Influencing factors of symptomatic anastomotic leakage after anterior resection of the rectum for cancer. World J Surg. 2009;33:1292-1297. [PMID: 19363687 DOI: 10.1007/s00268-009-0008-4]

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy

BACKGROUND

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy.

METHODS

In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance.

RESULTS

Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model.

CONCLUSIONS

This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Prediction model of anastomotic leakage after anterior resection for rectal cancer-based on nomogram and multivariate analysis with 1995 patients

BACKGROUND

Postoperative anastomotic leakage for rectal cancer shows higher morbidity with grievous concomitant symptoms. Accurate assessment of the incidence of anastomotic leakage, multivariate analysis, and establishment of a scientific prediction model can be useful to dispose of its possible severe clinical consequences.

METHODS

This retrospective study collected 1995 consecutive patients who underwent anterior resection of rectal cancer with primary anastomosis at Northern Jiangsu People's Hospital between January 2016 and June 2022. Independent risk factors associated with anastomotic leakage were analyzed by univariate and multivariate logistic regression. The chosen independent risk factors were used to construct a nomogram risk prediction model whose availability was evaluated by using a bootstrapped-concordance index and calibration plots with R software.

RESULTS

A total of 1995 patients who underwent anterior resection for rectal cancer were included while 120 patients were diagnosed with anastomotic leakage, an incidence of 6.0%. Univariate analysis and its concomitant multivariate cox regression analysis indicated that independent risk factors associated with anastomotic leakage included male gender (odds ratio (OR) = 2.873), diabetes (OR = 2.480), neoadjuvant therapy (OR = 5.283), tumor's distance from the anus verge < 5 cm (OR = 5.824), tumor size ≥ 5 cm (OR = 4.888), and the blood lose > 50 mL (OR = 9.606).We established a nomogram prediction model with proper applicability (concordance index, 0.83) and the calibration curve to justify its predictive ability that the predicted occurrence probability keeps a high degree of consistency with the actual occurrence probability. Meanwhile, the area under the receiver operating characteristic (ROC) curve was 0.83.

CONCLUSIONS

The characteristics of patients and tumor surgery-related conditions can affect the incidence of anastomotic leakage. However, whether the surgical method will affect morbidity is still controversial. Our nomogram can be seen as an effective instrument to predict anastomotic leakage after anterior resection for rectal cancer precisely.

Risk factors affecting benign anastomotic stricture in anterior and low anterior resections for colorectal cancer: a single-center retrospective cohort study

PURPOSE

Although not as life-threatening as anastomotic leakage, anastomotic stricture reduces the quality of life. The risk factors for such an important life complication have not been revealed. This article examines the risk factors affecting anastomotic strictures due to colorectal cancers.

METHODS

Patients who underwent anterior and low anterior resection for colorectal cancer under elective conditions between 2015 and 2021 were included in the study. The patients were divided into two groups, those who developed anastomotic stricture and those who did not. The parameters determined between the two groups were compared, and multivariate analysis of statistically significant parameters was performed.

RESULTS

A total of 375 patients were included in the study. The anastomotic stricture was detected in 36 (9.6%) patients. In the multivariate analysis, non-mobilization of the splenic flexure and a proximal clean surgical margin of < 10 cm and a distal surgical margin of < 2 cm were identified as risk factors affecting anastomotic stricture. The risk factor with the highest odds ratio in the development of anastomotic stricture is the non-mobilization of the splenic flexure (p = 0.001, OR 11.375).

CONCLUSION

It is recommended that the mobilization of the splenic flexure to reduce the development of strictures. In addition, a clean surgical margin of 10 cm proximally and 2 cm distally and high ligation of the inferior mesenteric artery may reduce the development of stricture.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Role of transanal drainage tubes in preventing anastomotic leakage after low anterior resection: a meta-analysis of randomized controlled trials

BACKGROUND

The transanal drainage tube (TDT) is thought to reduce the incidence of anastomotic leakage (AL) in patients with low anterior resection (LAR). However, results from different clinical trials are inconsistent, although nearly all meta-analyses agree on the efficacy. In contrast to results of many previous studies, 2 recent independent randomized controlled trials (RCTs) suggest that the use of TDT does not prevent AL. We performed a meta-analysis including only RCTs to compare patients with TDTs vs. those without TDTs in terms of AL rate.

METHODS

A systematic literature search was performed in the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov and WHO/ICTRP from inception until February 14, 2022. RCTs that evaluated the role of TDTs in AL prevention in patients who underwent LAR for rectal cancer were included. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by two authors independently, and random-effects models were implemented. The main outcome was AL, and the secondary outcome was the grade of AL.

RESULTS

Three RCTs were included involving a total of 1115 participants (559 patients in the TDT group and 556 in the non-TDT group). No significant difference in the AL rate was detected (RR = 0.69, 95% confidence interval (CI) 0.42-1.15, p = 0.15, I² = 21%, very low certainty evidence). The incidence of grade C AL was possibly lower in the TDT group (RR = 0.33, 95% CI 0.11-1.01, p = 0.05, very low certainty evidence), while the rate of grade B AL was similar between the two groups (RR = 1.17, 95% CI 0.66-2.08, p = 0.59, very low certainty evidence).

CONCLUSIONS

The present meta-analysis suggests that TDTs are not effective in reducing the overall incidence of AL, but possibly have a potential benefit in reducing the occurrence of grade C AL in patients with LAR. Based on the current limited data and existing heterogeneity, the inclusion of larger populations and the identification of more uniform indications for TDT need to be addressed in future studies.

Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study

BACKGROUND

Anastomotic leak after gastrointestinal anastomosis is a serious complication. Anastomotic failure depends on various parameters. The aim of our study was to evaluate the pressure resistance of a new device, EEA™ circular stapler with Tri-Staple™ technology 28 mm Medium/Thick (Triple-rows circular stapler; TCS) compared with EEA™ circular stapler with DST series™ technology 28 mm, 4.8 mm staples (double-rows circular stapler; DCS).

