Postoperative complications following surgery for rectal cancer. Ann Surg. 2010;251:807-818. [PMID: 20395841 DOI: 10.1097/sla.0b013e3181dae4ed]

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Cumulative incidence of permanent stoma after sphincter preserving low anterior resection of mid and low rectal cancer

BACKGROUND

Changes in the treatment of rectal cancer during the past decades have led to an increase in sphincter preservation with a consecutive decline in abdominoperineal resection rates.

OBJECTIVE

The aim of this study was to analyze the cumulative incidence of permanent stoma in patients undergoing sphincter-preserving resection of mid and low rectal cancer.

DESIGN

This study is a retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a tertiary referral cancer hospital.

PATIENTS

From 2003 to 2010, 125 patients with primary mid and low rectal cancer who underwent sphincter-preserving low anterior resection were included.

MAIN OUTCOME MEASURES

The occurrence of a permanent stoma over time was investigated by using a Cox proportional hazards regression model and competing-risk models, with death as a competing risk. The risk factors were assessed by computing HRs and a Cox proportional hazards regression.

RESULTS

After a median follow-up time of 61 months (range, 22-113), 15 of 125 patients ended up with a permanent stoma, accounting for a 5-year cumulative incidence of 6% (95% CI, 4%-11%). The reasons for obtaining a permanent stoma were anastomotic leakage (60%, 9/15), intractable fecal incontinence (27%, 4/15), and local recurrence (13%, 2/15). The Cox proportional hazards regression identified anastomotic leakage (HR, 6.10; 95% CI, 2.23-16.71; p = 0.0004) and coloanal anastomosis (HR, 4.31; 95% CI, 1.49-12.47; p = 0.007) as statistically significant risk factors.

LIMITATIONS

Because of the small number of events in this sample, further investigations with a larger number of patients are required. Fecal incontinence was assessed by patient self-reported data without the use of a validated score.

CONCLUSION

The 5-year cumulative incidence of a permanent stoma was 6%. Anastomotic leakage and coloanal anastomosis were identified as risk factors. These details should be considered before sphincter-preserving surgery.

Do we really know why colorectal anastomoses leak?

INTRODUCTION

Colorectal anastomotic leak, a feared complication, results in significantly increased patient morbidity, mortality, and hospital resource utilization. The overall incidence of colorectal anastomotic leak is approximately 11% with increasing rate the closer the anastomosis is to the anal verge. Because surgeons are unable to reliably predict which anastomosis would fail, most will construct a diverting ileostomy for low colorectal anastomosis to circumvent the devastating complications of anastomotic failure. Despite extensive investigations on technical considerations of anastomosis construction, anastomotic leaks continue to occur at an unacceptably high rate.

DISCUSSION

In this review, we examine the major known risk factors and technical considerations that have been implicated as factors in leakage. Although surgical technique has evolved over the past several decades with the advent of newer surgical staplers, laparoscopy, and robotics, we have not witnessed a decrease in the incidence of colorectal anastomotic leaks suggesting that the fundamental pathogenesis of anastomotic leak remains unknown. Among the factors contributing to anastomotic healing, intestinal bacteria remains largely overlooked even though compelling evidence exist that intraluminal microbes could play a major role in pathogenesis of anastomotic leak. Further investigation focusing on intestinal microbes could be one such avenue for uncovering the elusive cause of colorectal anastomotic leak.

Non-operative management for locally advanced rectal cancer: critical review and future perspective

SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.

Short-term outcome after neoadjuvant high-dose-rate endorectal brachytherapy or short-course external beam radiotherapy in resectable rectal cancer

AIM

Total mesorectal excision with preoperative radiotherapy reduces local recurrence in rectal cancer, but radiotherapy increases the risk of complications. This study compared the immediate postoperative outcome after external beam radiotherapy with outome after high-dose-rate endorectal brachytherapy (HDREBT).

METHOD

Patients (n = 318) treated with preoperative HDREBT (6.5 Gy, daily, over 4 days) followed by surgery 4-8 weeks later were matched with 318 patients from the Swedish Rectal Cancer Register treated with short-course radiotherapy (SCRT; 5 Gy, daily, over 5 days) and surgery in the subsequent week and with 318 patients who had surgery only (i.e. no preoperative radiotherapy; RT-) All 954 patients were followed for 30 days after surgery. Complications were divided into surgical, cardiovascular and infectious.

RESULTS

The SCRT group had fewer cardiovascular complications (3.1%) than did HDREBT (9.4%, P = 0.002) and RT- (7.2%, P = 0.03) groups. There was less perioperative bleeding in HDREBT patients (379.3 ml) than in SCRT (947.2 ml; P < 0.0001) or RT- (918.9 ml) patients, and the re-intervention rate was lower in HDREBT (4.1%) patients than in SCRT (14.2%; P = 0.005) and RT- (12.3%; P < 0.005) patients. The HDREBT group had fewer R2 resections than did the SCRT and RT- groups, but had a higher proportion of R0 resections compared with the RT- group (P = 0.03).

