1
|
Seow-En I, Wu J, Tan IEH, Zhao Y, Seah AWM, Wee IJY, Ying-Ru Ng Y, Kwong-Wei Tan E. Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost. Surg Laparosc Endosc Percutan Tech 2024; 34:54-61. [PMID: 37987634 PMCID: PMC10829900 DOI: 10.1097/sle.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA. METHODS This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs. RESULTS Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002). CONCLUSIONS TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.
Collapse
Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital
| | - Jingting Wu
- Department of Colorectal Surgery, Singapore General Hospital
| | | | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital
| | | | | |
Collapse
|
2
|
Collard MK, Rullier E, Tuech JJ, Sabbagh C, Souadka A, Loriau J, Faucheron JL, Benoist S, Dubois A, Dumont F, Germain A, Manceau G, Marchal F, Sourrouille I, Lakkis Z, Lelong B, Derieux S, Piessen G, Laforest A, Venara A, Prudhomme M, Brigand C, Duchalais E, Ouaissi M, Lebreton G, Rouanet P, Mège D, Pautrat K, Reynolds IS, Pocard M, Parc Y, Denost Q, Lefevre JH. Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR. Ann Surg 2023; 278:781-789. [PMID: 37522163 DOI: 10.1097/sla.0000000000006025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications. BACKGROUND DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA). METHODS All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included. RESULTS Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up. CONCLUSIONS DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.
Collapse
Affiliation(s)
- Maxime K Collard
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Eric Rullier
- Department of General and Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Jean-Jacques Tuech
- Department of General and Digestive Surgery, Hospital Charles Nicole, Rouen, France
| | - Charles Sabbagh
- Department of General and Digestive surgery, Amiens Hospital, France
| | - Amine Souadka
- Department of General and Digestive surgery, National Institute of Oncology, Rabat, Marocco
| | - Jérome Loriau
- Department of Digestive Surgery, Saint-Joseph Hospital, Paris, France
| | - Jean-Luc Faucheron
- Department of Colorectal Surgery, Hôpital Unversitaire de Grenoble, France
| | - Stéphane Benoist
- Department of General and Digestive surgery, Hôpital du Kremlin-Bicêtre, Kremlin-Bicêtre, France
| | - Anne Dubois
- Department of General and Digestive surgery, CHU Clermont-Ferrand Site Estaing, Clermont-Ferrand, France
| | - Frédéric Dumont
- Department of General and Digestive Surgery, Institut de cancérologie de l'ouest, Saint-Herblain, France
| | - Adeline Germain
- Department of General and Digestive Surgery, Hôpital Universitaire de Nancy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, Paris, France
| | - Frédéric Marchal
- Department of Surgical Oncology, Institut de Cancérologie de Lorraine, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | - Zaher Lakkis
- Department of Digestive Surgery, University Hospital of Besancon, Besancon, France
| | - Bernard Lelong
- Department of General and Digestive Surgery, Institute Paoli-Calmettes, Marseille, France
| | - Simon Derieux
- Department of General and Digestive Surgery, Groupe Hospitalier Diaconesses-Croix Saint Simon, Paris, France
| | - Guillaume Piessen
- Department of General and Digestive Surgery, Hôpital Huriez, Lille, France
| | - Anaïs Laforest
- Department of General and Digestive Surgery, Institute Monsouris, Paris, France
| | - Aurélien Venara
- Department of General and Digestive Surgery, Hôpital Universitaire d'Angers, France
| | - Michel Prudhomme
- Department of General and Digestive Surgery, Hôpital Universitaire de Nîmes, France
| | - Cécile Brigand
- Department of General and Digestive Surgery, Hôpital de Hautepierre-Hôpitaux Universitaires, Strasbourg, France
| | - Emilie Duchalais
- Department of General and Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
| | - Mehdi Ouaissi
- Department of General and Digestive Surgery, Hôpital Trousseau - CHRU Hôpitaux de Tours, Chambray-lès-Tours, France
| | - Gil Lebreton
- Department of General and Digestive Surgery, CHU côte de Nâcre, Caen, France
| | - Philippe Rouanet
- Department of General and Digestive Surgery, Institut du Cancer de Montpellier, Montpellier, France
| | - Diane Mège
- Department of General and Digestive Surgery, Hôpital de la Timone, Marseille, France
| | - Karine Pautrat
- Department of General and Digestive Surgery, Hôpital Lariboisière, Paris, France
| | - Ian S Reynolds
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marc Pocard
- Department of General and Digestive Surgery, Hôpital Pitié-Salpêtrère, Paris, France
| | - Yann Parc
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Quentin Denost
- Department of General and Digestive Surgery, Bordeaux Colorectal Institute, Bordeaux, France
| | - Jérémie H Lefevre
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| |
Collapse
|
3
|