PATIENTS AND METHODS

We performed 30 anastomoses (DSC: 15, TCS: 15) of DST with porcine colon model in vitro. We performed following 3 comparative experiences; Experiment 1: observation of staple shape with a colonoscopy, Experiment 2: comparison of the pressure resistance, Experiment 3: comparison of leakage points.

RESULTS

There was no hypoplasia of staples and the shapes were well-formed by colonoscopy. The leakage pressure of DCS was 19.6 ± 4.4 mm Hg (mean ± standard deviation) and that of TCS was 38.6 ± 10.2 mm Hg (mean ± standard deviation). There was a significantly difference between 2 groups (P < .001). 12 cases of DCS (80%) and 10 cases of TCS (66.7%) had leakages from Circular stapler point. 2 cases of DCS (13.3%) and 5 cases of TCS (33.3%) had leakages from Crossing points. Only 1 case of DCS had leakages from Dog ear point (6.7%). There was no significantly difference in leakage site between 2 groups (P = .195).

CONCLUSIONS

TSC showed high pressure resistance during DST compared with that of DCS. It was suggested that TCS may contribute to the reduction of anastomotic leakage rate.

Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease–A Retrospective Analysis of 54 Cases at a Tertiary Care Center

Background

Despite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.

Methods

Between 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.

Results

Of the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (&gt;C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).

Discussion

Morbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.

Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases

Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.

Survey Regarding Gastrointestinal Stoma Construction and Closure in Japan

Background and Aim

In Japan, the actual number of stoma constructions and stoma closures is not known. The aim of this study was to conduct a survey to determine the number of gastrointestinal stoma constructions and closures in Japan.

Methods

Enrolled participants comprised patients undergoing selected gastrointestinal surgeries who were recorded in the National Clinical Database. This database uses the "Common Items for Gastrointestinal Surgeons." These procedures were formulated by the Japanese Society of Gastroenterological Surgery during 2013-2018.

Results

According to the National Clinical Database, a total of 154,323 gastrointestinal stomas were constructed between January 1, 2013 and December 31, 2018. By procedure, there were 78,723 cases of stoma construction, 39,653 of abdominoperineal resection, 2470 total pelvic exenteration procedures, and 33,572 Hartmann's procedures. The ratio of stoma closures to stoma constructions increased annually in patients under 70 y of age but not in older patients. Approximately 35% of total colectomies, 60% of proctocolectomies, and 20% of low anterior resections were accompanied by stoma construction. The number of patients with rectal cancer who underwent colostomy increased gradually during the study period and the number who underwent stoma construction increased among older patients.

Conclusion

The number of cases of gastrointestinal stoma construction has increased gradually in Japan, and the proportion of older patients is increasing each year. The purposes and surgical techniques for stoma construction are diverse and are expected to increase in Japan, a super-aged society.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

A multicentre confirmatory single-arm trial of the safety and efficacy of a transanal drain for prevention of anastomotic leakage after surgery for rectal cancer

AIM

Recent reports have described the use and efficacy of several types of transanal tube (TAT) for preventing anastomotic leakage by reducing intraluminal pressure. The aim of this study was to evaluate the safety and efficacy of a newly developed TAT for the prevention of anastomotic leakage after low anterior resection (LAR) for rectal cancer.

METHOD

A multicentre confirmatory single-arm trial was designed to evaluate the safety and efficacy of a new TAT after LAR for rectal cancer. A total of 115 patients were registered in the trial at several cancer centres and other hospitals. All patients initially received reconstruction with a stapled anastomosis, but 18 then underwent creation of a diverting stoma. Of the remaining 97 patients, the first 96 were included in the protocol-defined primary analysis set. The primary outcome was the incidence of symptomatic leakage and the secondary endpoint was the incidence of complications associated with use of the TAT. The TAT was placed during LAR without creating a covering stoma and the drain was removed 4 or 5 days postoperatively.

RESULTS

The rate of symptomatic leakage was 5.2% (95% confidence interval 1.7-11.7), which was significantly lower than the predetermined threshold value of 15.8% (one-sided p-value 0.0013). Only one patient had Grade 3 rectal bleeding that might have been related to use of the TAT.

CONCLUSION

This nonrandomized study shows that the TAT appears to be safe and results in lower rates of anastomotic leakage in LAR compared with previous studies.

Transanal Drainage Tube Use for Preventing Anastomotic Leakage After Laparoscopic Low Anterior Resection in Patients With Rectal Cancer: A Randomized Clinical Trial

Importance

Preventing anastomotic leakage (AL) is crucial for colorectal surgery. Some studies have suggested a positive role of transanal drainage tubes (TDTs) in AL prevention after low anterior resection, but this finding is controversial.

Objective

To assess the effect of TDTs in AL prevention after laparoscopic low anterior resection for rectal cancer.

Design, Setting, and Participants

This multicenter randomized clinical trial with parallel groups (TDT vs non-TDT) was performed from February 26, 2016, to September 30, 2020. Participants included patients from 7 different hospitals in China who were undergoing laparoscopic low anterior resection with the double-stapling technique for mid-low rectal cancer; 576 patients were initially enrolled in this study, and 16 were later excluded. Ultimately, 560 patients were randomly divided between the TDT and non-TDT groups.

Interventions

A silicone tube was inserted through the anus, and the tip of the tube was placed approximately 5 cm above the anastomosis under laparoscopy at the conclusion of surgery. The tube was fixed with a skin suture and connected to a drainage bag. The TDT was scheduled for removal 3 to 7 days after surgery.

Main Outcomes and Measures

The primary end point was the postoperative AL rate within 30 days.

