trials Research UnitLeeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - V. Goh
- School of Biomedical Engineering and Imaging SciencesKing's College London and Honorary Consultant RadiologistGuy's and St Thomas’ Hospitals NHS Foundation TrustLondonUK
| | | | - C. Hulme
- Academic Unit of Health EconomicsLeeds Institute of Health SciencesUniversity of LeedsLeedsUK
| | - D. Tolan
- Leeds Teaching Hospital TrustLeedsUK
| | | | - R. Cahill
- University College DublinDublinIreland
| | | | | | - M. Coleman
- Derriford HospitalPlymouth NHS TrustPlymouthUK
| | - D. Jayne
- Leeds Institute of Biological and Clinical SciencesSt James's University HospitalLeedsUK
| |
Collapse
|
86
|
Grewal S, Korthouwer R, Bögels M, Braster R, Heemskerk N, Budding AE, Pouw SM, van Horssen J, Ankersmit M, Meijerink J, van den Tol P, Oosterling S, Bonjer J, Gül N, van Egmond M. Spillage of bacterial products during colon surgery increases the risk of liver metastases development in a rat colon carcinoma model. Oncoimmunology 2018; 7:e1461302. [PMID: 30228930 PMCID: PMC6140552 DOI: 10.1080/2162402x.2018.1461302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 01/03/2023] Open
Abstract
Surgical resection of the primary tumor provides the best chance of cure for patients with colorectal carcinoma (CRC). However, bacterial translocation during intestinal surgery has been correlated with poor long-term oncological outcome. Therefore, we investigated the influence of bacterial contamination during colon surgery on CRC liver metastases development. Blood and liver samples of patients undergoing resection of primary CRC or liver metastases were collected. Cell numbers, activation markers and inflammatory mediators were determined. Tumor cell adhesion and outgrowth after sham- or colectomy operations were determined in a rat model, in which tumor cells had been injected into the portal vein. White blood cells and granulocytes were increased in per- and post-operative patient blood samples. IL-6 was also increased post-operatively compared to the preoperative level. Expression of NOX-2, NOX-4 and polymorphonuclear cells (PMNs) numbers were elevated in post-operative human liver samples. In vitro stimulation of macrophages with plasma of rats after colectomy resulted in production of reactive oxygen species (ROS). Colectomy in rats increased D-lactate levels in plasma, supporting bacterial translocation. Decreased expression of tight junction molecules and increased tumor cell adhesion and outgrowth was observed. Treatment with a selective decontamination of the digestive tract (SDD) cocktail decreased tumor cell adherence after colectomy. In conclusion, postoperative bacterial translocation may activate liver macrophages and PMNs, resulting in ROS production. As we previously showed that ROS release led to liver vasculature damage, circulating tumor cells may adhere to exposed extracellular matrix and grow out into liver metastases. This knowledge is pivotal for development of therapeutic strategies to prevent surgery-induced liver metastases development.
Collapse
Affiliation(s)
- Simran Grewal
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands.,Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Rianne Korthouwer
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Marijn Bögels
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands.,Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Rens Braster
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Niels Heemskerk
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Andries E Budding
- Department of Medical Microbiology and Infection Control, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Stephan M Pouw
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Jack van Horssen
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Marjolein Ankersmit
- Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Jeroen Meijerink
- Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Petrousjka van den Tol
- Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Steven Oosterling
- Department of Surgery, Spaarne Gasthuis, PO Box 417, 2000 AK Haarlem, the Netherlands
| | - Jaap Bonjer
- Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Nuray Gül
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands.,Department of Surgery, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| |
Collapse
|
87
|
Poskus E, Kryzauskas M, Poskus T, Mikalauskas S, Samalavicius NE, Aliosin O, Dailidenas S, Tamelis A, Saladzinskas Z, Lizdenis P, Jakaitiene A, Smailyte G, Strupas K. Improved perioperative care is associated with improved long-term survival in colorectal cancer. Int J Colorectal Dis 2018. [PMID: 29532205 DOI: 10.1007/s00384-018-3021-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare perioperative colorectal cancer care and survival in patient cohorts operated in 2005 and in 2010 in Lithuania. METHODS Comparative observational cohort study was performed. The study was conducted in the three Lithuanian cancer hospitals. Patients, who underwent curative surgery for colorectal cancer in 2005 and 2010, were included. Demographic characteristics, distribution of the tumors, preoperative diagnostics and staging, surgical treatment, the quality of pathological examination, morbidity, and mortality were analyzed. One- and 5-year overall survival data were compared between the groups. RESULTS Colorectal cancer diagnostics and treatment improved from 2005 to 2010 significantly. The disease was identified as stage III-IV for 45 vs. 48% of the patients; however, computed tomography staging scan was performed only for 5.9 vs. 17.8% in 2005 and 2010, respectively. Laparoscopic operations were performed 1.5 vs. 10.5% and abdominoperineal resections-42.7 vs. 31.7% in 2005 and 2010, respectively. The number of harvested lymph nodes was mentioned in 55.8 vs. 97.7% of the cases, whereas more than 12 lymph nodes were examined in 18 vs. 66.6% of cases after histological examination. The overall 5-year survival was 52.1 vs. 63.1% (p < 0.0001), while the 5-year survival of the patients with stage IV of disease was 4.2 vs. 17.8% in 2005 and 2010, respectively. CONCLUSION Preoperative investigation, surgical treatment, pathological examination, and postoperative course are associated with improved overall survival in colorectal cancer patients, undergoing curative surgery in the resource-limited settings.
