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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Park IK. Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis. Ann Coloproctol 2018; 34:259-265. [PMID: 30419724 PMCID: PMC6238803 DOI: 10.3393/ac.2018.05.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. Methods Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. Results A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). Conclusion In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.
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Affiliation(s)
- In Teak Woo
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Kyu Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
BACKGROUND When a colorectal or coloanal anastomosis fails because of persistent leakage or stenosis, or the anastomosis has to be resected for recurrent cancer, constructing a new anastomosis might be an option in selected patients. This is a rare and complex type of redo surgery. OBJECTIVE The aim of this review was to evaluate the current literature on redo anastomosis for complicated colorectal or coloanal anastomosis. DATA SOURCES A systematic literature search of MEDLINE, EMBASE, the Cochrane Library, the PROSPERO register, clinicaltrials.gov, and the World Health Organization International Clinical Trials Registry Platform database was performed. STUDY SELECTION Two reviewers independently screened the available literature. All studies reporting on redo surgery and aiming at reconstruction of a prior low colorectal or coloanal anastomosis for any indication were included. MAIN OUTCOME MEASURES Primary outcome was successful restoration of continuity. Secondary outcomes were postoperative morbidity, pelvic sepsis, incontinence, and mortality. RESULTS Nine studies were included, comprising 291 patients, of whom 76% had index surgery for colorectal cancer. Pooled proportions showed an overall success rate of 79% (95% CI, 69-86), with a pooled incidence of major postoperative morbidity of 16% (95% CI, 10-24). The pooled pelvic sepsis rate was 16% (95% CI, 9-27), and the pooled surgical reintervention and readmission rates were 11% (95% CI, 8-17) and 7% (95% CI, 3-15). Five studies reported on incontinence, with a pooled proportion of 17% (95% CI, 10-26). LIMITATIONS The limitations of this review are the lack of randomized controlled trials and high-quality studies, and the small sample sizes and heterogeneous patient populations in the included studies. CONCLUSIONS Redo surgery is a valuable treatment option for the complicated colorectal or coloanal anastomosis with 79% successful restoration of bowel continuity in the published literature from experienced tertiary centers.
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Abstract
PURPOSE Sphincter-saving surgery is widely accepted operative modality to treat rectal cancer. It often requires temporary diverting stoma to avoid the complications of anastomotic failure. This study investigates the cumulative failure rate in sphincter preservation for rectal cancer and the risk factors associated with the permanent stoma. METHODS A retrospective study on 358 patients diagnosed with primary rectal cancer from 2009 to 2013 was conducted at a single institute. Three hundred and thirty-one out of 358 patients with rectal cancer located within 12 cm from the anal verge, who underwent sphincter-preserving surgery, were included in this study. The cumulative rate for permanent stoma was calculated. Univariate and multivariate analysis were performed, comparing the patients with stoma to the ones without. RESULTS Temporary diverting stoma was created in 223 (82%) patients. After median follow-up of 42 months, 18 patients (6.6%) persistently used temporary stoma or required re-creation of stoma. Univariate analysis revealed that BMI, tumor location below 4 cm from the anal verge, coloanal anastomosis, anastomotic leakage, and local recurrence were significantly associated with persistent use or re-formation of stoma. Multivariate analysis showed that anastomotic leakage (OR 50.3; 95% CI, 10.1-250.1; p < 0.0001) and local recurrence (OR 11.3; 95% CI, 1.61-78.5; p = 0.015) were the independent risk factors. CONCLUSION Patients with anastomotic leakage and local recurrence are at high risk for permanent stoma. Not only should patients be fully informed of possible failure in sphincter preservation preoperatively, but also patient-oriented decision should be made on patient-tailored surgical plan.
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Affiliation(s)
- Ri Na Yoo
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Gun Kim
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Bong-Hyeon Kye
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - Hyeon-Min Cho
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea
| | - HyungJin Kim
- St. Vincent Hospital, The Catholic University of Korea, 93-6 Ji-Dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Korea.
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104
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Schrempf M, Anthuber M. [Chronic anastomotic insufficiency after low anterior rectal resection]. Chirurg 2018; 89:480. [PMID: 29777256 DOI: 10.1007/s00104-018-0656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- M Schrempf
- Klinik für Allgemein‑, Viszeral- Transplantationschirurgie, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - M Anthuber
- Klinik für Allgemein‑, Viszeral- Transplantationschirurgie, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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105
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Mak JCK, Foo DCC, Wei R, Law WL. Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma. World J Surg 2018; 41:2912-2922. [PMID: 28620675 DOI: 10.1007/s00268-017-4090-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. OBJECTIVE The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. METHOD From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. RESULTS This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. CONCLUSION Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.
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Affiliation(s)
- Joanna Chung Kiu Mak
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Dominic Chi Chung Foo
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Rockson Wei
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Wai Lun Law
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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Chereau N, Lefevre JH, Chafai N, Hor T, Debove C, Tiret E, Parc Y. Hartmann's reversal after colonic perforation or anastomosis leakage, is it the same procedure? A retrospective study of 150 patients. Langenbecks Arch Surg 2018; 403:435-441. [PMID: 29671066 DOI: 10.1007/s00423-018-1667-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/19/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE The high morbidity rates reported might influence surgeons' decisions of whether to perform Hartmann's reversal (HR). Our aim was to report the results of HR after "primary" Hartmann's procedure (HP) or in redo surgery for failed anastomosis. METHODS All patients operated between 2007 and 2015 were included. Data and postoperative course were obtained from a review of medical records and databases. RESULTS One hundred fifty patients (age 60, range (20-91) years, 62% male) were included. Eighty-six patients (57%) were ASA ≥ 2. HP was mostly performed for diverticulitis (29.3%) and anastomotic leakage (24%). HR was possible in 145(97%) patients including six with previous failed attempt. Overall morbidity was 22.7% including 11.7% severe complications (Dindo 3-4). Operative blood loss and Charlson comorbidity index were the only significant risk factor for postoperative pelvic complications (p = 0.03; p = 0.0002, respectively). CONCLUSIONS In a colorectal tertiary center, HR was feasible in 97% with a low morbidity and a 3.4% anastomotic leakage rate.
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Affiliation(s)
- Nathalie Chereau
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
| | - Jeremie H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France.
| | - Najim Chafai
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
| | - Thevy Hor
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
| | - Clotilde Debove
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
| | - Emmanuel Tiret
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
| | - Yann Parc
- Department of Digestive and General Surgery, Hôpital Saint Antoine, Sorbonne Université, Paris VI, France
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Suhool A, Moszkowicz D, Cudennec T, Vychnevskaia K, Malafosse R, Beauchet A, Julié C, Peschaud F. Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation. J Visc Surg 2018; 155:17-25. [PMID: 29503170 DOI: 10.1016/j.jviscsurg.2017.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score. METHODS We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy. RESULTS Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%. CONCLUSIONS After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.
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Affiliation(s)
- A Suhool
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - D Moszkowicz
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - T Cudennec
- Service de gériatrie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - K Vychnevskaia
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France
| | - R Malafosse
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - A Beauchet
- Service de biostatistiques, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - C Julié
- UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France; Service d'anatomo-pathologie, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France
| | - F Peschaud
- Service de chirurgie digestive, oncologique et metabolique, hôpital Ambroise-Paré, AP-HP, 92100 Boulogne-Billancourt, France; UVSQ, université Paris-Saclay, UFR des sciences de la santé Simone Veil, 78180 Montigny-Le-Bretonneux, France.
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108
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Montemurro S, De Luca R, Caliandro C, Ruggieri E, Rucci A, Sciscio V, Ranaldo N, Federici A. Transanal Tube NO COIL® after Rectal Cancer Proctectomy. The “G. Paolo II” Cancer Centre Experience. TUMORI JOURNAL 2018; 98:607-14. [DOI: 10.1177/030089161209800511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study. Methods From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL®, 60–80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventhpostoperative day if no signs of leakage occurred. Results The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%. Conclusions The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.
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Affiliation(s)
- Severino Montemurro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Cosimo Caliandro
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Eustachio Ruggieri
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Antonello Rucci
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Vito Sciscio
- Department of Surgical Oncology, Istituto Tumori “G. Paolo II”, NCC, Bari, Italy
| | - Nunzio Ranaldo
- Institute of Gastroenterology, University Medical School, Bari, Italy
| | - Antonio Federici
- Department of Physiology, University Medical School, Bari, Italy
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109
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Westerduin E, Borstlap WAA, Musters GD, Westerterp M, van Geloven AAW, Tanis PJ, Wolthuis AM, Bemelman WA, D'Hoore A. Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases. Colorectal Dis 2018; 20:35-43. [PMID: 28795776 DOI: 10.1111/codi.13844] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
AIM The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA. METHOD This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up. RESULTS A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8-27]. The median duration of follow-up was 27 months (IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004-0.122). CONCLUSION Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.