Results

In total, 576 patients were initially enrolled in this study; 16 of these patients were excluded. Ultimately, 560 patients were randomly divided between the TDT group (n = 280; median age, 61.5 years [IQR, 54.0-68.8 years]; 177 men [63.2%]) and the non-TDT group (n = 280; median age, 62.0 years [IQR, 52.0-69.0 years]; 169 men [60.4%]). Intention-to-treat analysis showed no significant difference between the TDT and non-TDT groups in AL rates (18 [6.4%] vs 19 [6.8%]; relative risk, 0.947; 95% CI, 0.508-1.766; P = .87) or AL grades (grade B, 14 [5.0%] and grade C, 4 [1.4%] vs grade B, 11 [3.9%] and grade C, 8 [2.9%]; P = .43). In the stratified analysis based on diverting stomas, there was no significant difference in the AL rate between the groups, regardless of whether a diverting stoma was present (without stoma, 12 [5.8%] vs 15 [7.9%], P = .41; and with stoma, 6 [8.3%] vs 4 [4.5%], P = .50). Anal pain was the most common complaint from patients in the TDT group (130 of 280, 46.4%). Accidental early TDT removal occurred in 20 patients (7.1%), and no bleeding or iatrogenic colonic perforations were detected.

Conclusions and Relevance

The results from this randomized clinical trial indicated that TDTs may not confer any benefit for AL prevention in patients who undergo laparoscopic low anterior resection for mid-low rectal cancer without preoperative radiotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02686567.

Association Between Intraoperative Blood Glucose and Anastomotic Leakage in Colorectal Surgery

BACKGROUND

Perioperative hyperglycemia is a known risk factor for postoperative complications after colorectal surgery. The aim of this study was to investigate whether intraoperative blood glucose values are associated with colorectal anastomotic leakage in diabetic and non-diabetic patients undergoing colorectal surgery.

METHODS

This is an additional analysis of a previously published prospective, observational cohort study (the LekCheck study). Fourteen hospitals in Europe and Australia collected perioperative data. Consecutive adult patients undergoing colorectal surgery with primary anastomosis between 2016 and 2018 were included. From all patients, preoperative diabetic status was known and intraoperative blood glucose was determined just prior to the creation of the anastomosis. The primary outcome was the occurrence of anastomotic leakage within 30 days postoperatively.

RESULTS

Of 1474 patients (mean age 68 years), 224 patients (15%) had diabetes mellitus, 737 patients (50%) had intraoperative hyperglycemia (≥126 mg/dL, ≥7.0 mmol/L), and 129 patients (8.8%) developed anastomotic leakage. Patients with intraoperative hyperglycemia had higher anastomotic leakage rates compared to patients with a normal blood glucose level (12% versus 5%, P<0.001). Anastomotic leakage rate did not significantly differ between diabetic and non-diabetic patients (12% versus 8%, P=0.058). Logistic regression analyses showed that higher blood glucose levels were associated with an increasing leakage risk in non-diabetic patients only.

CONCLUSION

Incidence and severity of intraoperative hyperglycemia are associated with anastomotic leakage in non-diabetic patients. Whether hyperglycemia is an epiphenomenon, a marker for other risk factors or a potential modifiable risk factor per se for anastomotic leakage requires future research.

Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database

Background

Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR).

Methods

All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated.

Results

Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016–2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations.

Conclusion

Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.

Design and performance evaluation of a powered stapler for gastrointestinal anastomosis

OBJECTIVE

This paper reports the design of a powered stapler for gastrointestinal anastomosis and evaluates its performance. The proposed stapling instrument is intended to simplify and optimize the current procedure of mechanical stapling, while providing controllable operation for the powered stapling procedure, such as conditioning the tissue to the right stage before firing of the stapler.

MATERIAL AND METHODS

The feasibility and efficacy of the prototype were assessed by ex vivo experiments with porcine small intestine segments, where the tissue conditioning operation, burst pressure of the stapled intestine samples, and staple malformation rate were examined.

RESULTS

The functionality of the developed powered stapler was validated, where the theoretical, numerical, and experimental results agree well with each other. The preliminary results indicated that the proposed tissue conditioning operation could lower the clamping pressure with a maximum level of 1.35 g/mm². The average burst pressure of the stapled segments (16 samples) is 6.37 kPa, and the maximum malformation rate of the tested groups (five groups, each group with 90 staplers) was 5.56%.

CONCLUSION

The developed novel tissue conditioning procedure could reduce the pressure response of the intestine tissue samples. The proposed powered stapler proves effective for performing gastrointestinal anastomosis procedures.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

The impact of transanal tube design for preventing anastomotic leak in anterior resection: a systematic review and meta-analysis

BACKGROUND

Placement of a transanal tube (TAT) into the rectum is a strategy used to attempt to prevent anastomotic leak (AL) in anterior resection surgery. There is a wide variation in materials and tube design in devices used as TATs and previous meta-analyses have not considered TAT design in their analyses. This study reviews the impact that design of TAT has on AL rates.

METHODS

A systematic review of the literature was performed with the aim of identifying studies evaluating the use of TATs for preventing AL and then defining the design of TATs. Studies were then compared in groups based on TAT design in a meta-analysis to evaluate whether design is an important variable in outcomes.

RESULTS

Thirty-three studies were included. There was a wide variety of tubes used as TATs. On meta-analysis, catheter-type TATs were associated with a substantially lower rate of AL (OR: 0.46; 95% CI 0.30, 0.68). By contrast, stent-type TATs were not associated with any reduction in the incidence of AL (OR: 1.06, 95% CI 0.50, 2.22). Catheter-type TATs were also associated with substantial reductions in the rate of reoperation (OR: 0.32; 95% CI 0.20, 0.50), whereas stent-type TATs showed no benefit in the rate of reoperation (OR: 0.79; 95% CI 0.37, 1.65).

CONCLUSIONS

Off-the-shelf catheter-type transanal tubes appeared effective in preventing AL, whereas custom-designed stent-type TATs were not demonstrated to be effective; although high quality evidence is limited. TAT design should be an important consideration in further research of the use of TATs in anterior resection surgery.

Surgical-related risk factors associated with anastomotic leakage after resection for rectal cancer: a meta-analysis

OBJECTIVES

Anastomotic leakage (AL) after anterior resection always leads to longer hospital stays, decreased quality of life and even increased mortality. Despite extensive research, no consensus on the world well-concerned surgical-related risk factors exists. We therefore conducted a meta-analysis of the available published literature to identify the effects of surgical-related risk factors for AL after anterior resection for rectal cancer, hoping to provide more information and improved guidance for clinical workers managing patients with rectal cancer who are at a high risk for AL.