CONCLUSION

No major differences in postoperative complications were found. HDREBT patients had a higher rate of cardiovascular complications, but less perioperative bleeding and fewer re-interventions. A longer interval between radiotherapy and surgery may be beneficial for tumour regression and this could be reflected in the number of radical resections.

Multivisceral resection in colorectal cancer: a systematic review

BACKGROUND

The objective of this study was to critically evaluate current literature on outcomes following multivisceral resection (MVR) in colorectal cancer (CRC). Adequate surgical resection with clear margins is imperative in achieving long-term survival in colorectal cancer. Where there is adherence to or invasion of adjacent organs, (MVR) may be needed to achieve complete disease clearance.

METHODS

A systematic review of MVR in CRC was performed. Pubmed/Medline and Cochrane databases were searched for English language articles from 1995 to 2012 using a predefined strategy. Retrieved abstracts were independently screened for relevance and data extracted from selected studies by 2 researchers. Results are reported as weighted means.

RESULTS

Included were 22 studies comprising 1575 patients (87.0% primary colorectal cancer; 13.0% recurrent, 63.8% rectal; 36.2% colon). The most common organs resected were the bladder and reproductive organs. The perioperative mortality was 4.2% with morbidity of 41.5% (95% CI, 40.8-42.2%). The overall 5-year survival rate was 50.3% (95% CI, 49.9-50.8%). Surgery for recurrence was associated with worse outcomes than primary tumors with 5-year survival 19.5% (95% CI, 17.8-21.1%) for recurrent rectal cancer and primary rectal tumors 5-year overall survival 52.8% (95% CI, 52.0-53.8%). R0 resection was the strongest factor associated with long-term survival.

CONCLUSIONS

Multivisceral resection provides the best possibility of long-term survival in locally advanced primary colorectal cancer in which a clear margin has been achieved.

Late anastomotic leakage in colorectal surgery: a significant problem

AIM

Reported incidence rates of colorectal anastomotic leakage (AL) vary between 2.5 and 20%. There is little information on late anastomotic leakage (LAL). The aim of this study was to determine the incidence of LAL after colorectal resection.

METHOD

All patients undergoing colorectal resection with primary anastomosis between January 2004 and October 2009 at the University Medical Center Groningen were included. LAL was defined as anastomotic leakage diagnosed more than 30 days after surgery.

RESULTS

One hundred and forty-one patients were analysed. Indications for surgery included both benign and malignant conditions. The incidence of early anastomotic leakage (EAL) within 30 days after surgery was 13%. The LAL rate was 6%. Eighty-nine per cent of patients with EAL underwent relaparotomy compared with 44% for LAL (P = 0.02).

CONCLUSION

One-third of all anastomotic leakages were diagnosed more than 30 days after surgery. Of these, 44% underwent relaparotomy. Patients with leakage diagnosed within 30 days after surgery were more likely to undergo relaparotomy. LAL is a significant problem after colorectal surgery.

Abdominoperineal resection and low anterior resection: comparison of long-term oncologic outcome in matched patients with lower rectal cancer

PURPOSE

The current study aimed to compare the oncologic outcome and pattern of metastasis after abdominoperineal resection (APR) and low anterior resection (LAR) treating lower rectal cancer.

METHODS

A total of 804 patients undergoing curative resection (R0) were enrolled prospectively. The APR and LAR groups (n = 402, respectively) were matched for gender, age, and stage, for a retrospectively comparative analysis.

RESULTS

In a multivariate analysis with potential variables, APR itself was not a risk factor for increased local recurrence (LR) or reduced survival (P = 0.243-0.994). Circumferential resection margin (CRM) involvement as an operation-related risk was 1.6-fold more frequent in the APR group and was significantly associated with LR and systemic recurrence (OR, 2.487-4.017; P < 0.01). Circumferential margin positivity (CRM+) was concurrently correlated with advanced stage, larger tumor (long diameter, >4 cm), and longer sagittal midpelvic diameter (>10 cm) in a multivariate analysis (P < 0.001-0.05). The site of metastasis did not differ between the two groups, with the exception of lung metastasis which was more frequent in the APR group (APR vs. LAR: 15.9 vs. 10 %, P = 0.015). In the APR group, CRM+ and the presence of an infiltrating tumor were correlated with disease-free survival (hazard ratio (HR), 1.644 and 1.654, respectively), whereas elevated serum carcinoembryonic antigen and LVI+ were correlated with overall survival (HR, 1.57 and 1.671, respectively), in a multivariate analysis with potential variables (P < 0.05).

CONCLUSIONS

When performed with appropriate skill to achieve R0 resection, APR can be used safely without impairing oncological outcome, although sphincter-preserving surgery should remain the preferred option.

The association of hospital volume with rectal cancer surgery outcomes

PURPOSE

An association between hospital volume and postoperative mortality has been identified for several oncologic surgical procedures. Our objective was to analyze differences in surgical outcomes for patients with rectal cancer according to hospital volume in the state of California.