Mori S, Tanabe K, Wada M, Hamada Y, Yasudome R, Sonoda T, Matsushita D, Shimonosono M, Arigami T, Sasaki K, Kurahara H, Nakajo A, Ohtsuka T. Modified pull-through coloanal anastomosis to avoid permanent stomas and reduce postoperative complications for lower rectal tumors. Surg Endosc 2023:10.1007/s00464-023-10184-w. [PMID: 37311894 DOI: 10.1007/s00464-023-10184-w] [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: 04/03/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND We performed pull-through hand-sewn coloanal anastomosis immediately after sphincter-preserving ultralow anterior resection (ULAR) [pull-through ultra (PTU)] to avoid permanent stoma and reduce postoperative complications of lower rectal tumors. This study aimed to compare the clinical outcomes of PTU versus non-PTU (stapled or hand-sewn coloanal anastomosis with diverting stoma) after sphincter-preserving ULAR for lower rectal tumors. METHODS This retrospective cohort study analyzed prospectively maintained data from 100 consecutive patients who underwent PTU (n = 29) or non-PTU (n = 71) after sphincter-preserving ULAR for rectal tumors between January 2011 and March 2023. In PTU, hand-sewn coloanal anastomosis was immediately performed using 16 stitches of 4-0 monofilament suture during primary surgery. The clinical outcomes were assessed. The primary outcomes were rates of permanent stomas and overall postoperative complications. RESULTS The PTU group was significantly less likely to require a permanent stoma than the non-PTU group (P < 0.01). None of the patients in the PTU group required permanent stoma and the rate of overall complications was significantly lower in the PTU group (P = 0.01). The median operative time was comparable between the two groups (P = 0.33) but the median operative time during the second stage was significantly shorter in the PTU group (P < 0.01). The rates of anastomotic leakage and complications of Clavien-Dindo grade III were comparable between the two groups. Diverting ileostomy was performed in two patients with an anastomotic leak in the PTU group. The PTU group was significantly less likely to require a diverting ileostomy than those in the non-PTU group (P < 0.01). The composite length of hospital stay was significantly shorter in the PTU group (P < 0.01). CONCLUSIONS PTU via immediate coloanal anastomosis for lower rectal tumors is a safe alternative to the current sphincter-preserving ULAR with diverting ileostomy for patients who wish to avoid a stoma.
Collapse
Affiliation(s)
- Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan.
| | - Kan Tanabe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Masumi Wada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Yuki Hamada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Ryutaro Yasudome
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Tomohiro Sonoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Daisuke Matsushita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Masataka Shimonosono
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Akihiro Nakajo
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Sakuragaoka 8-35-1, Kagoshima City, Kagoshima, 890-8520, Japan
| |
Collapse
|
4
|
Seow-En I, Ng YYR, Tan IBH, Tan EKW. Transanal total mesorectal excision and delayed coloanal anastomosis without stoma for low rectal cancer. Tech Coloproctol 2023; 27:75-81. [PMID: 36029385 DOI: 10.1007/s10151-022-02677-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/28/2022] [Indexed: 01/12/2023]
Abstract
The management of low rectal cancer is a perennial challenge for colorectal surgeons. The benefits of transanal total mesorectal excision (TaTME) in low rectal cancer are to secure the distal margin and avoid surgical space constraints within the deep pelvis. However, anastomotic leak remains an important concern. We report our technique and results combining TaTME with delayed coloanal anastomosis (DCAA) without bowel diversion. First, the splenic flexure, left colon and rectum are laparoscopically mobilized to mid-rectum. TaTME is performed to complete the distal rectal mobilization, and the specimen is delivered transanally and transected. The abdominoperineal colonic pull-through is secured to the anal canal and hypertonic dressing is applied regularly in the ward. The handsewn DCAA is performed one week later. An accompanying video demonstrates this technique. Five consecutive patients with low rectal cancer underwent TaTME with DCAA. All had upfront surgical resection except one who underwent total neoadjuvant therapy. Mean operative duration, blood loss, and length of hospital stay was 290 (250-375) min, 142 (10-200) ml and 11.6 (10-14) days respectively. One patient (20%) suffered a postoperative complication of persistent urinary retention, requiring an indwelling urinary catheter on discharge. There were no cases of open conversion and no instances of anastomotic leakage. Two patients (40%) had minor low anterior resection syndrome (LARS) and one (20%) had major LARS. TaTME and DCAA without stoma are complimentary techniques that augment the minimally invasive effects of laparoscopic sphincter-sparing low rectal cancer surgery, with good perioperative outcomes.
Collapse
Affiliation(s)
- I Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore.
| | - Y Y-R Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - I B H Tan
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - E K-W Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|