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Affiliation(s)
- E Westerduin
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands
| | - W A A Borstlap
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - G D Musters
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - M Westerterp
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | | | - P J Tanis
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A M Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
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Tozzi R, Casarin J, Garruto-Campanile R, Majd HS, Morotti M. Morbidity and reversal rate of ileostomy after bowel resection during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer. Gynecol Oncol 2018; 148:74-78. [DOI: 10.1016/j.ygyno.2017.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/31/2017] [Accepted: 11/12/2017] [Indexed: 12/11/2022]
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111
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Ding YB, Wang P. Ponderings on low rectal surgery. Shijie Huaren Xiaohua Zazhi 2017; 25:3109-3114. [DOI: 10.11569/wcjd.v25.i35.3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most common malignant tumors. As the development of modern medicine and the wide application of early cancer screening, rectal cancer has been found and treated timely nowadays. At present, sphincter-preserving surgery for low rectal cancer is getting more and more popular. Low rectal anastomotic fistula and pelvic autonomic nerve injuries are common complications. Improving the oncological clearance and reducing the complications have been the goals of surgeons. This article discusses several problems in low rectal surgery: (1) the selection of the cut-off location of the inferior mesenteric artery; (2) the protection of pelvic autonomic nerve plexus; (3) the anatomy of Denonvilliers' fascia; (4) the surgical strategy for preventive stoma; and (5) the improvement of drainage in pelvic floor.
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Affiliation(s)
- Yong-Bin Ding
- Department of General Surgery, Shengze Branch of The First Affiliated Hospital of Nanjing Medical University, Suzhou 215228, Jiangsu Province, China
| | - Peng Wang
- Department of General Surgery, Shengze Branch of The First Affiliated Hospital of Nanjing Medical University, Suzhou 215228, Jiangsu Province, China
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112
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Muralee M, Singh R, Mathew AP, Cherian K, Chandramohan K, Augustine P, Roshni S, Ahamed I. Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre. Indian J Surg Oncol 2017; 8:479-483. [PMID: 29203977 DOI: 10.1007/s13193-017-0659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 04/20/2017] [Indexed: 11/24/2022] Open
Abstract
The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.
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Affiliation(s)
- Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Rajesh Singh
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Kurian Cherian
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - K Chandramohan
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Paul Augustine
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - S Roshni
- Division of Radiation Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
| | - Iqbal Ahamed
- Division of Surgical Oncology, Regional Cancer Centre, 11, Thiruvananthapuram, Kerala India
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Holmgren K, Kverneng Hultberg D, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis 2017; 19:1067-1075. [PMID: 28612478 DOI: 10.1111/codi.13771] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/13/2017] [Indexed: 12/11/2022]
Abstract
AIM Fashioning a defunctioning stoma is common when performing an anterior resection for rectal cancer in order to avoid and mitigate the consequences of an anastomotic leakage. We investigated the permanent stoma prevalence, factors influencing stoma outcome and complication rates following stoma reversal surgery. METHOD Patients who had undergone an anterior resection for rectal cancer between 2007 and 2013 in the northern healthcare region were identified using the Swedish Colorectal Cancer Registry and were followed until the end of 2014 regarding stoma outcome. Data were retrieved by a review of medical records. Multiple logistic regression was used to evaluate predefined risk factors for stoma permanence. Risk factors for non-reversal of a defunctioning stoma were also analysed, using Cox proportional-hazards regression. RESULTS A total of 316 patients who underwent anterior resection were included, of whom 274 (87%) were defunctioned primarily. At the end of the follow-up period 24% had a permanent stoma, and 9% of patients who underwent reversal of a stoma experienced major complications requiring a return to theatre, need for intensive care or mortality. Anastomotic leakage and tumour Stage IV were significant risk factors for stoma permanence. In this series, partial mesorectal excision correlated with a stoma-free outcome. Non-reversal was considerably more prevalent among patients with leakage and Stage IV; Stage III patients at first had a decreased reversal rate, which increased after the initial year of surgery. CONCLUSION Stoma permanence is common after anterior resection, while anastomotic leakage and advanced tumour stage decrease the chances of a stoma-free outcome. Stoma reversal surgery entails a significant risk of major complications.
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Affiliation(s)
- K Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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114
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Denost Q, Rullier E. Intersphincteric Resection Pushing the Envelope for Sphincter Preservation. Clin Colon Rectal Surg 2017; 30:368-376. [PMID: 29184472 DOI: 10.1055/s-0037-1606114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
During the last 15 years, a significant evolution has emerged in the surgical treatment of rectal cancer and restoration of bowel continuity has been one of the main goals. For many years the treatment of distal rectal cancer would necessarily require an abdominoperineal resection and end colostomy. The surgical procedure of intersphincteric resection has been proposed to offer sphincter preservation in patients with low rectal cancer and has been legitimized if executed according to adequate oncologic criteria. This article will discuss the best indications, technical aspects, functional, and oncological outcomes of intersphicteric resection in the management of rectal cancer.
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Affiliation(s)
- Quentin Denost
- Colorectal Unit, Department of Surgery, Centre Magellan, Haut Lévèque University Hospital, Bordeaux/Pessac, France
| | - Eric Rullier
- Colorectal Unit, Department of Surgery, Centre Magellan, Haut Lévèque University Hospital, Bordeaux/Pessac, France
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115
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Park J, Danielsen AK, Angenete E, Bock D, Marinez AC, Haglind E, Jansen JE, Skullman S, Wedin A, Rosenberg J. Quality of life in a randomized trial of early closure of temporary ileostomy after rectal resection for cancer (EASY trial). Br J Surg 2017; 105:244-251. [PMID: 29168881 PMCID: PMC5814870 DOI: 10.1002/bjs.10680] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/05/2017] [Accepted: 07/19/2017] [Indexed: 12/16/2022]
Abstract
Background A temporary ileostomy may reduce symptoms from anastomotic leakage after rectal cancer resection. Earlier results of the EASY trial showed that early closure of the temporary ileostomy was associated with significantly fewer postoperative complications. The aim of the present study was to compare health‐related quality of life (HRQOL) following early versus late closure of a temporary ileostomy. Methods Early closure of a temporary ileostomy (at 8–13 days) was compared with late closure (at more than 12 weeks) in a multicentre RCT (EASY) that included patients who underwent rectal resection for cancer. Inclusion of participants was made after index surgery. Exclusion criteria were signs of anastomotic leakage, diabetes mellitus, steroid treatment, and signs of postoperative complications at clinical evaluation 1–4 days after rectal resection. HRQOL was evaluated at 3, 6 and 12 months after resection using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ‐C30 and QLQ‐CR29 and Short Form 36 (SF‐36®). Results There were 112 patients available for analysis. Response rates of the questionnaires were 82–95 per cent, except for EORTC QLQ‐C30 at 12 months, to which only 54–55 per cent of the patients responded owing to an error in questionnaire distribution. There were no clinically significant differences in any questionnaire scores between the groups at 3, 6 or 12 months. Conclusion Although the randomized study found that early closure of the temporary ileostomy was associated with significantly fewer complications, this clinical advantage had no effect on the patients' HRQOL. Registration number: NCT01287637 (https://www.clinicaltrials.gov). No different after early ileostomy closure
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Affiliation(s)
- J Park
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - A K Danielsen
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej, Herlev, Denmark
| | - E Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - D Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - A C Marinez
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - E Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - J E Jansen
- Department of Surgery, Nordsjaellands Hospital, Hillerød, Denmark
| | - S Skullman
- Department of Surgery, Skaraborgs Sjukhus, Skövde, Sweden
| | - A Wedin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - J Rosenberg
- Department of Gastroenterology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej, Herlev, Denmark
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116
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Zhu H, Bai B, Shan L, Wang X, Chen M, Mao W, Huang X. Preoperative radiotherapy for patients with rectal cancer: a risk factor for non-reversal of ileostomy caused by stenosis or stiffness proximal to colorectal anastomosis. Oncotarget 2017; 8:100746-100753. [PMID: 29246018 PMCID: PMC5725060 DOI: 10.18632/oncotarget.20602] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/26/2017] [Indexed: 11/25/2022] Open
Abstract
The influence of radiotherapy on permanent stoma and the bowel proximal to anastomosis was not well investigated. The current study aimed to analyze the effect of preoperative radiotherapy on colorectal anastomosis and incidence of non-reversal ileostomy. A total of 184 eligible patients with rectal cancer undergoing loop ileostomy were included. Patients were well selected by excluding some confounding factors and divided into two groups according to whether they received preoperative radiotherapy. Patients with preoperative radiotherapy had higher incidence of non-reversal stoma (12.8%, P = 0.004) and stenosis or stiffness around anastomosis (21.1%, P < 0.01) including 13 patients with stenosis or stiffness proximal to anastomosis. Stenosis proximal to anastomosis was different from anastomotic stricture caused by surgery and could be described by imaging findings. Preoperative radiotherapy prolonged the interval to closure (P = 0.008) and was defined as a significant risk factor for permanent stoma (HR, 0.627; 95% CI, 0.405-0.973; P = 0.04) by multivariate Cox regression analysis. In conclusion, Preoperative radiotherapy increased incidence of non-reversal ileostomy and stenosis or stiffness proximal to anastomosis in rectal cancer patients with radical resection and diverting ileostomy.