Collapse
Affiliation(s)
- Eligijus Poskus
- Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius, Lithuania
| | - Marius Kryzauskas
- Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius, Lithuania.
| | - Tomas Poskus
- Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius, Lithuania
| | - Narimantas Evaldas Samalavicius
- Department of Surgery, Klaipeda University Hospital, 41 Liepojos Str, LT-92288, Klaipeda, Lithuania.,Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Clinic of Internal, Family Medicine and Oncology, Faculty of Medicine, Vilnius University, 1 Santariskiu Str, LT-08406, Vilnius, Lithuania
| | - Oleg Aliosin
- Department of Surgery, Klaipeda University Hospital, 41 Liepojos Str, LT-92288, Klaipeda, Lithuania
| | - Sarunas Dailidenas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Clinic of Internal, Family Medicine and Oncology, Faculty of Medicine, Vilnius University, 1 Santariskiu Str, LT-08406, Vilnius, Lithuania
| | - Algimantas Tamelis
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Paulius Lizdenis
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrone Jakaitiene
- Centre of Bioinformatics and Biostatistics, Department of Human and Medical Genetics, Vilnius University, Vilnius, Lithuania
| | - Giedre Smailyte
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania
| | - Kestutis Strupas
- Institute of Clinical Medicine, Clinic of Gastroenterology, Nephrourology and Surgery, Vilnius University, Vilnius, Lithuania
| |
Collapse
|
88
|
Belmouhand M, Svendsen LB, Kofoed SC, Normann G, Baeksgaard L, Achiam MP. Recurrence following curative intended surgery for an adenocarcinoma in the gastroesophageal junction: a retrospective study. Dis Esophagus 2018; 31:4714777. [PMID: 29228216 DOI: 10.1093/dote/dox136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022]
Abstract
Recurrence following a resection for an adenocarcinoma of the gastroesophageal junction leads to reduced long-term survival. This study aims to identify risk factors associated with recurrence, recurrence localization, time to recurrence, and long-term survival. All patients undergoing curative intended resection for an adenocarcinoma of the gastroesophageal junction at Rigshospitalet between June 2003 and December 2011 were identified through a prospectively maintained nationwide database and enrolled in this study. Only histologically verified recurrence was considered eligible. Recurrence within six months, microscopically incomplete resection margins, and death within eight weeks were excluded. A total of 348 patients were included in this study. Biopsy-verified recurrence occurred in 120 patients (34.5%), with 32 local (9.2%), and 88 distant (25.3%) recurrences. Lymph node metastases was associated with an increased risk of recurrence (hazard ratio; [95% confidence interval]: HR = 2.7; [1.7-4.3], P < 0.001). Median time to local versus distant recurrence was 18 months (interquartile range (IQR): 9-37 months) versus 17 months (IQR: 11-27 months), P = 0.96, respectively. A trend toward local recurrence was identified if patients had anastomotic leakage (HR = 2.64; [0.89-7.86], P = 0.08). Survival was inversely associated with recurrence, but a survival comparison between local and distant recurrences showed no significant difference: median survival time was 28 months (IQR: 17-43 months) versus 24 months (IQR: 16-36 months), P = 0.45, respectively. A trend toward local recurrence was seen if the patient had an anastomotic leakage event. However, no factors were associated with site-specific recurrence (local vs. distant).
