Surgical results of total mesorectal excision for rectal cancer in a specialised colorectal unit

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer

BACKGROUND AND AIMS

Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1-T2 rectal cancer.

METHODS

During the study period, a total of 298 rectal cancer patients were treated. Patients with T1-T2 rectal cancer (i.e., tumor level < or =15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded.

RESULTS

Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively.

CONCLUSIONS

Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure.

Morbidity of ostomy takedown

PURPOSE

Creation of a temporary ostomy is a surgical tool to divert stool from a more distal area of concern (anastomosis, inflammation, etc). To provide a true benefit, the morbidity/mortality from the ostomy takedown itself should be minimal. The aim of our study was therefore to evaluate our own experience and determine the complications and mortality of stoma closure in relation to the type and location of the respective ostomy.

METHODS

Patients undergoing an elective takedown of a temporary ostomy at our teaching institution between January 1999 and July 2005 were included in our analysis, and the medical records were retrospectively reviewed. Excluded were only patients with relevant chart deficiencies and nonelective stoma revisions/takedowns. Data collected included general demographics; the type and location of the stoma; the operative technique; and the type, timing, and impact of complications. Perioperative morbidity was defined as complications occurring within 30 days from the operation.

RESULTS

156 patients (median age 45 years, range 18-85) were included in the analysis: 31 loop and 59 end colostomy reversals and 56 loop and 10 end ileostomy takedowns. Mean follow-up was 6 months. The overall mortality rate was low (0.65%, 1/156 patients). However, the morbidity rate was 36.5% (57 patients), with 6 (3.8%) systemic complications and 51 (32.7%) local complications. Minor would infection (34 patients, 21.8%) and postoperative ileus (9 patients, 5.7%) were the most common surgery-related complications, but they generally resolved with conservative management. Anastomotic leak and formation/persistence of an enterocutaneous fistula (6 patients, 3.8%) were the most serious local complications and required reintervention in all of the patients. Closure of a loop colostomy accounted for half and Hartmann reversals for one third of these complications, as opposed to ileostomy takedowns, which accounted for only one sixth (1.8% absolute risk).

CONCLUSION

Takedown of a temporary ostomy has a low mortality but a nonnegligible morbidity. The stoma location (large vs. small bowel) has a higher impact than the type of stoma construction (end vs. loop) on the incidence and severity of complications.

Significance of detection for matrix metalloproteinase-7 in rectal cancer tissues and mesorectum after total mesorectal excision

AIM: To detect the expression of matrix metalloproteinase(MMP)-7 in the mesorectum of patients with rectal cancer, and to provide theoretical evidence for the total mesorectal excision (TME).

METHODS: The expression of MMP-7 was detected in the specimens from cancer tissues, mesorectum (in the plane, tissues 2 cm distal to the lower margin, and the distal end of the tumor), and outer pelvic fascia by SP immunohistochemistry in 47 patients after TME. And the data were compared with the result of HE staining.

RESULTS: The positive rate of MMP-7 expression was 29.8% (14/47) in the mesorectum. Of those positive expressions, 7 were in the plane of tumor, 3 in both the tumor plane and tissues 2 cm distal to the lower margin of the tumor, and 4 only in the tissues 2 cm distal to the tumor. The positive rate was 14.8% (7/47) by HE staining, and the result of MMP-7 staining was all positive. The positive rate of MMP-7 expression was 91.5% (14/47) in the tumor tissues. There was no MMP-7 expression in the mesorectum, distal end of the outer pelvic fascia, and the control tissues (normal rectal mucosa and mesorectum 10 cm distal to the upper margin of the tumor).

CONCLUSION: MMP-7 is expressed in mesorectal tis-sues of the tumor plane and tissues 2 cm distal to the tumor. The positive expression of MMP-7 is correlated with the degree of the tumor differentiation, depth of invasion, and the Dukes staging.