METHODS

In this study, the relevant articles were systematically searched from EMBASE, MEDLINE, PubMed, WangFang (Database of Chinese Ministry of Science & Technology), Chinese National Knowledge Infrastructure Database and China Biological Medicine Database. The pooled odds ratio (OR) with 95% confidence interval (95% CI) were calculated. Meta-analysis was performed using of RevMan 5.3 software.

RESULTS

A total of 26 studies met the inclusion criteria and comprised 34238 cases. Analysis of these 26 studies showed that no defunctioning stoma was highly correlated with AL (pooled OR = 1.28, 95%CI: 1.05-1.57, P = 0.01, random effect), and intraoperative blood transfusion was significantly associated with AL (pooled OR = 1.64, 95%CI: 1.34-2.02, P = 0.02, random effect). However, the AL was not associated with type of anastomosis, type of surgery, technique of anastomosis, level of inferior mesenteric artery ligation, operation time and splenic flexure mobilization.

CONCLUSIONS

Depend on this meta-analysis, no defunctioning stoma and intraoperative blood transfusion are the major surgical-related risk factors for AL after resection for rectal cancer. Because of the inherent limitations of the research, future prospective randomized controlled trials will need to confirm this conclusion.

Protective effect of adipose tissue-derived mesenchymal stromal cells in an experimental model of high-risk colonic anastomosis

BACKGROUND

Dehiscence of intestinal anastomosis results in high morbidity and mortality. The aim of this study was to investigate the effects of locally administered adipose tissue-derived mesenchymal stromal cells in a model of high-risk colonic anastomosis in rats.

METHODS

Seven days after induction of colitis with 2,4,6-trinitrobenzene sulfonic acid, Wistar rats were submitted to a transection of the descending colon followed by end-to-end anastomosis and were then treated with 2×10⁶ adipose tissue-derived mesenchymal stromal cells (from the preperitoneal fat) or an acellular culture solution instilled onto the surface of the anastomosis. At day 14, after macroscopic survey of the abdominal cavity, the anastomotic area was submitted to histologic and immunohistochemical analysis, evaluation of myeloperoxidase activity, fibrosis, epithelial integrity, NF-κ B activation, expression of inflammatory cytokines, and extracellular matrix-related genes.

RESULTS

Anastomotic leakage and mortality associated with high-risk anastomosis decreased with treatment with adipose tissue-derived mesenchymal stromal cells (P < .03). Application of adipose tissue-derived mesenchymal stromal cells resulted in lower histologic scores (P = .011), decreased deposition of collagen fibers (P = .003), preservation of goblet cells (P = .033), decreased myeloperoxidase activity (P = .012), decreased accumulation of CD4+ T-cells (P = .014) and macrophages (P = .011) in the lamina propria, a decrease in the number of apoptotic cells (P = .008), and the activation of NF-κ B (P = .036). Overexpression of IL-17, TNF-α , IFN-γ, and metalloproteinases in the acellular culture solution-treated, high-risk anastomosis group decreased (P < .05) to near normal values with adipose tissue-derived mesenchymal stromal cells treatment.

CONCLUSION

Improvements in outcomes of a high-risk colonic anastomosis with adipose tissue-derived mesenchymal stromal cells therapy reflect the immunomodulatory activity and healing effect of these cells, even after just topical administration and reinforces their use in future translational research.

Is Circular Fibrin Sealing of Low Rectal Anastomosis Able to Prevent Leakage in 21-Day Follow-up? Randomized Experimental Trial in Pigs

Purpose. Clinically apparent anastomotic leakage (AL) after low anterior rectal resection (LAR; <7 cm from anal verge) using circular double-stapled anastomosis without defunctioning stoma is up to 37.5%. However, it is unclear whether there is reduction of LAR after 21 postoperative days without defunctioning stoma but with extraluminal anastomotic application of fibrin sealant. Methods. Forty-eight-week-old pigs underwent LAR and circular double-stapled anastomosis in end-to-end technique (descendo-rectostomy). Animals were randomized into therapy and control group (cg). Therapy group (n = 20) received additional extraluminal circular anastomotic application of fibrin sealant. Objective was to assess incidence of clinically apparent and nonclinically apparent leakage through the 21st postoperative day. Remaining animals were sacrificed on the 21st day, and anastomotic region was analyzed. In case of earlier diagnosed AL, animals were sacrificed. Results. In cg, we observed clinically and nonclinically AL in 20% (n = 4). No animal was identified with a nonclinical-apparent leakage in this group, and all 4 animals with leakages presented clinical signs. In the therapy group, no animal (0/20) developed clinically apparent leakage signs. There were no leakages in this group, but 3 animals had ulcerative lesions without leak and without clinical signs. These lesions were observed intraluminally at crossing of staple lines after 21 days. In one of these animals, incomplete leakage was observed, blocked by fibrin sealant. Conclusion. In circular stapled colorectal anastomosis, circular fibrin glue sealant successfully protected anastomotic intraluminal wall defects at crossing of staple lines, reducing leakage rate from 20% to 0% (cg vs therapy group) after 21 postoperative days.

Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study

To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.

Different clinical features according to the anastomotic leakage subtypes after rectal cancer surgeries: contained vs. free leakages

Background

Anastomotic leakage can be classified by free and contained leakage according to clinical manifestations. The risk factors and their comparison between these leakage subtypes are uncertain. This study aims to evaluate anastomotic leakage patterns and to compare clinical features between free and contained leakages after low anterior resection for rectal cancer.

Materials and methods

Between January 2005 and December 2012, a total of 2035 consecutive patients who underwent low anterior resection for primary rectal cancer were evaluated retrospectively at two-tertiary referral centers. The primary end points of this study were to assess detailed clinical features among leakage subtypes. The secondary end point was to compare risk factors between free and contained leakages.