Collapse
Affiliation(s)
- M Belmouhand
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L B Svendsen
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - S C Kofoed
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - G Normann
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L Baeksgaard
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M P Achiam
- Department of Surgical Gastroenterology, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
89
|
Mitchem JB, Stafford C, Francone TD, Roberts PL, Schoetz DJ, Marcello PW, Ricciardi R. What is the optimal management of an intra-operative air leak in a colorectal anastomosis? Colorectal Dis 2018; 20:O39-O45. [PMID: 29172236 DOI: 10.1111/codi.13971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/07/2017] [Indexed: 01/26/2023]
Abstract
AIM An airtight anastomosis on intra-operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left-sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra-operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra-operative air leak. METHOD This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left-sided colorectal or ileorectal anastomoses and evidence of air leak during intra-operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre-existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days. RESULTS From a sample of 2360 patients, 119 had an intra-operative air leak during leak testing. Sixty-eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2-15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm. CONCLUSION Suture repair alone does not meet the criteria for noninferiority for the management of intra-operative air leak during left-sided colorectal anastomosis. Further repair of intra-operative air leak by suture repair alone should be reconsidered given these findings.
Collapse
Affiliation(s)
- J B Mitchem
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - C Stafford
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - T D Francone
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P L Roberts
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Department of Colon and Rectal Surgery, The Lahey Clinic, Burlington, Massachusetts, USA
| | - D J Schoetz
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Department of Colon and Rectal Surgery, The Lahey Clinic, Burlington, Massachusetts, USA
| | - P W Marcello
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Department of Colon and Rectal Surgery, The Lahey Clinic, Burlington, Massachusetts, USA
| | - R Ricciardi
- Section of Colon and Rectal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
90
|
Abstract
Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.
Collapse
|
91
|
Wu Y, Zheng H, Guo T, Keranmu A, Liu F, Xu Y. Temporary Diverting Stoma Improves Recovery of Anastomotic Leakage after Anterior Resection for Rectal Cancer. Sci Rep 2017; 7:15930. [PMID: 29162894 PMCID: PMC5698498 DOI: 10.1038/s41598-017-16311-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/07/2017] [Indexed: 12/14/2022] Open
Abstract
Temporary diverting stoma might be a protective factor for the prevention of anastomotic leakage (AL) after anterior resection. Its role in leakage recovery is unknown. This study aimed to evaluate the effect of temporary diverting stoma on anastomotic leakage severity and recovery. We analyzed 323 patients who underwent anterior resection for rectal cancer and developed anastomotic leakage, in which 44 had temporary diverting stoma. Association between diverting stoma and occurrence of anastomotic leakage, recovery time, length of hospital stay, overall costs, local and distant relapse-free survival were further studied. In non-severe AL group, temporary diverting stoma improved leakage recovery by 4 days (mean: 20.7 days vs. 16.1 days, p = 0.031), especially in patients who did not receive neoadjuvant treatment (mean time: 20.9 days vs. 14.4 days, p = 0.016). However, it did not delay the occurrence of anastomotic leakage. Moreover, no significant difference was found in the overall length of hospital stay and costs among patients with versus without a diverting stoma. In severe AL group, however, no difference was detected. The advantage of shortened leakage recovery did not reduce the local and distant relapse-free survival. In conclusion, our findings indicated the recovery benefit from diverting stoma in patients with anterior resection.
Collapse
Affiliation(s)
- Yuchen Wu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Hongtu Zheng
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Tianan Guo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Adili Keranmu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Fangqi Liu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China
| | - Ye Xu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong An Road, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, No. 130, Dong An Road, Shanghai, 200032, China.
| |
Collapse
|
92
|
Management of Low Colorectal Anastomotic Leakage in the Laparoscopic Era: More Than a Decade of Experience. Dis Colon Rectum 2017; 60:807-814. [PMID: 28682966 DOI: 10.1097/dcr.0000000000000822] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy. OBJECTIVE The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses. SETTING This was a single-institute case series. PATIENTS A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000-2012 were included. MAIN OUTCOME MEASURES Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien-Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured. RESULTS Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses <5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%). LIMITATIONS This study was limited by the lack of a cohort of open cases for comparison. CONCLUSIONS Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.