METHODS

A cross-sectional study from 2000 to 2005 was performed using the state of California Office of Statewide Health Planning and Development database. Hospitals were categorized into low (≤30)-, medium (31-60)-, and high (>60)-volume groups based on the total number of rectal cancer operations performed during the study period.

RESULTS

Overall, 7,187 rectal cancer operations were performed. Of the 321 hospitals in the study cohort, 72 % (n = 232), 20 % (n = 65), and 8 % (n = 24) were low-, medium-, and high-volume hospitals, respectively. Postoperative mortality was significantly lower- in high-volume hospitals (0.9 %) when compared to medium- (1.1 %) and low-volume hospitals (2.1 %; p < 0.001). High-volume hospitals also performed more sphincter-preserving procedures (64 %) when compared to medium- (55 %) and low-volume hospitals (51 %; p < 0.001).

CONCLUSIONS

These data indicate that hospital volume correlates with improved outcomes in rectal cancer surgery. Rectal cancer patients may benefit from lower mortality and increased sphincter preservation in higher-volume centers.

Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.

Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile?

BACKGROUND

There is no consensus in the literature as to whether all patients who undergo anterior resection of the rectum with total mesorectal excision should have a defunctioning stoma or only those at high risk of anastomotic dehiscence.

OBJECTIVE

The aim of this retrospective study was to evaluate the results of placing a removable Silastic band around the ileum during the abdominal phase to exteriorize it and create a loop ileostomy postoperatively without the need for laparotomy in case of an anastomotic complication. This approach is known as "ghost ileostomy."

INTERVENTIONS

A vascular loop was passed around the terminal ileum through a window adjacent to the ileal wall. The loop was then exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. Two 24F Silastic drains were placed next to the anastomosis (anteriorly and posteriorly).

PATIENTS

From May 1997 to May 2011, 168 patients underwent anterior resection of the rectum with total mesorectal excision plus ghost ileostomy.

RESULTS

Symptomatic anastomotic dehiscence was observed in 20 of 168 patients (11.96%) and developed on postoperative days 4 to 12 (median, postoperative day 7). In 13 of 20 cases, an ileostomy was fashioned with the patient under local anesthesia, and there was no need for relaparotomy. In 5 of 20 cases, the complication resolved with conservative management. In 2 of 20 cases, the patient's clinical condition rapidly deteriorated, generalized peritonitis developed, and surgical reintervention with abdominal toilette and colostomy was required.

CONCLUSIONS

Ghost ileostomy allows selective loop ileostomy formation after low anterior resection of the rectum without the need for laparotomy in most cases. However, the technique should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neoadjuvant therapy. The role of routine ghost ileostomy following higher-risk anastomoses remains to be determined.

Thirty-seven patients treated with the C-seal: protection of stapled colorectal anastomoses with a biodegradable sheath

PURPOSE

The present study was performed to get a better insight in the incidence of anastomotic leakage leading to reintervention when using the C-seal: a biodegradable sheath that protects the stapled colorectal anastomosis from leakage.

METHODS

The C-seal is a thin walled tube-like sheath that forms a protective sheath within the bowel lumen. Thirty-seven patients undergoing surgery with creation of a stapled colorectal anastomosis with C-seal were analyzed. Follow-up was completed until 3 months after surgery.

RESULTS

One patient (3%) developed anastomotic leakage leading to reintervention. None of the 37 anastomoses was dismantled. One patient was diagnosed with a rectovaginal fistula. In three patients (8%), a perianastomotic abscess spontaneously drained.

CONCLUSION

The incidence of anastomotic leakage leading to reintervention when using the C-seal (3%) is lower than expected based on the literature (11%). We have currently set-up a multicenter randomized trial to confirm the efficiency of the C-seal (www.csealtrial.nl).

Treatment of colorectal cancer in older patients

Colorectal cancer (CRC) largely affects older individuals; almost half of cases occur in patients >75 years old. The incidence increases with advancing age, doubling every 7 years in patients aged ≥50 years. The medical and societal burdens of CRC will probably worsen over the coming decades as the number of older individuals (>70) continues to grow. No evidence-based guidelines are available for this age group, as older patients with CRC are generally excluded from randomized clinical trials and the fit ones who are recruited are not representative of the general elderly population. When feasible, surgery is the most successful treatment option for eradicating the primary lesion, as well as any metastases. The operative risk under elective conditions is not markedly different in older than in younger patients; however, the acute setting is to be avoided as it is associated with high operative death rates. Well-selected older patients can tolerate chemotherapy, but benefits need to be balanced against potentially limited life expectancy and reduced quality of life. The use of combination chemotherapy is an area of much controversy, but this treatment should not necessarily be withheld because of the age of the patient. Careful monitoring of toxicities and early intervention is essential in older patients undergoing chemotherapy.

Anastomotic leak after restorative proctosigmoidectomy for cancer: what are the chances of a permanent ostomy?

OBJECTIVE

The objective of this study is to identify rates and factors associated with permanent diversion following restorative proctosigmoidectomy for rectal cancer when complicated by an anastomotic leak.