Results

Patients were subdivided into a no leakage group (n = 1890), free leakage group (n = 73), and contained leakage group (n = 72). Free leakage occurred more frequently in laparoscopic and robotic surgeries than open surgery (p = 0.015). On the other hand, contained leakage was developed in a higher rate of patients who received preoperative chemoradiotherapy (p<0.001). The mean development time was 4.6 days in the free leakage group, and 23.6 days in the contained leakage group. Patients with free leakage had a lower rate of a defunctioning stoma than contained leakage (5.5% vs. 29.2%, p<0.001). Risk factors for free leakage were smoking, tumor location, and laparoscopic surgery. However, tumor location and preoperative chemoradiotherapy increased the risk for contained leakage.

Conclusions

Contained leakage in rectal cancer surgery showed different clinical manifestations and risk factors compared to free leakage. It is necessary to pay more attention to patients with particular risk factors for anastomotic leakage subtypes.

An updated meta-analysis of transanal drainage tube for prevention of anastomotic leak in anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage (AL) is one of the most serious complications after anterior resection for rectal cancer. Transanal drainage tube (TDT) placement is widely used to reduce AL, but its efficacy remains controversial. We performed a meta-analysis to evaluate the effectiveness of TDT for prevention of AL, using updated evidence.

METHODS

Randomized controlled trials (RCTs) and cohort studies evaluating the effectiveness of TDT for prevention of AL after anterior resection for rectal cancer were identified by using a predefined search strategy. Meta-analysis was performed to estimate the pooled rates of AL, reoperation, anastomotic bleeding and mortality separately.

RESULTS

One RCT and ten cohort studies which including 1170 cases with TDT and 1262 cases without TDT were considered eligible for inclusion. Meta-analysis showed that the TDT group was associated with a significant lower rates of AL (RR: 0.42, 95% CI: 0.31-0.58, P < 0.00001) and reoperation (RR: 0.29, 95% CI: 0.19-0.45, P < 0.00001). There was no significant difference in anastomotic bleeding rate and mortality between the two groups.

CONCLUSIONS

TDT placement is associated with significant lower rates of AL and reoperation, hence it is likely to be an effective method of preventing and reducing AL after rectal cancer surgery.

Impact of transanal drainage tube on anastomotic leakage after laparoscopic low anterior resection

BACKGROUND

Although a few reports have suggested transanal drainage tube (TDT) can reduce the pressure in the anastomotic portion, it remains unclear whether TDT can prevent anastomotic leakage (AL). In addition, little is known about the relationship between AL and daily fecal volume through TDT. This study investigated the role of TDT for the prevention of AL following laparoscopic low anterior resection (LAR).

METHODS

This is a retrospective analysis of a prospectively maintained database of 201 rectal cancer patients who underwent laparoscopic LAR. The relationship between AL and daily fecal volume through TDT was examined.

RESULTS

AL occurred in 25 patients. Based on the TDT grouping, AL occurred in 10.7% (19/178) of the TDT group, whereas it occurred in 26.1% (6/23) of the non-TDT group (P = 0.046). In the 178 patients with TDT placement, the daily fecal volumes on postoperative days (PODs) 2-5 were significantly higher compared with those on POD 1 (P < 0.05). The daily fecal volume was observed to be gradually increasing until POD 3 or 4 (median, 25 or 23 ml/day, respectively) and then significantly decreasing on POD 5 (10 ml/day) (P < 0.05). The AL rate of the patients whose daily fecal volume exceeded 100 ml/day in two or more days was significantly higher than that of those in 0 or 1 day (26.9 vs. 7.9%; P < 0.01).

CONCLUSIONS

TDT could be efficient to prevent AL following laparoscopic LAR. Postoperative fecal volume may be a reliable predictor of AL.

Serum cytokines in early prediction of anastomotic leakage following low anterior resection

Introduction

Anastomotic leakage continues to be one of the most serious complications following low anterior resections. Early diagnosis of a leak is difficult but critical to minimize morbidity and mortality.

Aim

To evaluate changes in serum concentrations of 27 different cytokines following low anterior resection, with the goal of finding new, early biomarkers of anastomotic leak.

Material and methods

This is a prospective observational study that includes 32 patients undergoing elective low anterior resection for rectal cancer. Blood samples were collected preoperatively and on postoperative day 3.

Results

Five patients developed anastomotic leak (15%). On postoperative day 3, high-sensitivity C-reactive protein (hs-CRP), interleukin (IL)-6, and regulated on activation, normal T cell expressed and secreted (RANTES) were significantly higher in patients with anastomotic leak, while IL-9 and fibroblast growth factor (FGF) 2 were significantly lower. Analysis of relative changes in the concentration of cytokines from preoperative to postoperative day 3 revealed a significant increase of IL-6 and granulocyte-colony stimulating factor (G-CSF) in patients with an anastomotic leak. Upon receiver operating curve (ROC) analysis, the performance of hs-CRP was found to be excellent (AUC = 0.99), and performance of ΔIL-6, IL-6, RANTES, and FGF2 was good (AUC: 0.81–0.87). Patients who developed an anastomotic leak preoperatively had significantly lower levels of macrophage inflammatory protein-1 α (MIP-1α), monocyte chemotactic protein-1 (MCP-1), IL-8, FGF2, and G-CSF.

Conclusions

The single most accurate serum biomarker of anastomotic leakage continues to be hs-CRP. However, when analyzing relative changes of cytokine levels, ΔIL-6 appears to be a better leak predictor than CRP.

Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial

PURPOSE

The aim of this study was to determine the risk factors for anastomotic leakage after laparoscopic rectal surgery.

METHODS

We conducted a prospective trial involving 395 patients with stage 0/I rectal carcinoma who underwent laparoscopic low anterior resection using a double stapling technique. Data concerning variables related to patient background, tumors and surgical factors were evaluated. The outcomes with respect to anastomotic leakage were recorded, and univariate and multivariate analyses were performed to identify relevant risk factors.

RESULTS

The overall anastomotic leakage rate was 8.4%. A univariate analysis showed male gender (P = 0.006) and preoperative blood sugar level (P = 0.0034) to be significantly associated with anastomotic leakage. The variables of gender, preoperative blood sugar level, American Society of Anesthesiologists (ASA) classification (P = 0.15), transanal decompression tube (P = 0.06) and number of stapler cartridges used for rectal transection (P = 0.18) were selected for the multivariate analysis because of their P values being <0.2. The multivariate analysis identified male gender (odds ratio 4.12, P = 0.006) and the absence of a transanal decompression tube (odds ratio 3.11, P = 0.0484) as independent risk factors predicting anastomotic leakage.