Collapse
|
93
|
Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity. Surg Endosc 2017; 32:702-711. [PMID: 28726138 DOI: 10.1007/s00464-017-5726-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 07/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical trainee association with operative outcomes is controversial. Studies are conflicting, possibly due to insufficient control of confounding variables such as operative time, case complexity, and heterogeneous patient populations. As operative complications worsen long-term outcomes in oncologic patients, understanding effect of trainee involvement during laparoscopic colectomy for cancer is of utmost importance. Here, we hypothesized that resident involvement was associated with worsened 30-day mortality and 30-day overall morbidity in this patient population. METHODS Patients undergoing laparoscopic colectomy for oncologic diagnosis from 2005 to 2012 were assessed using the American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score matching accounted for demographics, comorbidities, case complexity, and operative time. Attending only cases were compared to junior, middle, chief resident, and fellow level cohorts to assess primary outcomes of 30-day mortality and 30-day overall morbidity. RESULTS A total of 13,211 patients met inclusion criteria, with 4075 (30.8%) cases lacking trainee involvement and 9136 (69.2%) involving a trainee. Following propensity matching, junior (PGY 1-2) and middle level (PGY 3-4) resident involvement was not associated with worsened outcomes. Chief (PGY 5) resident involvement was associated with worsened 30-day overall morbidity (15.5 vs. 18.6%, p = 0.01). Fellow (PGY > 5) involvement was associated with worsened 30-day overall morbidity (16.0 vs. 21.0%, p < 0.001), serious morbidity (9.3 vs. 13.5%, p < 0.001), minor morbidity (9.8 vs. 13.1%, p = 0.002), and surgical site infection (7.9 vs. 10.5%, p = 0.006). No differences were seen in 30-day mortality for any resident level. CONCLUSION Following propensity-matched analysis of cancer patients undergoing laparoscopic colectomy, chief residents, and fellows were associated with worsened operative outcomes compared to attending along cases, while junior and mid-level resident outcomes were no different. Further study is necessary to determine what effect the PGY surgical trainee level has on post-operative morbidity in cancer patients undergoing laparoscopic colectomy in the context of multiple collinear factors.
Collapse
|
94
|
Evolution of Surgical Treatment for Rectal Cancer: a Review. J Gastrointest Surg 2017; 21:1166-1173. [PMID: 28444558 DOI: 10.1007/s11605-017-3427-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/06/2017] [Indexed: 02/08/2023]
Abstract
Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle-that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.
Collapse
|
95
|
Ha GW, Kim JH, Lee MR. Oncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3289-3299. [DOI: 10.1245/s10434-017-5881-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Indexed: 12/15/2022]
|
96
|
Interpretative Guidelines and Possible Indications for Indocyanine Green Fluorescence Imaging in Robot-Assisted Sphincter-Saving Operations. Dis Colon Rectum 2017; 60:376-384. [PMID: 28267004 DOI: 10.1097/dcr.0000000000000782] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since the introduction of indocyanine green angiography more than 25 years ago, few studies have presented interpretative guidelines for indocyanine green fluorescent imaging. OBJECTIVE We aimed to provide interpretative guidelines for indocyanine green fluorescent imaging through quantitative analysis and to suggest possible indications for indocyanine green fluorescent imaging during robot-assisted sphincter-saving operations. DESIGN This is a retrospective observational study. SETTINGS This study was conducted at a single center. PATIENTS A cohort of 657 patients with rectal cancer who consecutively underwent curative robot-assisted sphincter-saving operations was enrolled between 2010 and 2016, including 310 patients with indocyanine green imaging (indocyanine green fluorescent imaging+ group) and 347 patients without indocyanine green imaging (indocyanine green fluorescent imaging- group). MAIN OUTCOME MEASURES We tried to quantitatively define the indocyanine green fluorescent imaging findings based on perfusion (mesocolic and colic) time and perfusion intensity (5 grades) to provide probable indications. RESULTS The anastomotic leakage rate was significantly lower in the indocyanine green fluorescent imaging+ group than in the indocyanine green fluorescent imaging- group (0.6% vs 5.2%) (OR, 0.123; 95% CI, 0.028-0.544; p = 0.006). Anastomotic stricture was closely correlated with anastomotic leakage (p = 0.002) and a short descending mesocolon (p = 0.003). Delayed perfusion (>60 s) and low perfusion intensity (1-2) were more frequently detected in patients with anastomotic stricture and marginal artery defects than in those without these factors (p ≤ 0.001). In addition, perfusion times greater than the mean were more frequently observed in patients aged >58 years, whereas low perfusion intensity was seen more in patients with short descending mesocolon and high ASA classes (≥3). LIMITATIONS The 300 patients in the indocyanine green fluorescent imaging- group underwent operations 3 years before indocyanine green fluorescent imaging. CONCLUSIONS Quantitative analysis of indocyanine green fluorescent imaging may help prevent anastomotic complications during robot-assisted sphincter-saving operations, and may be of particular value in high-class ASA patients, older patients, and patients with a short descending mesocolon.