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Affiliation(s)
- Hongbo Zhu
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Biotherapy of Zhejiang province, Hangzhou, China
| | - Bingjun Bai
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Biotherapy of Zhejiang province, Hangzhou, China
| | - Lina Shan
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Biotherapy of Zhejiang province, Hangzhou, China
| | - Xiaowei Wang
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Chen
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weifang Mao
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xuefeng Huang
- Department of Colorectal Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg 2017; 266:870-877. [PMID: 28746154 DOI: 10.1097/sla.0000000000002429] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Little is known about late detected anastomotic leakage after low anterior resection for rectal cancer, and the proportion of leakages that develops into a chronic presacral sinus. METHODS In this collaborative snapshot research project, data from registered rectal cancer resections in the Dutch Surgical Colorectal Audit in 2011 were extended with additional treatment and long-term outcome data. Independent predictors for anastomotic leakage were determined using a binary logistic model. RESULTS A total of 71 out of the potential 94 hospitals participated. From the 2095 registered patients, 998 underwent a low anterior resection, of whom 88.8% received any form of neoadjuvant therapy. Median follow-up was 43 months (interquartile range 35-47). Anastomotic leakage was diagnosed in 13.4% within 30 days, which increased to 20.0% (200/998) beyond 30 days. Nonhealing of the leakage at 12 months was 48%, resulting in an overall proportion of chronic presacral sinus of 9.5%. Independent predictors for anastomotic leakage at any time during follow-up were neoadjuvant therapy (odds ratio 2.85; 95% confidence interval 1.00-8.11) and a distal (≤3 cm from the anorectal junction on magnetic resonance imaging) tumor location (odds ratio 1.88; 95% confidence interval 1.02-3.46). CONCLUSIONS This cross-sectional study of low anterior resection for rectal cancer in the Netherlands in 2011, with almost routine use of neoadjuvant radiotherapy, shows that one third of anastomotic leakages is diagnosed beyond 30 days, and almost half of the leakages eventually do not heal. Chronic presacral sinus is a significant clinical problem that deserves more attention.
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118
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Mussetto A, Arena R, Buzzi A, Fuccio L, Dari S, Brancaccio ML, Triossi O. Long-term efficacy of vacuum-assisted therapy (Endo-SPONGE ®) in large anastomotic leakages following anterior rectal resection. Ann Gastroenterol 2017; 30:649-653. [PMID: 29118559 PMCID: PMC5670284 DOI: 10.20524/aog.2017.0194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background: The aim of our study was to test the long-term efficacy of Endo-SPONGE® therapy in a group of patients treated in our center with vacuum-assisted therapy because of anastomotic leakages after colorectal surgery. Methods: Eleven patients [male: 6; mean age: 71 (range: 44-82) years] who had anastomotic leakage treated with Endo-SPONGE® placement were included in the study. Patient records were examined retrospectively. All patients with documented anastomotic leakage on abdominal computed tomography following an anterior resection of the rectum for rectal cancer underwent sigmoidoscopy to determine the extent of the anastomotic defect and the size of the presacral abscess. Results: Ten of the 11 patients (90.9%) showed closure of the anastomotic leakage after a mean of 16 sponge changes. During follow up [mean: 29 (range: 6-64) months], we observed two cases of anastomotic stricture. Treatment failure was observed in one patient who presented an increased size of dehiscence after 23 sessions of endoscopic treatment, despite an initial good response. Conclusions: Our study substantially confirms previous conclusions and reaffirms that Endo-SPONGE® treatment for colorectal anastomotic leakages, performed in suitable patients, represents a successful and safe approach. The reduction in wound closure time, mild-to-moderate discomfort and possibly shorter hospitalization suggest that Endo-SPONGE® treatment can be a prominent therapeutic regimen with adequate patient acceptance.
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Affiliation(s)
- Alessandro Mussetto
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
| | - Rosario Arena
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
| | - Andrea Buzzi
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna (Lorenzo Fuccio), Italy
| | - Silvia Dari
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
| | - Mario Luciano Brancaccio
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
| | - Omero Triossi
- Division of Gastroenterology, S. Maria delle Croci Hospital, Ravenna (Alessandro Mussetto, Rosario Arena, Andrea Buzzi, Silvia Dari, Mario Luciano, Omero Triossi), Italy
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119
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Use of a nomogram to predict the closure rate of diverting ileostomy after low anterior resection: A retrospective cohort study. Int J Surg 2017; 47:83-88. [PMID: 28951289 DOI: 10.1016/j.ijsu.2017.09.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although temporary ileostomy is widely used to prevent complications due to anastomotic leakage after middle and low rectal cancer surgery, some patients fail to achieve stoma closure after primary surgery. The aim of this study was to identify the risk factors for permanent stoma following low anterior resection (LAR) or intersphincteric resection (ISR) with a temporary ileostomy for rectal cancer, while focusing on the time course, to develop a nomogram that can predict the rate of unreversed ileostomy 1 year after initial surgery. METHOD A total of 212 consecutive rectal cancer patients who underwent LAR or ISR with or without a temporary stoma between 2012 and 2015 at the University of Tokyo Hospital were retrospectively reviewed. Data analyses were performed using JMP Pro 11.0 and R 3.0.1 with rms and Hmisc packages to identify the risk factors for diverting ileostomy resulting in un-reversed stoma, and to develop a nomogram using these factors. RESULTS Among 212 patients, diverting ileostomy and colostomy were performed in 116 and 11 patients, respectively, and a stoma was not created in 85 patients. Among the ileostomy cases, 94 underwent stoma reversal, and the median interval from initial surgery to stoma closure was 6.9 months. Three patients eventually underwent stoma re-creation, and hence, 25 patients had permanent stoma. The following variables were correlated with the stoma non-reversal rate and were included in the nomogram: depth of invasion (p = 0.02), presence of metastatic organs (p = 0.07), and preoperative chemoradiotherapy (p = 0.03). The nomogram C-index was 0.612, indicating moderate predictive ability. CONCLUSIONS The most common factors preventing stoma closure included distant metastasis or rectal cancer recurrence. The nomogram developed in the present study can help identify rectal cancer patients with high risk of stoma non-reversal.
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120
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Guimas V, Boustani J, Schipman B, Lescut N, Puyraveau M, Bosset JF, Servagi-Vernat S. Preoperative Chemoradiotherapy for Rectal Cancer in Patients Aged 75 Years and Older: Acute Toxicity, Compliance with Treatment, and Early Results. Drugs Aging 2017; 33:419-25. [PMID: 27138958 DOI: 10.1007/s40266-016-0367-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Treatment of locally advanced rectal cancer (T3-T4 or N+) is based on short-course radiotherapy (RT) or chemoradiotherapy (CRT) followed by surgery. It is estimated that 30-40 % of rectal cancer occurs in patients aged 75 years or more. Data on adherence to neoadjuvant CRT and its safety remain poor owing to the under-representation of older patients in randomized clinical trials and the discordance in the results from retrospective studies. The aim of this study was to assess adherence with preoperative CRT and tolerability in older patients with a stage II/III unresectable rectal cancer. METHODS Patients aged 75 years or more with stage II/III rectal cancer treated with preoperative CRT at the University Hospital of Besancon from 1993 to 2011 were included. Feasibility, toxicities, overall survival, and local recurrence rates were studied. RESULTS Fifty-six patients with a Charlson score from 2 to 6 were included. The mean age was 78 years. The compliance rates for RT and chemotherapy were 91 and 41.1 %, respectively. Two patients stopped CRT; one for hemostatic surgery, and one for severe sepsis. For CRT, the rate of grade ≥3 toxicity was 14.29 %, mainly the digestive type. Fifty-two patients underwent tumor resection, including 76.79 % total mesorectal excision resection with 84.6 % complete resection, and a rate of postoperative complications of 39.6 %. At 2 years, the overall survival and local recurrences rates were 87.3 and 7.8 %, respectively. CONCLUSION In older patients, selected preoperative CRT, with an adapted chemotherapy dose, is well tolerated. The main toxicity was gastrointestinal. Adherence to RT is comparable to that of younger patients.