DESIGN

This study is a retrospective review.

SETTING

The setting of this study is a tertiary referral hospital

PATIENTS

Patients involved in this study were those who underwent restorative rectal cancer surgery from 1997 through 2008 identified from an institutional cancer database.

INTERVENTIONS

No interventions were performed in this study.

MAIN OUTCOME MEASURES

Factors associated with time to ostomy closure and rates of permanent diversion following anastomotic leaks

RESULTS

One hundred and thirty patients (mean age 59.7 years) were identified, 111 (85%) of whom had stoma diversion at the index surgery. Asymptomatic occult radiological leaks occurred in 52 patients (40%). Seventy-eight patients (60%) underwent ultimate ostomy closure at a median time of 6.3 months after the index surgery, which was not significantly affected by previous radiotherapy (p = 0.08). Twelve patients (9%) underwent anastomotic reconstruction. Pathologic stage II or greater (OR 4.42; 1.95-10.04), symptomatic presentation (OR 4.13; 1.86-9.19) and anastomotic disruption >5 mm (OR 4.42; 2.01-9.74) were independently associated with permanent diversion. Among all survivors, 33% did not have their ostomy reversed. Stoma diversion constructed after leak detection in 19 patients (15%) did not affect permanent stoma rate (OR 0.86; 0.31-2.34) or time to stoma closure (p = 0.29).

CONCLUSIONS

The majority of anastomotic leaks after restorative rectal cancer surgery can be salvaged without anastomotic reconstruction. However, in one third of the patients, an anastomotic leak results in a permanent stoma.

Neoadjuvant chemoradiation followed by interstitial prostate brachytherapy for synchronous prostate and rectal cancer

PURPOSE

To describe outcomes with the use of neoadjuvant pelvic chemoradiation followed by prostate interstitial brachytherapy for the treatment of synchronous prostate and rectal cancers.

METHODS AND MATERIALS

An Internal Review Board approved retrospective review was undertaken of 4 patients with synchronous prostate and rectal cancer treated between 2006 and 2008. Patients underwent pelvic chemoradiation followed by prostate brachytherapy, then low anterior resection of the rectum with diverting loop ileostomy and adjuvant chemotherapy. Follow-up evaluation included imaging and laboratory analysis of cancer markers in addition to routine interval history and physical examination.

RESULTS

At 38-62 months postdiagnosis (24-53 months post-treatment), 6 of 8 cancers remained without evidence of relapse. One patient had rising carcinoembryonic antigen levels but no clinically evident rectal cancer relapse; another developed bony metastasis of his high-risk prostate cancer. Three patients experienced grade 1-2 treatment-related toxicity; one patient had grade 3 gastrointestinal toxicity from radiation and surgery, which precluded his receiving adjuvant chemotherapy and ileostomy reversal.

CONCLUSIONS

Chemoradiation followed by prostate brachytherapy, surgery, and adjuvant chemotherapy may be utilized to manage patients with synchronous prostate and rectal cancers.

Risk factor analysis of postoperative complications after robotic rectal cancer surgery

BACKGROUND

The robotic system has been adopted as the new modality for minimally invasive surgery for rectal cancer. However, analysis of risk factors for complications after robotic rectal cancer surgery (RRS) has been limited. This study aimed to identify the risk factors for complications after RRS.

METHODS

The records of 389 consecutive patients who underwent RRS between June 2006 and October 2010 were retrieved from our prospectively collected database.

RESULTS

The overall complication rate was 19%. The most common complication was anastomotic leakage (7.0%), followed by voiding difficulty, intrapelvic abscess, and ileus/obstruction. Multivariate analysis revealed the following as risk factors for postoperative complications: male gender, history of previous abdominal surgery, and lower tumor level (hazard ratio [HR] = 1.8, 95% confidence interval [CI] = 1.0-3.1, p = 0.041; HR = 2.3; 95% CI = 1.2-4.6, p = 0.012; and HR = 1.9, 95% CI = 1.1-3.3, p = 0.020, respectively). With regard to pelvic septic complications, lower tumor level, large tumor size, and preoperative chemoradiation remained variables that retained their statistical significance in multivariate analysis (HR = 2.6, 95% CI = 1.1-6.1, p = 0.029; HR = 2.7, 95% CI = 1.1-6.1, p = 0.017; HR = 2.9, 95% CI = 1.3-6.5, p = 0.007, respectively). The rate of postoperative complications was not influenced by the difference in laparoscopic surgery experience or the technique of robotic surgery.

CONCLUSION

Surgeons should be more cautious with these patient factors to optimize the benefits of robotic rectal resection.

Critical appraisal of the 'wait and see' approach in rectal cancer for clinical complete responders after chemoradiation

BACKGROUND

Some 10-20 per cent of patients with locally advanced rectal cancer achieve a pathological complete response (pCR) at surgery following preoperative chemoradiation (CRT). Some demonstrate a sustained clinical complete response (cCR), defined as absence of clinically detectable residual tumour after CRT, and do not undergo resection. The aim of this review was to evaluate non-operative treatment of rectal cancer after CRT, and the outcome of patients observed without radical surgery.