CONCLUSIONS

Male gender and the absence of a transanal decompression tube appeared to be independent risk factors for anastomotic leakage. Insertion of a transanal decompression tube may help prevent anastomotic leakage after low anterior resection, particularly in male patients.

Rectal tube drainage reduces major anastomotic leakage after minimally invasive rectal cancer surgery

AIM

Anastomotic leakage is the most serious complication following low anterior resection for rectal cancer and is a major cause of postoperative morbidity and mortality. The object of the present study was to investigate whether rectal tube drainage can reduce anastomotic leakage after minimally invasive rectal cancer surgery.

METHOD

Three hundred and seventy-four patients who underwent laparoscopic or robotic LAR for tumours located ≤ 15 cm above the anal verge between 1 April 2012 and 31 October 2014 were assessed retrospectively. Of these, 107 with intermediate risk of anastomotic leakage received transanal rectal tube drainage. The rectal tube group was matched by propensity score analysis with patients not having rectal tube drainage, giving 204 patients in the study. Covariates for propensity score analysis included age, sex, body mass index, tumour height from the anal verge and preoperative chemoradiation.

RESULTS

Patient demographics, tumour location, preoperative chemoradiation and operative results were similar between the two groups. The overall leakage rate was 10.8% (22/204), with no significant difference between the rectal tube group (9.8%) and the nonrectal tube group (11.8%, P = 0.652). Of the patients with anastomotic leakage, major leakage requiring reoperation developed in 11.8% of those without and 3.9% of those with a rectal tube. On multivariate analysis, age over 65 years and nonuse of a rectal tube were found to be independent risk factors for major anastomotic leakage.

CONCLUSION

Rectal tube placement may be a safe and effective method of reducing the rate of major anastomotic leakage, alleviating the clinical course of leakage following minimally invasive rectal cancer surgery.

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Prophylactic transanal decompression tube versus non-prophylactic transanal decompression tube for anastomotic leakage prevention in low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

Transanal decompression tube (TDT), an alternative intervention believed to have potential equivalent efficacy in reducing anastomotic leakage after rectal cancer surgery and lower complication rates compared to protective stoma, was sporadically applied in some medical centers during recent decade. The objective of this meta-analysis was to evaluate the effect of the TDT in preventing the anastomotic leakage after low anterior resection for rectal cancer.

METHODS

The studies comparing TDT and non-TDT in rectal cancer were researched up to March 22, 2016 without language preference, in databases of PubMed, Web of Science, Cochrane library, International Clinical Trials Registry Platform, and National Clinical Trials Registry. The rates of anastomotic leakage, bleeding, and re-operation were separately calculated and compared between TDT and non-TDT groups using RevMan 5.3. Funnel plots, and Egger's tests were used to evaluate the publication biases of the studies.

RESULTS

Two prospective randomized controlled trial studies and five observational cohort studies with 833 participants in TDT group and 939 participants in non-TDT group were finally included in this meta-analysis. The results indicated that the TDT group had lower anastomotic leakage rate than non-TDT group with significant RR (RR 0.44; 95 % CI 0.29-0.66; P < 0.0001) and heterogeneity (I ² = 33 %; P = 0.18). So did the re-operation rate, with RR (RR 0.16; 95 % CI 0.07-0.37; P < 0.0001) and heterogeneity among the studies (I ² = 0 %; P = 0.80). There was no significant difference in anastomotic bleeding rates (RR 1.48; 95 % CI 0.79-2.77; P = 0.22) (I ² = 58 %; P = 0.09). No publication bias was found by Egger's test (anastomotic leakage rate, Pr > |z| = 0.224; re-operation rate, Pr > |z| = 0.425).

CONCLUSIONS

TDT might be an efficient and economic intervention in preventing anastomotic leakage after rectal cancer surgery.

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis

Background

Anastomotic leakage is a serious complication that can occur after anterior resection of the rectum. There is a question regarding whether the placement of a transanal tube can decrease the rate of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the efficacy of transanal tube placement after anterior resection.

Methods

We searched three major databases (PubMed, Embase, and the Cochrane Library) up until January 2015 for studies evaluating the benefit of transanal tubes after anterior resection for rectal cancer. The primary outcome measure was the rate of clinical anastomotic leakage. Secondary outcome was the rate of reoperation. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were obtained using random effects models.

Results

One randomized controlled trial and three observational studies involving 909 patients met inclusion criteria. Clinical anastomotic leakage occurred in 3.49 % (14 of 401) of patients with transanal tubes and 12.01 % (61 of 508) of patients without transanal tubes. Meta-analysis of the studies showed a lower risk of anastomotic leakage (RR, 0.32; 95 % CI 0.18–0.58) and reoperation related to leakage (RR, 0.19; 95 % CI 0.08–0.46) when the transanal tube was placed.

Conclusions

While studies are few and mostly observational, the data to date indicate that placement of a transanal tube decreases the rate of clinical anastomotic leakage and reoperation related to leakage. More studies are needed to confirm these findings.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors

PURPOSE

To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage.

METHODS

The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution.

RESULTS

The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator.

CONCLUSIONS

The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis: A case controlled study

Background and aims

The aim of this study was to investigate the clinical usefulness of the placement of a transanal drainage tube to prevent anastomotic leakage in colorectal anastomoses.

Material and methods

This single-center retrospective trial included all patients treated with surgery for benign or malign colorectal disease between January 2009 and December 2012. The transanal drainage tube was immediately placed after colorectal anastomosis until day five and was routinely used since 2010. Patients treated with a transanal drainage tube were compared with the control group. Statistical analysis was performed using Fisher's exact or Chi-square tests for group comparison and a linear regression model for multivariate analysis.