Collapse
|
97
|
Ellinger S. Can specific nutrients stimulate bowel wound healing? Curr Opin Clin Nutr Metab Care 2016; 19:371-376. [PMID: 27348151 DOI: 10.1097/mco.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of review is to provide an overview on specific nutrients which play an important role in bowel wound healing, and to judge the efficacy of supplementation to derive recommendations for clinical practice. RECENT FINDINGS Glutamine, arginine, butyrate, ω-3 fatty acids, nucleotides, and several micronutrients are involved in bowel wound healing. However, with regard to clinical trials, the efficacy of supplementation of specific nutrients on bowel wound healing in patients with inflammatory bowel diseases has not been clarified yet. In patients undergoing colon surgery, sufficient evidence exists that the perioperative supply of an enteral immunomodulating formula enriched with arginine, nucleotides, and ω-3 fatty acids may improve intestinal wound healing, considering the lower risk of wound infections, wound dehiscence, and intra-abdominal abscess. SUMMARY Even if a range of nutrients are involved in bowel wound healing, only perioperative supply of an enteral immunomodulating formula to cancer patients undergoing colon surgery, can be recommended. Further randomized controlled trials are needed to elucidate the efficacy of individual nutrients on intestinal wound healing.
Collapse
Affiliation(s)
- Sabine Ellinger
- Faculty of Food, Nutrition and Hospitality Sciences, Hochschule Niederrhein, University of Applied Sciences, Mönchengladbach, Germany
| |
Collapse
|
98
|
Sammour T, Hayes IP, Jones IT, Steel MC, Faragher I, Gibbs P. Impact of anastomotic leak on recurrence and survival after colorectal cancer surgery: a BioGrid Australia analysis. ANZ J Surg 2016; 88:E6-E10. [PMID: 27255690 DOI: 10.1111/ans.13648] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/03/2016] [Accepted: 05/08/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is conflicting evidence regarding the oncological impact of anastomotic leak following colorectal cancer surgery. This study aims to test the hypothesis that anastomotic leak is independently associated with local recurrence and overall and cancer-specific survival. METHODS Analysis of prospectively collected data from multiple centres in Victoria between 1988 and 2015 including all patients who underwent colon or rectal resection for cancer with anastomosis was presented. Overall and cancer-specific survival rates and rates of local recurrence were compared using Cox regression analysis. RESULTS A total of 4892 patients were included, of which 2856 had completed 5-year follow-up. The overall anastomotic leak rate was 4.0%. Cox regression analysis accounting for differences in age, sex, body mass index, American Society of Anesthesiologists score and tumour stage demonstrated that anastomotic leak was associated with significantly worse 5-year overall survival (χ 2 = 6.459, P = 0.011) for colon cancer, but only if early deaths were included. There was no difference in 5-year colon cancer-specific survival (χ 2 = 0.582, P = 0.446) or local recurrence (χ 2 = 0.735, P = 0.391). For rectal cancer, there was no difference in 5-year overall survival (χ 2 = 0.266, P = 0.606), cancer-specific survival (χ 2 = 0.008, P = 0.928) or local recurrence (χ 2 = 2.192, P = 0.139). CONCLUSION Anastomotic leak may reduce 5-year overall survival in colon cancer patients but does not appear to influence the 5-year overall survival in rectal cancer patients. There was no effect on local recurrence or cancer-specific survival.
Collapse
Affiliation(s)
- Tarik Sammour
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ian P Hayes
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Colorectal Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian T Jones
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Colorectal Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Malcolm C Steel
- Colorectal Unit, Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Ian Faragher
- Colorectal Unit, Department of Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Peter Gibbs
- Department of Medical Oncology, Walter + Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| |
Collapse
|