METHODS

A systematic computerized search identified 30 publications (9 series, 650 patients) evaluating a non-operative approach after CRT. Original data were extracted and tabulated, and study quality evaluated. The primary outcome measure was cCR. Secondary outcome measures included locoregional failure rate, disease-free survival and overall survival.

RESULTS

The most recent Habr-Gama series reported a low locoregional failure rate of 4·6 per cent, with 5-year overall and disease-free survival rates of 96 and 72 per cent respectively. These findings were supported by a small prospective Dutch study. However, other retrospective series have described higher recurrence rates. All studies were heterogeneous in staging, inclusion criteria, study design and rigour of follow-up after CRT, which might explain the different outcomes. The definition of cCR was inconsistent, with only partial concordance with pCR. The results suggested that patients who are observed, but subsequently fail to sustain a cCR, may fare worse than those who undergo immediate tumour resection.

CONCLUSION

The rationale of a 'wait and see' policy relies mainly on retrospective observations from a single series. Proof of principle in small low rectal cancers, where clinical assessment is easy, should not be extrapolated uncritically to more advanced cancers where nodal involvement is common. Long-term prospective observational studies with more uniform inclusion criteria are required to evaluate the risk versus benefit.

Locally advanced mid/low rectal cancer with synchronous liver metastases

BACKGROUND

Management of patients with T3/4 and/or N+ mid/low rectal cancer with synchronous liver metastases is not codified. The aim of this study was to analyze outcomes of our approach which consists of neoadjuvant chemotherapy or chemoradiotherapy, according to liver disease extension, followed by simultaneous rectal and liver resection.

METHODS

Between 2000 and 2009, 354 patients underwent hepatectomy for synchronous metastases. Thirty-six consecutive patients who underwent rectal and liver resection for metastatic T3/4 and/or N+ mid/low rectal cancer were analyzed.

RESULTS

Liver metastases were multiple in 27 patients, bilobar in 22, and >5 cm in six. Up-front treatment was chemotherapy in 15 patients, chemoradiotherapy in seven, chemotherapy followed by chemoradiotherapy in six, and surgery in eight (five symptomatic tumors). After chemotherapy alone (median number of cycles = 6), primary tumor response was observed in 11 patients (three complete responses). After chemoradiotherapy, only one patient had liver disease progression. Eighty-nine percent of patients underwent simultaneous rectal and hepatic resection. Mortality and morbidity rates were 2.8% (one pulmonary embolism) and 36%, respectively. After a mean follow-up of 39 months, 5-year overall and disease-free survival were 59.3 and 39.6%, respectively. Twenty-one patients had recurrence, including three pelvic recurrences (8.3%). No pelvic recurrence occurred among patients who correctly completed treatment strategy. All patients who received neoadjuvant chemoradiotherapy were alive and disease-free; 5-year overall and disease-free survival of patients receiving neoadjuvant chemotherapy were 59.3 and 25%, respectively.

CONCLUSIONS

For patients with metastatic T3/4 and/or N+ mid/low rectal cancer, the present strategy was safe and effective. Good disease control was achieved by neoadjuvant treatments, low morbidity rates were associated with simultaneous resection, and excellent long-term outcomes with low local relapse rate were obtained.

Risk factors for excess mortality in the first year after curative surgery for colorectal cancer

Background

Thirty-day mortality after surgery for colorectal cancer may vastly underestimate 1-year mortality. This study aimed to quantify the excess mortality in the first postoperative year of stage I–III colorectal cancer patients and to identify risk factors for excess mortality.

Methods

All 2,131 patients who were operated with curative intent for stage I–III colorectal cancer in the western region of the Netherlands between January 1, 2006, and December 31, 2008, were analyzed. Thirty-day mortality and relative survival were calculated. In addition, relative excess risk (RER) of death was estimated by a multivariable model.

Results

Thirty-day mortality was 4.9%. One-year mortality was 12.4%. Risk factors for excess mortality in the first postoperative year for colon cancer patients were emergency surgery (excess mortality 29.7%, RER 2.5, 95% confidence interval 2.5–5.0), a Charlson score of >1 (excess mortality 12.6%, RER 2.3, 95% confidence interval 1.5–3.7), stage II or III disease (excess mortality 14.9%, RER 3.9, 95% confidence interval 1.9–8.1), and postoperative adverse events (excess mortality 22.6%, RER 2.1, 95% confidence interval 1.4–3.2).

Conclusions

The 30-day mortality rate highly underestimates the risk of dying in the first year after surgery, with excess 1-year mortality rates varying from 15 to 30%. This excess mortality was especially prominent in patients with comorbidities, higher stages of disease, emergency surgery, and postoperative surgical complications.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-012-2294-6) contains supplementary material, which is available to authorized users.