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Affiliation(s)
- Valentine Guimas
- Department of Radiation Oncology, Besançon University Hospital, University Hospital of Franche-Comté, Boulevard Fleming, 25030, Besançon Cedex, France
| | - Jihane Boustani
- Department of Radiation Oncology, Besançon University Hospital, University Hospital of Franche-Comté, Boulevard Fleming, 25030, Besançon Cedex, France
| | | | - Nicolas Lescut
- Department of Radiation Oncology, Besançon University Hospital, University Hospital of Franche-Comté, Boulevard Fleming, 25030, Besançon Cedex, France
| | - Marc Puyraveau
- Department of Clinical Investigation Center, Besançon University Hospital, Besançon, France
| | - Jean François Bosset
- Department of Radiation Oncology, Besançon University Hospital, University Hospital of Franche-Comté, Boulevard Fleming, 25030, Besançon Cedex, France
| | - Stéphanie Servagi-Vernat
- Department of Radiation Oncology, Besançon University Hospital, University Hospital of Franche-Comté, Boulevard Fleming, 25030, Besançon Cedex, France.
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Pappalardo G, Coiro S, De Lucia F, Giannella A, Ruffolo F, Frattaroli FM. Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol. G Chir 2017; 37:257-261. [PMID: 28350972 DOI: 10.11138/gchir/2016.37.6.257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIM Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. PATIENTS AND METHODS 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. RESULTS Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). CONCLUSION FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.
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122
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Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database. Dis Colon Rectum 2017; 60:706-713. [PMID: 28594720 DOI: 10.1097/dcr.0000000000000800] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant. OBJECTIVE This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer. DESIGN All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit. SETTINGS Data were derived from the Dutch Surgical Colorectal Audit. MAIN OUTCOME MEASURES The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured. RESULTS Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage. LIMITATIONS Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database. CONCLUSIONS Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.
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123
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Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, Festen S, van der Zaag EJ, Tanis PJ, Bemelman WA. Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc 2017; 32:315-327. [PMID: 28664443 PMCID: PMC5770507 DOI: 10.1007/s00464-017-5679-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/19/2017] [Indexed: 12/13/2022]
Abstract
Introduction Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of anastomotic leakage after pre-treatment with the Endosponge® therapy. Methods In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed. Results Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient. Conclusion Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
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Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - G D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - L P S Stassen
- Department of Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands
| | | | - D Hess
- Department of Surgery, Antonius Zorggroep, Sneek, The Netherlands
| | - S van Dieren
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - E J van der Zaag
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Early Closure of a Temporary Ileostomy in Patients With Rectal Cancer: A Multicenter Randomized Controlled Trial. Ann Surg 2017; 265:284-290. [PMID: 27322187 DOI: 10.1097/sla.0000000000001829] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective was to study morbidity and mortality associated with early closure (8-13 days) of a temporary stoma compared with standard procedure (closure after > 12 weeks) after rectal resection for cancer. BACKGROUND A temporary ileostomy may reduce the risk of pelvic sepsis after anastomotic dehiscence. However, the temporary ileostomy is afflicted with complications and requires a second surgical procedure (closure) with its own complications. Early closure of the temporary ileostomy could reduce complications for rectal cancer patients. METHODS Early closure (8-13 days after stoma creation) of a temporary ileostomy was compared with late closure (>12 weeks) in a multicenter randomized controlled trial, EASY (www.clinicaltrials.gov, NCT01287637) including patients undergoing rectal resection for cancer. Patients with a temporary ileostomy without signs of postoperative complications were randomized to closure at 8 to 13 days or late closure (>12 weeks after index surgery). Clinical data were collected up to 12 months. Complications were registered according to the Clavien-Dindo Classification of Surgical Complications, and Comprehensive Complication Index was calculated. RESULTS The trial included 127 patients in eight Danish and Swedish surgical departments, and 112 patients were available for analysis. The mean number of complications after index surgery up to 12 months follow up was significantly lower in the intervention group (1.2) compared with the control group (2.9), P < 0.0001. CONCLUSIONS It is safe to close a temporary ileostomy 8 to 13 days after rectal resection and anastomosis for rectal cancer in selected patients without clinical or radiological signs of anastomotic leakage.
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125
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Benchmarking recent national practice in rectal cancer treatment with landmark randomized controlled trials. Colorectal Dis 2017; 19:O219-O231. [PMID: 28258642 DOI: 10.1111/codi.13644] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/22/2016] [Indexed: 12/23/2022]
Abstract
AIM A Snapshot study design eliminates changes in treatment and outcome over time. This population based Snapshot study aimed to determine current practice and outcome of rectal cancer treatment with published landmark randomized controlled trials as a benchmark. METHOD In this collaborative research project, the dataset of the Dutch Surgical Colorectal Audit was extended with additional treatment and long-term outcome data. All registered patients who underwent resection for rectal cancer in 2011 were eligible. Baseline characteristics and outcome were evaluated against the results of the Dutch TME trial and the COLOR II trial from which the original datasets were obtained. RESULTS A total of 71 hospitals participated, and data were completed for 2102 out of the potential 2633 patients (79.8%). Median follow-up was 41 (interquartile range 25-47) months. Overall circumferential resection margin (CRM) involvement was 9.3% in the Snapshot cohort and 18.5% in the Dutch TME trial. CRM positivity after laparoscopic resection was 7.8% in the Snapshot and 9.5% in the COLOR II trial. Three-year overall local recurrence rate in the Snapshot was 5.9%, with a disease-free survival of 67.1% and overall survival of 79.5%. Benchmarking with the randomized controlled trials revealed an overall favourable long-term outcome of the Snapshot cohort. CONCLUSION This study showed that current rectal cancer care in a large unselected Dutch population is of high quality, with less positive CRM since the TME trial and oncologically safe implementation of minimally invasive surgery after the COLOR II trial.
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Affiliation(s)
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- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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126
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Abstract
Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.
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Affiliation(s)
- Karen L Sherman
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
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127
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Risk Factors Associated With Nonclosure of Defunctioning Stomas After Sphincter-Preserving Low Anterior Resection of Rectal Cancer: A Meta-Analysis. Dis Colon Rectum 2017; 60:544-554. [PMID: 28383455 DOI: 10.1097/dcr.0000000000000819] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Some patients receiving defunctioning stomas will never undergo stoma reversal, but it is difficult to preoperatively predict which patients will be affected. OBJECTIVE The aim of this meta-analysis was to identify the risk factors associated with nonclosure of temporary stomas after sphincter-preserving low anterior resection for rectal cancer. DATA SOURCES We performed a comprehensive search of the PubMed, Embase, and Cochrane Central Library databases for all of the studies analyzing risk factors for nonclosure of defunctioning stomas. STUDY SELECTION We only included articles published in English in this meta-analysis. The inclusion criteria were as follows: 1) original article with extractable data, 2) studies including only defunctioning stomas created after low anterior resection for rectal cancer, 3) studies with nonclosure rather than delayed closure as the main end point, and 4) studies analyzing risk factors for nonclosure. INTERVENTION Defunctioning stomas were created after low anterior resection for rectal cancer. MAIN OUTCOME MEASURES Stoma nonclosure was the only end point, and it included nonclosure and permanent stoma creation after primary stoma closure. The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies, and risk ratios and 95% CIs were used to assess risk factors. RESULTS Ten studies with 8568 patients were included. The nonclosure rate was 19% (95% CI, 13%-24%; p < 0.001; I= 96.2%). Three demographic factors were significantly associated with nonclosure: older age (risk ratio= 1.50 (95% CI, 1.12-2.02); p = 0.007; I= 39.3%), ASA score >2 (risk ratio = 1.66 (95% CI, 1.51-1.83); p < 0.001; I= 0%), and comorbidities (risk ratio = 1.58 (95% CI, 1.29-1.95); p < 0.001; I= 52.6%). Surgical complications (risk ratio = 1.89 (95% CI, 1.48-2.41); p < 0.001; I= 29.7%), postoperative anastomotic leakage (risk ratio = 3.39 (95% CI, 2.41-4.75); p < 0.001; I= 53.0%), stage IV tumor (risk ratio = 2.96 (95% CI, 1.73-5.09); p < 0.001; I= 88.1%), and local recurrence (risk ratio = 2.84 (95% CI, 2.11-3.83); p < 0.001; I= 6.8%) were strong clinical risk factors for nonclosure. Open surgery (risk ratio = 1.47 (95% CI, 1.01-2.15); p = 0.044; I= 63.6%) showed a borderline significant association with nonclosure. LIMITATIONS Data on some risk factors could not be pooled because of the low number of studies. There was conspicuous heterogeneity between the included studies, so the pooled data were not absolutely free of exaggeration or influence. CONCLUSIONS Older age, ASA score >2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence are risk factors for nonclosure of defunctioning stomas after low anterior resection in patients with rectal cancer, whereas tumor height, radiotherapy, and chemotherapy are not. Patients with these risk factors should be informed preoperatively of the possibility of nonreversal, and joint decision-making is preferred.