Results

This study included 242 patients (46% female; median age 63 years; range 18–93); 34% of the patients underwent a laparoscopic procedure, and 57% of the patients received a placement of a transanal drainage tube. Anastomotic leakage occurred in 19 patients (7.9%). Univariate analysis showed a higher rate of anastomotic leakage in patients with an ASA score 4 (p = 0.02) and a lower rate in patients with transanal drainage placement (3.6% vs. 13.6%; p = 0.007). The grading of the complication of anastomotic leakage was reduced with transanal drainage (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006), and the hospital stay was shortened (17.6 ± 12.5 vs. 22.1 ± 17.6 days; p = 0.02). Multivariate analysis revealed that transanal drainage was the only significant factor (HR = −2.90; −0.168 to −0.032; p = 0.007) affecting anastomotic leakage.

Conclusions

Placement of a transanal drainage tube in patients with colorectal anastomoses is a safe and simple technique to perform and reduces anastomotic leakage, the severity of the complication and hospital stay.

•

A transanal drainage tube as a mechanism to reduce anastomotic leakage is proposed.

•

Transanal drainage tube reduces anastomotic leakage 3.6% vs. 13.6% (p = 0.007).

•

Transanal drainage reduced the grade of complication (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006).

Transanal tube placement for prevention of anastomotic leakage following low anterior resection for rectal cancer: a systematic review and meta-analysis

Purpose

Anastomotic leakage following low anterior resection (LAR) for rectal cancer is a serious complication that increases morbidity and mortality rates. Transanal tube placement may reduce postoperative anastomotic leakage rate by reducing intraluminal pressure and preventing fecal extrusion through the staple line. This meta-analysis evaluated the effectiveness of transanal tube placement to prevent anastomotic leakage after LAR for rectal cancer using a stapling technique.

Methods

A systematic review of the literature was consistent with the recommendations of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement. Multiple comprehensive databases, including PubMed, Embase, Cochrane Library and KoreaMed, were searched. The main study outcomes were anastomotic leakage.

Results

Two randomized clinical trials and 4 nonrandomized studies involving 1,118 patients were included. Subgroup analyses of randomized clinical trials found that transanal tube placement had no effect on study outcomes. Meta-analysis of nonrandomized studies showed that transanal tube placement was associated with a lower incidence of anastomotic leakage (relative risk, 0.32; 95% CI, 0.15-0.67; I² = 0%).

Conclusion

Transanal tube placement may be effective in preventing or reducing the occurrence of anastomotic leakage after LAR for rectal cancer using a stapling technique. Randomized clinical trials with sufficient power are needed to confirm the benefit of transanal tube placement.

Distant Metastasis in Colorectal Cancer is a Risk Factor for Anastomotic Leakage

PURPOSE

The aim of this study was to investigate whether metastatic colorectal cancer (Union for International Cancer Control stage IV disease) represents a risk factor for anastomotic leakage after colorectal surgery without major hepatic resection.

METHODS

This retrospective cohort study was based on an existing prospective colorectal database of all consecutive colorectal resections undertaken at the authors' institution from July 2002 to July 2012 (n = 2104). All patients with colorectal resection and primary anastomosis for colorectal cancer were identified (n = 500). A temporary loop ileostomy was constructed in low rectal anastomosis up to 6 cm from the anal verge (n = 128 cases, 26%). A routine contrast enema was undertaken at the occasion of other prospective studies in 254 patients. UICC stage IV disease was present in 94 patients (19%), while 406 patients (81%) had UICC stage I-III disease.

RESULTS

The overall anastomotic leak rate was 2.6% (13/500), 2.2% (11/500) for both clinical and radiological leaks, and 0.8% (2/254) for radiological leaks only. Four were managed conservatively and nine (1.8%) required revision laparotomy. In the case of UICC stage IV disease, the anastomotic leak rate was 6.3% (6/94), while in the case of UICC stage I-III disease the leak rate was 1.7% (7/406). UICC stage IV disease [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.3-14.4; p = 0.015] and diabetes (OR 5.7, 95% CI 1.7-18.7; p = 0.004) were independent risk factors for anastomotic leakage after colorectal surgery.

CONCLUSIONS

Patients with stage IV colorectal cancer have an increased anastomotic leak rate after colorectal surgery. Whether this is due to an impaired immune system remains speculative.

Impact of anal decompression on anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis

PURPOSE

The effectiveness of a transanal drainage tube for the prevention of anastomotic leakage (AL) is still uncertain. This study aimed to investigate the impact of anal decompression on AL after rectal cancer surgery.

METHODS

We retrospectively reviewed 536 rectal cancer patients who underwent low anterior resection without diverting stoma, with (n = 154) or without (n = 382) placing of a transanal drainage tube, between January 2005 and December 2014. Risk factors for AL were analyzed, and propensity score matching analysis was used to compensate for the differences in baseline characteristics.

RESULTS

AL occurred in 50 (9.3%) of the patients. Male sex (odds ratio [OR] 3.097, p = 0.005), high ASA score (OR 3.505, p = 0.025), and neoadjuvant chemoradiation (OR 2.506, p = 0.018) were independent predictors of AL on multivariable analysis. After propensity score matching, transanal drainage tube tended to lessen rates of grade C AL with definite peritonitis (1.9 vs. 5.8%, p = 0.077), although there was no difference in the incidence of AL in patients with or without transanal drainage tubes (5.8 vs. 9.1%, p = 0.278).

CONCLUSIONS

Placement of a transanal drainage tube was not associated with a reduction in the total incidence of AL after low anterior resection for rectal cancer.

Transanal Tube as a Means of Prevention of Anastomotic Leakage after Rectal Cancer Surgery

BACKGROUND

Anastomotic leaks after low anterior resection for rectal cancer remain the most feared complication. The aim of our study was to investigate whether the use of a transanal tube could reduce the leakage rate after this surgical procedure.

METHODS

This is a retrospective analysis of a single-institution experience. The study includes 66 patients who underwent low anterior resection for rectal cancer without stoma creation between January 2008 and June 2013. Patients were divided into two groups, i.e. those with a transanal drainage tube (TT; n = 9) and those without tube (NTT; n = 57), and evaluated for clinically evident anastomotic leakage and postoperative complications.