Postoperative adjuvant chemotherapy for stage II colorectal cancer: a systematic review of 12 randomized controlled trials

BACKGROUND

The impact of postoperative adjuvant chemotherapy on the oncological outcomes for stage II colorectal cancer remains controversial.

METHODS

The literature was searched for studies published between 1985 and 2010 in which patients with stage II colorectal cancer were randomly assigned to receive either surgery combined with postoperative adjuvant chemotherapy or surgery alone. End points included 5-year overall survival, 5-year disease-free survival, recurrence, and mortality.

RESULTS

A significant improvement in 5-year overall survival was associated with surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.81; 95% confidence interval (CI), 0.71-0.91) and for stage II rectal cancer (hazard ratio, 0.72; 95% CI, 0.61-0.86). The 5-year disease-free survival also favored the group of surgery combined with postoperative adjuvant chemotherapy for stage II colon cancer (hazard ratio, 0.86; 95% CI, 0.75-0.98) and for stage II rectal cancer (hazard ratio, 0.34; 95% CI, 0.22-0.51). For stage II colon cancer, a significant reduction in risk of recurrence was found in favor of postoperative adjuvant chemotherapy (risk ratio, 0.82; 95% CI, 0.71-0.95).

CONCLUSIONS

Postoperative adjuvant chemotherapy for stage II colorectal cancer appears to be associated with improved 5-year overall survival and 5-year disease-free survival, and reduction in risk of recurrence.

Risk factors for surgical site infection after elective resection for rectal cancer. A multivariate analysis on 2131 patients

AIM

Surgical site infection (SSI) is the most common cause of morbidity after colorectal surgery. The aim of this study was to analyze risk factors for SSI in patients who had undergone surgery for rectal cancer.

METHOD

A multicentre observational study was carried out on 2131 patients operated on for rectal cancer between May 2006 and May 2009. Twenty-nine centres were involved. SSI included wound infection and organ space infection within 30 days after the operation. Univariate and multivariate analyses were carried out to study possible risk factors for SSI.

RESULTS

Wound infection and organ space infection were diagnosed in 8.9% and 10%, respectively, of patients. The anastomotic leakage rate was 8%. Multivariate analysis showed that wound infection was related to tumour stage, a converted laparoscopic procedure and open surgery. Organ space infection was related to Stage IV tumour, a tumour < 11 cm from the anal verge, low anterior resection and Hartmann's procedure.

CONCLUSION

Rectal surgery for malignant disease is associated with a considerable rate of SSI. Wound infection and organ space infection are related to different factors and therefore should be evaluated separately.

Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.

Risk factors of early postoperative small bowel obstruction following a proctectomy for rectal cancer

Purpose

Postoperative small bowel obstruction is a common and serious complication following a proctectomy, and early postoperative small bowel obstruction (EPSBO) leads to longer hospital stays, delays chemotherapy in advanced cases, and may be a contributor to mortality. The goal of this study is to identify the risk factors of EPSBO after a proctectomy for rectal cancer, thereby seeking to reduce the incidence of EPSBO.

Methods

Patients (735) who underwent a proctectomy for rectal cancer between March 2005 and February 2010 were entered into this study, and data were collected prospectively. Patients were judged to have EPSBO if, within the first 30 days, they presented symptoms such as nausea, vomiting and abdominal distention lasting for 2 days, and radiologic finding of small bowel obstruction after evidence of return of small bowel motility. The association between EPSBO and patients and surgery-related variables were studied by using univariate and multivariate analyses.

Results

EPSBO developed in 47 cases (6.4%) and was the most frequently occurring complication in the early perioperative period following a proctectomy. The frequency of EPSBO according to operative variables shows that EPSBO developed in 3.0% of the patients who underwent laparoscopic surgery (LS) compared with 8.4% of the patients who underwent open surgery (OS) (P = 0.004). OS (odds ratio [OR], 2.5) and a previous laparotomy (OR, 2.3) were independent risk factors for the development of EPSBO after a proctectomy for rectal cancer.

Conclusion

EPSBO is more likely to occur in patients who undergo OS or who have had a previous laparotomy. LS may be considered as a surgical procedure that can reduce the risk of EPSBO in patients undergoing a proctectomy for rectal cancer.

Laparoscopic surgery for rectal cancer: a single-centre experience of 120 cases

INTRODUCTION

For colorectal surgeons, laparoscopic rectal cancer surgery poses a new challenge. The defence of the questionable oncological safety tempered by the impracticality of the long learning curve is rapidly fading. As a unit specialising in minimally invasive surgery, we have routinely undertaken rectal cancer surgery laparoscopically since 2005.

METHODS

Patients undergoing surgery for rectal cancer between June 2005 and February 2010 were retrospectively reviewed from a prospectively maintained colorectal cancer database.