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128
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Risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery. Surg Today 2017; 47:1238-1242. [DOI: 10.1007/s00595-017-1510-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/12/2017] [Indexed: 12/11/2022]
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Zhen L, Wang Y, Zhang Z, Wu T, Liu R, Li T, Zhao L, Deng H, Qi X, Li G. Effectiveness between early and late temporary ileostomy closure in patients with rectal cancer: A prospective study. Curr Probl Cancer 2017; 41:231-240. [PMID: 28434582 DOI: 10.1016/j.currproblcancer.2017.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/27/2017] [Indexed: 11/29/2022]
Abstract
A temporary stoma is often used in rectal cancer surgery to protect a distal anastomosis, which remains a major concern after rectal cancer surgery, particularly after low anterior resection. The temporary stoma is scheduled for closure. However, the optimal time of closure of the protecting stoma remains unclear because of sparse studies and data. We aimed to detect the efficacy between early and late temporary ileostomy closure in patients with rectal cancer during or after neoadjuvant chemoradiotherapy. We conducted a prospective, 2-group design between early and late ileostomy closure group in patients after rectal cancer surgery with temporary stoma. Participants were recruited in a teaching hospital in Guangzhou, China. A total of 161 patients confirmed diagnosis of rectal cancer underwent curative surgery and temporary ileostomy. Participants with temporary ileostomy received closure surgery after 1 (early) or 6 (late) months were assessed by clinical parameters and quality of life. Patients in late closure group received more adjuvant chemotherapy cycles but with comparable incidence of stoma closure-related complications and length of hospital stay compared to early closure group. Participants in late closure group with standardized postoperative chemotherapy might have a better prognosis compared with those in early closure group. An increased emphasis should be given to choose the optimal closure time of patients with rectal cancer having temporary ileostomy. Colorectal nurses could provide support to physician for observation of prognosis of different closure time.
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Affiliation(s)
- Li Zhen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanan Wang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ze Zhang
- Department of Head and Neck Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Tongwei Wu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ruoyan Liu
- Department of Breast Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Tingting Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Liying Zhao
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haijun Deng
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaolong Qi
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Guoxin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Floodeen H, Hallböök O, Hagberg L, Matthiessen P. Costs and resource use following defunctioning stoma in low anterior resection for cancer – A long-term analysis of a randomized multicenter trial. Eur J Surg Oncol 2017; 43:330-336. [DOI: 10.1016/j.ejso.2016.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/06/2016] [Indexed: 01/14/2023] Open
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Glynne-Jones R, Hughes R. Current Status of the Watch-and-Wait Policy for Patients with Complete Clinical Response Following Neoadjuvant Chemoradiation in Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2017. [DOI: 10.1007/s11888-017-0344-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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132
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Hu MH, Huang RK, Zhao RS, Yang KL, Wang H. Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis. Colorectal Dis 2017; 19:16-26. [PMID: 27321374 DOI: 10.1111/codi.13424] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/28/2016] [Indexed: 12/13/2022]
Abstract
AIM The aim was to evaluate the association of neoadjuvant therapy with increases in the incidence of anastomotic leakage (AL) after middle and low rectal anterior resection. METHOD The electronic databases of PubMed, Web of Science, Scopus and Ovid were searched between 1980 and 2015. The random effects model was used to model the pooled data to determine the odds ratio with 95% confidence interval. Heterogeneity was evaluated using the Q test and I2 statistics. Subgroup, sensitivity and meta-regression analysis was conducted to explore heterogeneity. RESULTS Neoadjuvant therapy was not shown to increase the incidence of postoperative AL as demonstrated by an OR of 1.16 [95% CI 0.99-1.36; P = 0.07 (random effects model)]. The subgroup analysis of neoadjuvant radiotherapy using the random effects model suggested that it did not increase the rate of postoperative AL (OR = 1.24, 95% CI 0.97-1.58; P = 0.08). The subgroup analysis of neoadjuvant chemoradiotherapy indicated that the rate of postoperative AL again did not increase with an OR = 1.06 [95% CI 0.86-1.30; P = 0.59 (random effects model)]. The interval to surgery after neoadjuvant therapy and preoperative radiotherapy (short or long course) was not associated with an increased incidence of postoperative AL. CONCLUSION Neoadjuvant therapy does not appear to increase the incidence of postoperative AL after anterior resection for mid and low rectal cancer. In addition, neither the interval to surgery after neoadjuvant therapy nor the radiotherapy regimen increases the rate of postoperative AL.
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Affiliation(s)
- M-H Hu
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - R-K Huang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - R-S Zhao
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - K-L Yang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - H Wang
- Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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133
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Haksal M, Okkabaz N, Atici AE, Civil O, Ozdenkaya Y, Erdemir A, Aksakal N, Oncel M. Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer. Ann Surg Treat Res 2016; 92:35-41. [PMID: 28090504 PMCID: PMC5234425 DOI: 10.4174/astr.2017.92.1.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/23/2016] [Accepted: 09/12/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer. METHODS All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival. RESULTS Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143). CONCLUSION Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.
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Affiliation(s)
- Mustafa Haksal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey.; Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Nuri Okkabaz
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Ali Emre Atici
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Osman Civil
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Yasar Ozdenkaya
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
| | - Ayhan Erdemir
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Nihat Aksakal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Oncel
- Department of General Surgery, Medipol University Medical School, Istanbul, Turkey
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Khor BY, McSorley ST, Horgan PG, McMillan DC. The relationship between systemic inflammation and stoma formation following anterior resection for rectal cancer: A cross-sectional study. Int J Surg 2016; 37:79-84. [PMID: 27940290 DOI: 10.1016/j.ijsu.2016.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 12/05/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION There is evidence that temporary defunctioning stoma formation in patients undergoing anterior resection reduces the risk of anastomotic leakage. The aim of the present study was to investigate the relationship between stoma formation, the postoperative systemic inflammatory response and complications following anterior resection for rectal cancer. METHODS Data was recorded prospectively for patients who underwent anterior resection for histologically proven rectal cancer, from 2008 to 2015 at a single centre, n = 167. Patients had routine preoperative and postoperative blood sampling including serum C-reactive protein (CRP). Postoperative complications including anastomotic leakage were recorded. RESULTS Of the 167 patients, the majority were male (61%) and over 65 years old (56%) with node negative disease (60%). 36 patients (22%) underwent preoperative neoadjuvant treatment. 100 patients (60%) had a stoma formed at the time of surgery. Stoma formation was significantly associated with male sex (69% vs. 50%, p = 0.017), neoadjuvant chemoradiotherapy (30% vs 9%, p = 0.001) and open surgery (71% vs. 55%, p = 0.040). Of those 100 patients who had a stoma formed, 80 had it reversed. Permanent stoma was significantly associated with increasing age (p = 0.011), exceeding the established CRP threshold of 150 mg/L on postoperative day 4 (67% vs 37%, p = 0.039), higher incidence of postoperative complications (76% vs 47%, p = 0.035), anastomotic leakage (24% vs 2%, p = 0.003) and higher Clavien Dindo score (p = 0.036). CONCLUSIONS There was no significant association between stoma formation during anterior resection and the postoperative systemic inflammatory response. However, in these patients both the postoperative systemic inflammatory response and complications were associated with permanent stoma.
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Affiliation(s)
- Bo Y Khor
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.
| | - Paul G Horgan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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135
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Borstlap WAA, Tanis PJ, Koedam TWA, Marijnen CAM, Cunningham C, Dekker E, van Leerdam ME, Meijer G, van Grieken N, Nagtegaal ID, Punt CJA, Dijkgraaf MGW, De Wilt JH, Beets G, de Graaf EJ, van Geloven AAW, Gerhards MF, van Westreenen HL, van de Ven AWH, van Duijvendijk P, de Hingh IHJT, Leijtens JWA, Sietses C, Spillenaar-Bilgen EJ, Vuylsteke RJCLM, Hoff C, Burger JWA, van Grevenstein WMU, Pronk A, Bosker RJI, Prins H, Smits AB, Bruin S, Zimmerman DD, Stassen LPS, Dunker MS, Westerterp M, Coene PP, Stoot J, Bemelman WA, Tuynman JB. A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer. BMC Cancer 2016; 16:513. [PMID: 27439975 PMCID: PMC4955121 DOI: 10.1186/s12885-016-2557-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/13/2016] [Indexed: 12/13/2022] Open
Abstract
Background Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients. Methods/Study design In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients. Discussion The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery. Trial registration NCT02371304, registration date: February 2015
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Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - T W A Koedam
- Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
| | - C A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - C Cunningham
- Department of Surgery, Oxford University Hospital, Oxford, UK
| | - E Dekker
- Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M E van Leerdam
- Department of Gastroenterology, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - G Meijer
- Department of Pathology, Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - N van Grieken
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - I D Nagtegaal
- Department of Pathology, RadboudUMC, Nijmegen, The Netherlands
| | - C J A Punt
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J H De Wilt
- Department of Surgery, RadboudUMC, Nijmegen, The Netherlands
| | - G Beets
- Department of Surgery, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - E J de Graaf
- Department of Surgery, IJselland Hospital, Capelle aan de Ijssel, The Netherlands
| | | | - M F Gerhards
- Department of surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | | | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - J W A Leijtens
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - C Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | | | | | - C Hoff
- Department of Surgery, Medisch Centrum Leewarden, Leeuwarden, The Netherlands
| | - J W A Burger
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - A Pronk
- Department of Surgery, Diaconessenziekehuis, Utrecht, The Netherlands
| | - R J I Bosker
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
| | - H Prins
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - A B Smits
- Department of Surgery, Sint. Antonius Hospital, Nieuwegein, The Netherlands
| | - S Bruin
- Department of Surgery, Slotervaart Hospital, Amsterdam, The Netherlands
| | - D D Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - L P S Stassen
- Department of Surgery, MUMC, Maastricht, The Netherlands
| | - M S Dunker
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - M Westerterp
- Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands
| | - P P Coene
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - J Stoot
- Department of Surgery, Zuyderland Hospital, Sittard, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J B Tuynman
- Department of Surgery, VU University Medical Center, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands.