RESULTS

The postoperative anastomotic leakage appeared in 5 patients (9%) in the NTT group while no single case was observed within the TT group. Despite the disadvantageous background in the TT group (a transanal stent was used in the most high-risk patients), these patients had no postoperative complications. In the NTT group, 23% had some kind of postoperative complications, and 5% died. The difference between the two groups is not significant.

CONCLUSIONS

Our study showed that the use of a transanal tube in low anterior resection for rectal cancer could potentially be a simple and effective method of reducing anastomotic leakage. In order to prove our observations, larger prospective randomized studies should be performed.

Circular anastomotic experimental fibrin sealant protection in deep colorectal anastomosis in pigs in a randomized 9-day survival study

PURPOSE

The reported rate of clinically apparent anastomotic leakage (AL) in a low anterior resection of the rectum (LAR) (≤7 cm from the anal verge) using a circular double-stapled anastomosis (CDSA) without defunctioning stoma is up to 37.5 %. Since AL may result in life-threatening peritonitis, sepsis, and multiple organ failure, LAR and CDSA are regularly combined with defunctioning stoma. Accordingly, we now evaluated whether LAR and CDSA without defunctioning stoma but with extraluminal anastomotic application of an experimental fibrin sealant reduce the AL rate. This might prevent humans from defunctioning stoma increasing quality of life and decreasing surgical costs.

METHODS

Forty 8-week-old pigs underwent LAR and CDSA in an end-to-end technique (descendo-rectostomy). Animals were randomized into a therapy and control group (gr.). The therapy gr. (n = 20) received an additional extraluminal circular application of an experimental fibrin sealant to the anastomosis. The objective was to assess the incidence of clinically apparent and non-clinically apparent leakage through the ninth postoperative day. Double-contrast barium CT radiographs of the colorectal region were performed on the ninth postoperative day or earlier, in case there were clinical signs of AL. All remaining animals were sacrificed on the ninth postoperative day and the anastomotic region was histopathologically analyzed. In case of earlier diagnosed AL, animals were sacrificed immediately. Blood samples were taken for complete blood count, chemistry, and coagulation profile prior to surgery and on the first, third, fifth, seventh, and ninth postoperative day.

RESULTS

A circular extraluminal anastomotic application of an experimental fibrin protection decreased the rate of clinically and non-clinically apparent AL from 20 % (n = 4) in the control group to 5 % (n = 1) in the treatment group. Ulcerations were also observed in both gr. (control gr.-5 animals, therapy gr. -3 animals). All animals with AL showed necrosis surrounding the hole at the anastomoses. Three additional animals had a full wall defect at the anastomotic region that was blocked by the experimental fibrin sealant. The fibrin sealant was present at necropsy in all treated animals.

CONCLUSION

Circular anastomotic protection with the experimental fibrin sealant blocked anastomotic full wall defects, preventing peritonitis and significantly reducing the AL rate from 25 to 5 %.

Effectiveness of a transanal tube for the prevention of anastomotic leakage after rectal cancer surgery

AIM

We evaluated the effectiveness and safety of a transanal tube placed for the prevention of anastomotic leakage after rectal surgery.

METHODS

Between 2007 and 2011, a total of 243 patients underwent anterior resection using the double stapling technique for rectal cancer at our institution. We excluded 67 patients with diverting stoma and divided the remaining patients into two groups: patients who did not receive a transanal tube and diverting stoma (n = 140; control group) and those who received a transanal tube (n = 36). We compared the rate of anastomotic leakage, evaluated the complications associated with the transanal tube, and analyzed the risk factors for anastomotic leakage.

RESULTS

The following perioperative parameters were significantly different between the two groups as follows (control group vs. transanal tube group): diabetes mellitus (8 [22 %] vs. 12 [8.5 %] patients, respectively; p = 0.03), surgical duration (262 ± 54.1 min [171-457] vs. 233 ± 61.7 min [126-430], respectively; p < 0.01). The postoperative anastomosis leakage appeared significantly different between the two groups (1 [2.7 %] vs. 22 [15.7 %] patients, respectively; p = 0.04). Anastomotic leakage was significantly associated with the distance between the anastomosis line and the anal verge (odds ratio [OR] 8.58; 95 % confidence interval [CI] 1.53-48.0; p = 0.01) and non-use of a transanal tube (OR 11.1; 95 % CI 1.04-118; p = 0.04) in both univariate and multivariate analyses.

CONCLUSIONS

Placement of a transanal tube is effective in decreasing the rate of anastomotic leakage after anterior resection using the double stapling technique. However, complications associated with a transanal tube should be carefully considered.

A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer

BACKGROUND

The safety and efficacy of transanal drainage tube (TDT) placement to decrease the risk of postoperative anastomotic leakage after rectal cancer surgery has not been validated. The objective of this meta-analysis was to evaluate the usefulness of a TDT for the prevention of anastomotic leakage after an anterior resection for rectal cancer.

METHODS

The PubMed and Cochrane Library databases were searched for studies comparing TDT and non-TDT. The endpoint utilized in this study was defined as the rates of anastomotic leakage and re-operation. The relative effects of these variables were synthesized using Review Manager 5.1 software.

RESULTS

Four trials including 909 participants (401 TDT cases and 508 non-TDT cases) met our inclusion criteria. The weighted mean anastomotic leakage rate was 4% [95% confidence interval (CI) 1-6%], and a significantly lower risk of anastomotic leakage was identified in the TDT group compared with the non-TDT group [odds ratio (OR) 0.30; 95% CI 0.16-0.55; p = 0.0001]. Furthermore, there were significant differences between the TDT and non-TDT groups in terms of the re-operation rate (OR 0.18; 95% CI 0.07-0.44; p = 0.0002). No significant covariates related to anastomotic leakage or re-operation were identified in meta-regression analysis. Both the anastomotic leakage and re-operation rates for all studies lay inside the 95% confidence interval boundaries. No visible publication bias was found by visual assessment of the funnel plot (Egger's test; anastomotic leakage: p = 0.056, re-operation: p = 0.681).

CONCLUSIONS

Placement of a TDT is an effective and safe procedure that can decrease the rate of anastomotic leakage and re-operation after an anterior resection.