RESULTS

One hundred and thirty patients underwent surgery for rectal cancer during the study period. One hundred and twenty patients had a laparoscopic resection, six were converted to open (conversion rate 5%) and 10 had a planned primary open procedure. Fifty four were low rectal tumours and 76 were upper rectal tumours. One hundred and thirteen patients had an anterior resection (87%), 17 patients an abdomino-perineal resection (13%) and 62 of the 130 patients (47.6%) had neoadjuvant radiotherapy. The median lymph node retrieval rate was 12 (9-14), five patients (3.8%) had a positive circumferential margin and the clinical anastomotic leak rate was 3.8% (n = 5 patients). There was no significant difference in the stated parameters for neoadjuvant versus non-neoadjuvant patients and for upper versus lower rectal tumours. Ninety three percent of mesorectal excision specimens were complete on pathological assessment.

CONCLUSIONS

During the study period, 92% of rectal cancers underwent a laparoscopic resection with low rates of morbidity and acceptable short-term oncological outcomes. This data supports the view that laparoscopic surgery for rectal cancer can be safely delivered in mid-volume centres by surgeons who have completed the learning curve for laparoscopic colorectal surgery.

Evaluation of modified estimation of physiologic ability and surgical stress in colorectal carcinoma surgery

BACKGROUND

We recently modified Estimation of Physiologic Ability and Surgical Stress, our prediction scoring system.

OBJECTIVE

This study evaluated the usefulness of our modified version for colorectal carcinoma in comparison with existing models.

DESIGN

This investigation studied a multicenter cohort.

SETTINGS

The study was conducted in regional referral hospitals in Japan.

PATIENTS

Patients were included who underwent elective surgery for colorectal carcinoma.

MAIN OUTCOME MEASURES

Postoperative morbidity, mortality, and predicted mortality rates for original and modified Estimation of Physiologic Ability and Surgical Stress were investigated in 2388 patients in comparison with existing European models.

RESULTS

Among the models, the modified Estimation of Physiologic Ability and Surgical Stress demonstrated the highest discriminatory power in terms of in-hospital mortality (area under receiver operating characteristic curve: 0.84 for Estimation of Physiologic Ability and Surgical Stress, 0.87 for modified Estimation of Physiologic Ability and Surgical Stress, 0.84 for Portsmouth modification of POSSUM, 0.74 for ASA status-based model), as well as 30-day mortality (area under receiver operating characteristic curve: 0.82 for Estimation of Physiologic Ability and Surgical Stress, 0.84 for modified Estimation of Physiologic Ability and Surgical Stress, 0.81 for POSSUM, 0.78 for colorectal POSSUM, 0.76 for Association of Coloproctology of Great Britain and Ireland score). British models, in general, overpredicted postoperative mortality rates by more than 10 times.

LIMITATIONS

The current study analyzed only the Japanese population treated in medium-volume centers.

CONCLUSIONS

Among the models, modified Estimation of Physiologic Ability and Surgical Stress was the most accurate in predicting postoperative mortality in colorectal carcinoma surgery. These findings should be validated in Western populations, because the Japanese population may differ from Western populations in terms of body shape or reserve capacity.

Synchronous rectal and hepatic resection of rectal metastatic disease

BACKGROUND

The objectives were to determine the feasibility of combined rectal and hepatic resections and analyze the disease-free survival and overall survival.

STUDY DESIGN

Sixty patients who underwent resection for metastatic rectal disease from 1991 to 2005 at Mayo Clinic were reviewed. Inclusion criteria were: rectal cancer with metastatic liver disease and resectability of metastases. The exclusion criteria were: metachronous resection (n = 15). Kaplan-Meier Survival estimated overall survival (OS) and disease-free survival (DFS). Cox proportional hazard models examined the association between groups and survival.

RESULTS

The cohort comprised 22 men and 23 women, with median age of 63 years. Surgical management included: abdominoperineal resection, 13 patients (29%); low anterior resection, 29 (64%); local excision, one; total proctocolectomy, one; and pelvic exenteration, one. Major hepatic resection was performed in 22%. There was no mortality, but there were 26 postoperative complications. Disease-free survival from local recurrence at 1, 2, and 5 years was 92%, 86%, and 80%, respectively. Disease-free survival from distant recurrence at 1, 2, and 5 years was 62%, 43%, and 28%, respectively. Overall survival at 1, 2 and 5 years was 88%, 72%, and 32%, respectively.

CONCLUSIONS

Combined rectal and hepatic resection is safe. Morbidity and mortality do not preclude concurrent resection. The DFS and OS are comparable to that of patients undergoing a staged procedure.

Ghost Ileostomy with or without abdominal parietal split

Background

In patients who undergo low anterior rectal resection, the fashioning of a covering stoma (CS) is still controversial. In fact, a covering stoma (ileostomy or colostomy) is worsened by major complications related to the procedure, longer recovery time, necessity of a re-intervention under general anesthesia for stoma closure and poorer quality of life. The advantage of Ghost Ileostomy (GI) is that an ileostomy can be performed only when there is clinical evidence of anastomotic leakage, without performing further interventions with related complications when anastomotic leak is absent and therefore the procedure is not necessary. Moreover, in case of anastomotic dehiscence and necessity of delayed stoma opening, mortality and morbidity in patients with GI are comparable with the ones that occur in patients which had a classic covering stoma. On the other hand, is simple to think about the possible economic saving: avoiding an admission for performing the closure of the ileostomy, with all the costs connected (OR, hospitalization, post-operative period, treatment of possible complications) represents a huge saving for the hospital management and also raise the quality of life of the patients.