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Krezalek MA, Skowron KB, Guyton KL, Shakhsheer B, Hyoju S, Alverdy JC. The intestinal microbiome and surgical disease. Curr Probl Surg 2016; 53:257-93. [PMID: 27497246 DOI: 10.1067/j.cpsurg.2016.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Monika A Krezalek
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Kinga B Skowron
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Kristina L Guyton
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Baddr Shakhsheer
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Sanjiv Hyoju
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - John C Alverdy
- Department of Surgery, Center for Surgical Infection Research and Therapeutics, Pritzker School of Medicine, University of Chicago, Chicago, IL.
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137
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Kuryba AJ, Scott NA, Hill J, van der Meulen JH, Walker K. Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service. Colorectal Dis 2016; 18:O199-205. [PMID: 27005316 DOI: 10.1111/codi.13339] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/30/2015] [Indexed: 12/14/2022]
Abstract
AIM The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified. METHOD The records of 4879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics. Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate the impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk. RESULTS Within 18 months from anterior resection, 3536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients [hazard ratio (HR) 0.90; 95% CI 0.84-0.96, aged 80 vs 70 years], male gender (HR 0.90; 0.84-0.97), higher American Society of Anesthesiologists (ASA) grade (HR 0.64; 0.56-0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69-0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74-0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84-1.00, one vs no comorbidity) and open surgical procedure (HR 0.90; 0.84-0.97, open vs laparoscopic). CONCLUSION Overall, two-thirds of ileostomies were reversed within 18 months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness and stage), mode of surgical access and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access.
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Affiliation(s)
- A J Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - N A Scott
- Colorectal Surgical Department, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK
| | - J Hill
- Department of General Surgery, Central Manchester University Hospitals NHS Foundation Trust, Manchester Royal Infirmary, Manchester, UK
| | - J H van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - K Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Persistent Asymptomatic Anastomotic Leakage After Laparoscopic Sphincter-Saving Surgery for Rectal Cancer: Can Diverting Stoma Be Reversed Safely at 6 Months? Dis Colon Rectum 2016; 59:369-76. [PMID: 27050598 DOI: 10.1097/dcr.0000000000000568] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic leakage after rectal cancer surgery raises the problem of the timing of diverting stoma reversal. OBJECTIVE The purpose of this study was to assess whether stoma reversal can be safely performed at 6 months after laparoscopic sphincter-saving surgery for rectal cancer with total mesorectal excision in patients with persistent asymptomatic anastomotic leakage. DESIGN This was a retrospective analysis of a prospective database. SETTINGS The study was conducted at a tertiary colorectal surgery referral center. PATIENTS All of the patients with anastomotic leakage were treated conservatively after sphincter-saving laparoscopic total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES The main study measure was postoperative morbidity. RESULTS A total of 110 (26%) of 429 patients who presented with anastomotic leakage and were treated conservatively were diagnosed only on CT scan (60 symptomatic (14%) and 50 asymptomatic (12%)). During follow up, 82 (75%) of 110 anastomotic leakages healed spontaneously after a mean delay of 16 ± 6 weeks (range, 4-30 weeks). Among these patients, 7 (9%) of 82 developed postoperative symptomatic pelvic sepsis after stoma reversal. Among the 28 patients remaining, 3 died during follow-up. The remaining 25 patients (23%) presented with persistent asymptomatic anastomotic leakage with chronic sinus >6 months after rectal surgery. Stoma reversal was performed in 19 asymptomatic patients, but 3 (16%) of 19 developed postoperative symptomatic pelvic sepsis after stoma reversal (3/19 vs 7/82 patients; p = 0.217), requiring a redo surgery with transanal colonic pull-through and delayed coloanal anastomosis (n = 2) or standard coloanal anastomosis (n = 1). Regarding the 6 final patients, abdominal redo surgery was performed because of either symptoms or anastomotic leakage with a large presacral cavity. LIMITATIONS This study was limited by its small sample size. CONCLUSIONS In the great majority of patients with persistent anastomotic leakage at 6 months after total mesorectal excision, stoma reversal can be safely performed.
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139
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Anderin K, Gustafsson UO, Thorell A, Nygren J. The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer. Eur J Surg Oncol 2016; 42:788-93. [PMID: 27132071 DOI: 10.1016/j.ejso.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/15/2016] [Accepted: 04/05/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a severe complication after low anterior resection (LAR) in rectal cancer surgery. A diverting loop ileostomy has been reported to reduce early clinical AL and thereby decrease short-term morbidity. Less is known if long-term morbidity is affected by a loop ileostomy constructed at LAR. METHODS At Ersta Hospital, Sweden, 287 consecutive patients were operated on with LAR, 2002-2011. Follow-up time was 3 years after LAR. Due to a shift in routines, 15% were diverted at LAR, 2002-2006 and 91%, 2007-2011. Data on long-term morbidity and permanent stoma in patients with or without a diversion at primary surgery were compared. RESULTS During LAR, 139 patients were diverted (S+), 148 were not (S-). Total rate of AL, both early and late, was 26% in S+ and 30% in S-, p 0.25. Late AL (>30 days after LAR) was found in 6% and 15% were readmitted in the late postoperative period with no difference between the groups. Total length of hospital stay (30 days-3 years after LAR) was longer among S+ compared to S-, mean 7 vs. 4 days (p < 0.001). One out of six ended up with a permanent stoma (17% S+, 14% S-, p 0.47). Clinical AL was an independent risk factor and the most common cause for a permanent stoma in both groups. CONCLUSION A diverting loop ileostomy at LAR did not reduce long-term morbidity but was associated with a longer total length of hospital stay during a 3-year follow up.
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Affiliation(s)
- K Anderin
- Center for Digestive Diseases, Karolinska University Hospital, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden.
| | - U O Gustafsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden; Department of Surgery, Danderyd Hospital, Sweden
| | - A Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden
| | - J Nygren
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden; Department of Surgery, Ersta Hospital, Sweden
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140
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Rutegård M, Boström P, Haapamäki M, Matthiessen P, Rutegård J. Current use of diverting stoma in anterior resection for cancer: population-based cohort study of total and partial mesorectal excision. Int J Colorectal Dis 2016; 31:579-85. [PMID: 26670673 DOI: 10.1007/s00384-015-2465-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE A diverting stoma is commonly used to reduce the risk of anastomotic leakage when performing total mesorectal excision (TME) in anterior resection for rectal cancer. The purpose of this study was to evaluate the impact of fecal diversion in relation to partial mesorectal excision (PME). METHODS A retrospective analysis was undertaken on a national cohort, originally created to study the impact of central arterial ligation on patients with increased cardiovascular risk. Some 741 patients operated with anterior resection for rectal cancer during the years 2007 through 2010 were followed up for 53 months. Multivariate logistic regression was used to evaluate the impact of diverting stoma on the risk of anastomotic leakage and permanent stoma, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The risk of anastomotic leakage was increased in TME surgery when not using a diverting stoma (OR 5.1; 95% CI 2.2-11.6), while the corresponding risk increase in PME patients was modest (OR 1.8; 95% CI 0.8-4.0). At study completion or death, 26 and 13% of TME and PME patients, respectively, had a permanent stoma. A diverting stoma was a statistically significant risk factor for a permanent stoma in PME patients (OR 4.7; 95% CI 2.5-9.0), while less important in TME patients (OR 1.8; 95% CI 0.6-5.5). CONCLUSION The benefit of a diverting stoma concerning anastomotic leakage in this patient group seems doubtful. Moreover, the diverting stoma itself may contribute to the high rate of permanent stomas.
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Petrus Boström
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Markku Haapamäki
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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141
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Musters GD, Borstlap WA, Bemelman WA, Buskens CJ, Tanis PJ. Intersphincteric completion proctectomy with omentoplasty for chronic presacral sinus after low anterior resection for rectal cancer. Colorectal Dis 2016; 18:147-54. [PMID: 26277690 DOI: 10.1111/codi.13086] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/20/2015] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to determine the clinical outcome of salvage surgery without restoring continuity for symptomatic chronic presacral sinus after low anterior resection (LAR) for rectal cancer. METHOD Out of a prospective cohort of 46 patients with chronic presacral sinus (> 1 year after LAR), 27 underwent completion proctectomy with omentoplasty between January 2005 and July 2014. RESULTS The initial treatment for rectal cancer included neoadjuvant radiotherapy in 26 (96%) patients. Besides a chronic presacral sinus, a secondary fistula was present in 15 (56%) patients. Definitive salvage surgery was performed after a median of 40 (12-350) months from the primary resection. The median hospital stay after single- and multiple-stage salvage surgery was 11 and 17 days. Postoperative complications occurred in 44% of patients. The re-intervention rate was 33% with a range of 1-10 interventions per patient. During a median follow-up of 20 (4-45) months from salvage surgery, healing of the chronic presacral sinus occurred in 78% of patients, with a healing rate after single- and multiple-stage procedures of 88% and 64% respectively (P = 0.19). CONCLUSION Patients with a symptomatic chronic presacral sinus after LAR for rectal cancer, in whom restoration of continuity is not intended, can be effectively managed by completion proctectomy with complete debridement of the sinus and fistula tracts followed by an omentoplasty to fill the presacral cavity, preferably as a single-stage procedure.
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Affiliation(s)
- G D Musters
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Borstlap
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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142
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Pan HD, Peng YF, Wang L, Li M, Yao YF, Zhao J, Zhan TC, Gu J. Risk Factors for Nonclosure of a Temporary Defunctioning Ileostomy Following Anterior Resection of Rectal Cancer. Dis Colon Rectum 2016; 59:94-100. [PMID: 26734966 DOI: 10.1097/dcr.0000000000000520] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In patients with colorectal cancer, a defunctioning ileostomy is commonly constructed to reduce anastomotic complications. However, many patients do not undergo a subsequent procedure to have their temporary stoma closed. OBJECTIVE This study investigated the incidence of nonclosure of ileostomies and identified factors associated with nonclosure. DESIGN This study is a retrospective analysis of prospectively collected data. SETTING This study was conducted at a tertiary referral cancer hospital. PATIENTS A total of 296 patients who received anterior resection with a defunctioning ileostomy with protective intention from 2006 to 2013 were included. MAIN OUTCOME MEASURES The primary outcomes measured were the incidence of nonclosure of ileostomy and associated risk factors. RESULTS Patients were followed for a median time of 29 months (range, 21-100 months). At the end of the study, 51 (17.2%) patients were left with a permanent ileostomy. The median time interval from the creation of a defunctioning ileostomy to closure was 192 days (range, 14-865 days). Multivariate analyses using a logistic regression model showed that metastatic diseases (OR, 0.179, p < 0.001), Charlson Comorbidity Index score >1 (OR, 0.268; p < 0.01), and complications from the index surgery (OR, 0.391; p = 0.013) were significant independent risk factors for failing to close a defunctioning ileostomy. LIMITATIONS Although our study has a large patient cohort, it is limited by its retrospective nature. It is difficult to fully evaluate stoma complications after hospital discharge, and the prevalence may be underestimated. CONCLUSION One in 6 temporary ileostomies constructed during an elective anterior resection for rectal cancer was not closed. Patients should be told before the index surgery that there is a risk of nonclosure and possible complications associated with permanent ileostomy.
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Affiliation(s)
- Hong-Da Pan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery, Peking University Cancer Hospital & Institute, Beijing Cancer Hospital, Beijing, China
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143
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Musters GD, Atema JJ, van Westreenen HL, Buskens CJ, Bemelman WA, Tanis PJ. Ileostomy closure by colorectal surgeons results in less major morbidity: results from an institutional change in practice and awareness. Int J Colorectal Dis 2016; 31:661-7. [PMID: 26732261 PMCID: PMC4773497 DOI: 10.1007/s00384-015-2478-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Previous institutional analysis of ileostomy closure revealed substantial morbidity. This subsequent study aimed at determining if a change in clinical practice resulted in reduced complication rates. METHODS Between June 2004 and January 2014, all consecutive adult patients undergoing ileostomy closure were retrospectively identified. Postoperative outcome after change in clinical practice consisting of routine participation of a colorectal surgeon, stapled side-to-side anastomosis and increased clinical awareness (cohort B) was compared with our previously published historical control group (cohort A). The primary outcome was major morbidity, defined as Clavien-Dindo grade three or higher. Independent risk factors of major morbidity were identified using multivariable analysis. RESULTS In total, 165 patients underwent ileostomy closure in cohort A, and 144 patients in cohort B. At baseline, more primary diverting ileostomies were present in cohort A (94 vs. 82%; p = 0.001) with a similar rate of loop and end-ileostomy between the two cohorts (p = 0.331). A significant increase in colorectal surgeon participation (89 vs. 53%; p < 0.001) and stapled side-to-side anastomosis was observed (63 vs. 16%; p < 0.001). The major morbidity rate was 11% in cohort A, which significantly reduced to 4% in cohort B (p = 0.03). Surgery being performed or supervised by a colorectal surgeon (odds ratio [OR] 0.28, 95% CI 0.11-0.67) and loop-ileostomy compared to end-ileostomy (OR 0.18, 95% CI 0.07-0.52) were independently associated with lower major morbidity. CONCLUSION Ileostomy closure appears to be more complex surgery then generally considered, especially end-ileostomy closure. Postoperative outcome could be significantly improved by a change in surgical practice.
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Affiliation(s)
- G. D. Musters
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - J. J. Atema
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | | | - C. J. Buskens
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - W. A. Bemelman
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
| | - P. J. Tanis
- />Department of Surgery, Academic Medical Centre, University of Amsterdam, Post Box 22660, 1105 AZ Amsterdam, The Netherlands
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144
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Celerier B, Denost Q, Van Geluwe B, Pontallier A, Rullier E. The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer. Colorectal Dis 2016; 18:59-66. [PMID: 26391723 DOI: 10.1111/codi.13124] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/15/2015] [Indexed: 12/11/2022]
Abstract
AIM The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer. METHOD From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis. RESULTS During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1 year to 22% at 10 years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P = 0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age > 65 years and surgical morbidity. CONCLUSION The risk of a definitive stoma after SSR increased two-fold between 1 and 10 years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.
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Affiliation(s)
- B Celerier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - Q Denost
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - B Van Geluwe
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - A Pontallier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - E Rullier
- Department of Digestive Surgery, CHU Bordeaux, Saint André Hospital, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
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145
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Willenz U, Wasserberg N, Botero-Anug AM, Greenberg R. Feasibility of an Intraluminal Bypass Device in Low Colorectal Anastomosis. Surg Innov 2015; 23:298-304. [DOI: 10.1177/1553350615617250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background: The Cologuard CG-100 is a novel intraluminal bypass device designed to reduce the clinical outcomes associated with low colorectal anastomotic leak. The device is inserted transanally, anchored to the colon above the anastomosis, and deployed intraluminally to cover the anastomosis from within. The purpose of this study was to evaluate the safety and performance of the device in a porcine model. Method: Twelve pigs underwent low colorectal anastomosis with insertion of the Cologuard CG-100 device. Contrast material injection, abdominal X-ray, and histologic studies were used to evaluate sealing quality, device positioning, and tissue damage, respectively. The surgeons completed a usability and satisfaction questionnaire after completion of the procedure. Results: Absolute sealing was observed in all 4 animals euthanized immediately after surgery. In the other 8 animals, the device was kept in situ for 10 days and then extracted. X-ray films with injection of contrast material through a designated injection tube before device removal showed that the sheath and ring were correctly placed. No leak was demonstrated. There were no device-related adverse events, and no critical histological abnormalities were noted in the bowel area that was compressed by the device. The device was found to be easy to insert, position, and extract. Conclusion: The Cologuard CG-100 device efficiently reduced contact between fecal content and low colorectal anastomosis in a porcine model and is easily deployed and extracted. It holds promise for possible clinical use pending further studies.