Methods

In this study we prospectively analyzed 20 patients who underwent anterior extra-peritoneal rectum resection for rectal carcinoma with TME and fashioning of GI realized with or without abdominal parietal split.

Results

In the group of patients that received a GI without split laparotomy mortality was absent and in one case an anastomotic leak occurred. In the group of patients in which GI with split laparotomy was fashioned, one death occurred and there were one case of infection and one respiratory complication. Clinical follow-up was 12 months.

Conclusions

The use of different techniques for fashioning a GI do not present significant differences when they are performed by expert surgeons, but further evidence is needed with more randomized trials, in order to have more data supporting the clinical observation.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Safe anastomosis in laparoscopic low anterior resection for rectal cancer

INTRODUCTION

In laparoscopic rectal surgery, there are some limitations on a surgeon's ability to maneuver, especially in transection of the lower rectum. To achieve minimally invasive surgery, safe anastomosis, including proper rectal transaction, is necessary.

METHODS

To overcome the difficulty in lower rectal resection, we followed a series of steps. First, we completely mobilized the rectum to the pelvic bottom, just above the anal canal, making the lower rectum mobile and allowing for an easy rectal transection. To secure the transaction, the mesorectum around the transection must be properly divided. We recommend placing the lower right quadrant port as caudal as possible to properly staple the rectum. We found a 60 mm compression-type stapler most suitable for rectal transection. To wash and flatten the rectum, a detachable intestinal clip is quite useful because of its flexibility. Finally, in addition to conventional abdominal drains around the anastomotic site, we employed transanal tube to actively decompress rectal pressure inside the anastomotic site.

RESULTS

Between August 2009 and July 2010, 101 patients underwent laparoscopic low anterior resection using this technique. Most patients, 98.0% (99/101), underwent lower rectum transection using a single-fire cartridge. The anastomotic leakage rate was only 1.0% (1/101) in total and 1.3% (1/78), when not including patients with diverting stoma.

CONCLUSION

We have to follow up with more patients to conclude whether our technique is effective in the long term. However, this step-by-step technique could lead to safe anastomosis in laparoscopic low anterior resection for rectal cancer.

Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience

PURPOSE

The aim of this study was to describe and evaluate the feasibility and the eventual advantages of ghost ileostomy (GI) versus covering stoma (CS) in terms of complications, hospital stay and quality of life of patients and their caregivers after anterior resection for rectal cancer.

METHODS

In this prospective study, we included patients who had rectal cancer treated with laparotomic anterior resection and confectioning a stoma (GI or CS), in the period comprised between January 2008 and January 2009. Short-term and long-term surgery-related mortality and morbidity after primary surgery (including that stoma-related and colorectal anastomosis-related) and consequent to the intervention of intestinal recanalization (CS group) and GI closure were evaluated. We evaluated hospital stay and quality of life of patients and their caregivers.

RESULTS

Stoma-related morbidity rate was higher in the CS group than in GI group (37% vs. 5.5%, respectively, P = 0.04). Morbidity rate after intestinal recanalization in the CS group was 25.9% and 0% after GI closure (P = 0.08). Overall stoma morbidity rate was significantly lower in the GI group with respect to CS group (5.5% vs. 40.7%, respectively, P = 0.03). CS group was characterized by a significantly longer recovery time (P = 0.0002). Caregivers and stoma-related quality of life were better in the GI group than in CS group (P < 0.0001 and P = 0.0005, respectively).

CONCLUSIONS

GI is feasible, characterized by shorter recovery, lesser degree of total, as well as anastomosis-related morbidity and higher quality of life of patients and the caregivers in respect to CS. We suggest that GI (should be evaluated as an alternative to conventional ileostomy) could be indicated in selected patients that do not present risk factors, but require caution for anastomotic leakage for the low level of colorectal anastomosis.

[Stoma creation during low anterior resection: the cons]

Creation of a protective stoma is nowadays considered the standard of care in patients undergoing low rectal resection to protect these patients from the potentially hazardous consequences of an anastomotic leak. This appears reasonable in patients with acknowledged risk factors such as male gender, low anastomosis, preoperative radiochemotherapy, intraoperative complications, or steroid treatment to ensure patients' safety. However, from our view, it is debatable, if patients without these risk factors can undergo low rectal resection without a stoma. This approach can prevent patients form potential risks of stoma creation as well as closure and the associated readmission to the hospital. Based on reliable patient selection, avoiding a protective stoma during low rectal resection can increase patients' satisfaction and decrease primary and secondary medical costs. However, this approach is hampered by the lack of evidence for patient selection, leading to legal concerns that justify this approach only in highly motivated patients after detailed counseling of the individual patient.