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Affiliation(s)
- Udi Willenz
- The Institute of Animal Research, Kibbutz Lahav, Israel
| | - Nir Wasserberg
- Rabin Medical Center, Petach Tikva, Israel
- Tel Aviv University, Tel Aviv, Israel
| | | | - Ron Greenberg
- Tel Aviv University, Tel Aviv, Israel
- Tel Aviv Medical Center, Tel Aviv, Israel
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146
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Vermeer TA, Orsini RG, Nieuwenhuijzen GAP, Rutten HJT, Daams F. Stoma placement in obstructive rectal cancer prior to neo-adjuvant treatment and definitive surgery: A practical guideline. Eur J Surg Oncol 2015; 42:273-80. [PMID: 26681383 DOI: 10.1016/j.ejso.2015.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/01/2015] [Accepted: 11/09/2015] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Mechanical bowel obstruction in rectal cancer is a common problem, requiring stoma placement to decompress the colon and permit neo-adjuvant treatment. The majority of patients operated on in our hospital are referred; after stoma placement at the referring centre without overseeing final type of surgery. Stoma malpositioning and its effects on rectal cancer care are described. METHODS All patients who underwent surgery for locally advanced or locally recurrent rectal cancer between 2000 and 2013 in our tertiary referral centre were reviewed and included if they received a stoma before curative surgery. Patients with recurrent rectal cancer were only included if the stomas from the primary surgery had been restored. The main outcome measures are stoma malpositioning, postoperative and stoma-related complications. RESULTS A total of 726 patients were included; of these, 156 patients (21%) had a stoma before curative surgery. In the majority of patients, acute or pending large bowel obstruction was the main indication for emergent stoma creation; some of the patients had tumour-related fistulae. In 53 patients (34%), the stoma required revision during definitive surgery. No significant differences were found regarding postoperative complications. CONCLUSION One-third of the previously placed emergency stomas were considered to be located inappropriately and required revision. We were able to avoid increased complication rates in patients with a malpositioned stoma, however unnecessary surgery for an inappropriately placed stoma should be avoided to decrease patient inconvenience and risks. An algorithm is proposed for the placement of a suitable stoma.
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Affiliation(s)
- T A Vermeer
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
| | - R G Orsini
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
| | - G A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
| | - F Daams
- Department of Surgery, VU Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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147
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Buscail E, Blondeau V, Adam JP, Pontallier A, Laurent C, Rullier E, Denost Q. Surgery for rectal cancer after high-dose radiotherapy for prostate cancer: is sphincter preservation relevant? Colorectal Dis 2015; 17:973-9. [PMID: 25824545 DOI: 10.1111/codi.12962] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/23/2015] [Indexed: 12/14/2022]
Abstract
AIM The feasibility and outcome of sphincter-saving resection for rectal cancer were assessed in patients previously treated by high-dose radiotherapy for prostate cancer. METHOD Between 2000 and 2012, 1066 patients underwent rectal excision for rectal cancer. Of these, 236 were treated by conventional radiotherapy (45 Gy) and sphincter-saving resection (Group A) and 12 were treated by external-beam radiotherapy (EBRT) for prostate cancer (70 Gy) and sphincter-saving resection (Group B) of whom five had a metachronous and seven a synchronous cancer. The end-points were surgical morbidity, pelvic sepsis, reoperation and definitive stoma. RESULTS Tumour characteristics were similar in both groups. Surgical morbidity (67% vs 25%, P = 0.004), anastomotic leakage (50% vs 10%, P = 0.001, and reoperation (50% vs 17%, P = 0.011) were significantly higher in Group B. Multivariate analyses showed that EBRT for prostate cancer was the only independent factor for anastomotic leakage (OR = 5.12; 95% CI 1.45-18.08; P = 0.011) and definitive stoma (OR = 10.56; 95% CI 3.02-39.92; P < 0.001). CONCLUSION High-dose radiotherapy for prostate cancer increases morbidity from rectal surgery and the risk of a permanent stoma. This suggests that a delayed coloanal anastomosis or a Hartmann procedure should be proposed as an alternative to low anterior resection in this population.
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Affiliation(s)
- E Buscail
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - V Blondeau
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - J-P Adam
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - A Pontallier
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - C Laurent
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - E Rullier
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
| | - Q Denost
- Department of Digestive Surgery and Université Bordeaux Segalen, CHU Bordeaux, Saint André Hospital, Bordeaux, France
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148
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Snijders HS, Kunneman M, Tollenaar RAEM, Boerma D, Pieterse AH, Wouters MJWM, Stiggelbout AM. Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus. Acta Oncol 2015; 55:509-15. [PMID: 26449339 DOI: 10.3109/0284186x.2015.1091498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVES When deciding about the use of a defunctioning stoma in rectal cancer surgery, benefits and risks need to be weighed. This study investigated: (1a) factors associated with the use of defunctioning stomas; (1b) hospital variation; and (2) surgeons' perceptions regarding factors that determine this decision. METHODS Population-based data from the Dutch Surgical Colorectal Audit were used. Factors for receiving a defunctioning stoma were analyzed with multivariate logistic regression analysis. Hospital variation was assessed before and after case-mix adjustment. A survey was performed among gastroenterological surgeons on the importance of factors for the decision to construct a defunctioning stoma. RESULTS In total 4368 patients were analyzed and 103 (34%) surgeons participated. Male gender, higher body mass index, lower tumors, preoperative radiotherapy, and treatment in a teaching/university hospital increased the odds for a defunctioning stoma. Unadjusted hospital variation ranged from 0% to 98%. Variation remained after case-mix adjustment (0-100%). There was large variation in factors considered important for the decision; almost all factors were ranked as 'most important' at least once. CONCLUSIONS There is large variation in the use of defunctioning stomas for patients with rectal cancer, and a lack in uniformity of the selection criteria. These results underline the need to improve current decision making and identification of high-risk patients.
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Affiliation(s)
- Heleen S. Snijders
- Department of Surgery Leiden, University Medical Center, Leiden, The Netherlands
| | - Marleen Kunneman
- Department of Medical Decision Making Leiden, University Medical Center, Leiden, The Netherlands
| | | | - Djamila Boerma
- Department of Surgery St Antonius Hospital, Nieuwegein, The Netherlands, and
| | - Arwen H. Pieterse
- Department of Medical Decision Making Leiden, University Medical Center, Leiden, The Netherlands
| | - Michel J. W. M. Wouters
- Department of Surgery Leiden, University Medical Center, Leiden, The Netherlands
- Department of Surgery, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Anne M. Stiggelbout
- Department of Medical Decision Making Leiden, University Medical Center, Leiden, The Netherlands
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149
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Räsänen M, Renkonen-Sinisalo L, Carpelan-Holmström M, Lepistö A. Low anterior resection combined with a covering stoma in the treatment of rectal cancer reduces the risk of permanent anastomotic failure. Int J Colorectal Dis 2015; 30:1323-8. [PMID: 26111635 DOI: 10.1007/s00384-015-2291-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The adoption of the total mesorectum excision technique and circular stapler devices has enabled the performance of ultralow colorectal anastomosis in rectal cancer surgery. However, rupture of the anastomosis still usually leads to a permanent stoma. The aim of this study was to analyze the cumulative failure rate and risk factors associated with reversal of colorectal or coloanal anastomosis after sphincter-saving surgery for rectal cancer, using standardized surgical regimen with the routine use of covering stoma. Our secondary interest was the feasibilities of redo surgery after failure. METHODS This was a retrospective study with 579 consecutive rectal cancer patients operated on at Helsinki University Hospital, Helsinki, Finland during 2005-2011. Data were collected from patient records. After exclusions, 273 consecutive patients treated with a low anterior resection with a protective stoma were included. RESULTS In total, 23 out of 271 (8.5 %) of the colorectal/coloanal anastomoses were converted to a permanent stoma. In five patients (1.8 %), the covering stoma was not closed. The permanent stoma rate was thus 28 out of 271 (10.3 %). The risk factors associated with failure were the tumor distance from the anal verge (p = 0.03), coloanal anastomosis (p = 0.003), early anastomotic complication (p < 0.001), anastomotic fistula (p < 0.001), anal incontinence (p = 0.05), and local recurrence (p < 0.001). CONCLUSIONS Our standardized surgical regimen with a covering stoma in low anterior resection for rectal cancer resulted in a minor anastomosis failure rate and a low risk of permanent stoma.
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Affiliation(s)
- Minna Räsänen
- Colorectal Surgery, Abdominal Center, Helsinki University Hospital, Kasarmikatu 11-13, Pl 263, 00029, Helsinki, Finland. .,University of Helsinki, Helsinki, Finland.
| | - Laura Renkonen-Sinisalo
- Colorectal Surgery, Abdominal Center, Helsinki University Hospital, Kasarmikatu 11-13, Pl 263, 00029, Helsinki, Finland. .,Research Programs Unit, Genome-Scale Biology, University of Helsinki, Helsinki, Finland.
| | - Monika Carpelan-Holmström
- Colorectal Surgery, Abdominal Center, Helsinki University Hospital, Kasarmikatu 11-13, Pl 263, 00029, Helsinki, Finland.
| | - Anna Lepistö
- Colorectal Surgery, Abdominal Center, Helsinki University Hospital, Kasarmikatu 11-13, Pl 263, 00029, Helsinki, Finland.
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150
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Seo SI, Lee JL, Park SH, Ha HK, Kim JC. Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery. Ann Coloproctol 2015; 31:131-7. [PMID: 26361614 PMCID: PMC4564664 DOI: 10.3393/ac.2015.31.4.131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/04/2015] [Indexed: 12/19/2022] Open
Abstract
Purpose This study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR). Methods Between January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine. Results Of the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis. Conclusion WCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.
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Affiliation(s)
- Seok In Seo
- Department of Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Jong Lyul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Ho Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Kwon Ha
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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