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Svoboda M, Procházka V, Grolich T, Pavlík T, Mazalová M, Kala Z. Does Pathological Complete Response after Neoadjuvant Therapy Influence Postoperative Morbidity in Rectal Cancer after Transanal Total Mesorectal Excision? J Gastrointest Cancer 2023; 54:528-535. [PMID: 35524090 DOI: 10.1007/s12029-022-00826-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is still unclear if pathological complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) in patients treated for rectal cancer causes worse postoperative outcomes, especially after transanal total mesorectal excision (TaTME). Worse postoperative outcomes might be an argument for an organ preserving watch and wait strategy in fragile patients and patients with comorbidities. The aim of this study is to evaluate whether patients treated for rectal cancer who had pCR to neoadjuvant therapy develop worse postoperative outcomes after TaTME than patients without complete response. METHODS Comparative retrospective analysis (with nearest neighbor matching algorithm) of postoperative outcomes in two groups of patients, with pCR, n = 15 and without pCR (non-pCR), n = 57. All patients were operated on only by one surgical approach, TaTME, for middle and distal rectal tumors. All procedures were performed by one surgical team between 2014 and 2020 at the University Hospital Brno in Czech Republic. RESULTS Overall morbidity was comparable between the groups (pCR group - 53.8% vs. non-pCR - 38.6%, p = 0.381). Anastomotic leak (AL) was observed in 33.3% of patients with pCR and in 17.5% of patients in the non-pCR group without statistical significance (p = 0.281). CONCLUSION In conclusion, pathological complete response after neoadjuvant therapy does not appear to affect postoperative morbidity in rectal cancer after TaTME. Therefore, in patients with complete response who are not adherent to W&W surveillance, surgical resection can be perform without increased postoperative complications.
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Affiliation(s)
- Martin Svoboda
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Vladimír Procházka
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic.
| | - Tomáš Grolich
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
| | - Tomáš Pavlík
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Monika Mazalová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Kala
- Department of Surgery, Faculty of Medicine, University Hospital Brno Bohunice, Masaryk University, Brno, Czech Republic
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Bediako-Bowan AAA, Naalane N, Dakubo JCB. Morbidity and oncological outcomes after intersphincteric resection of the rectum for low-lying rectal cancer: experience of a single center in a lower-middle-income country. BMC Surg 2023; 23:39. [PMID: 36805711 PMCID: PMC9938915 DOI: 10.1186/s12893-023-01940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Intersphincteric resection (ISR) of the rectum for low-lying rectal cancer with colo-anal anastomosis was introduced years ago, allowing for bowel continuity, and avoiding permanent stomas. The colorectal unit of Korle Bu Teaching Hospital adopted this procedure in 2014 when indicated, for the management of rectal cancers, where hitherto, abdominoperineal resection of the rectum with a permanent stoma was indicated. This study aimed to assess morbidity, mortality, and oncological outcomes associated with ISR of the rectum and determine the factors contributing to these. METHODS This was an observational study from prospectively stored data. All patients who underwent intersphincteric resection of the rectum due to low-lying rectal cancer from July 2014 to June 2021 were included in the study, and their records were assessed for intra-operative and 30-day postoperative complications, as well as mortality and their related risk factors and their oncological outcomes in terms of local recurrence at one year. RESULTS 102 patients were included in this analysis. Six percent (6/102) of patients had intra-operative complications, including bleeding, and 41% (42/102) had 30-day postoperative complications, which were associated with pelvic side wall attachment of tumor and intra-op complications. Mortality risk was 12.7% (13/102) in the early postoperative period, and nine patients had a local recurrence within the first year of surgery. CONCLUSION There is a high risk of early postoperative morbidity and mortality after intersphincteric resection of the rectum in our setting. The oncological outcomes are favorable in a population that abhors a permanent colostomy.
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Affiliation(s)
- Antoinette Afua Asiedua Bediako-Bowan
- Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana. .,Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana. .,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana.
| | - Narious Naalane
- grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana
| | - Jonathan C. B. Dakubo
- grid.8652.90000 0004 1937 1485Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana ,grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana ,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana
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When Is a Diverting Stoma Indicated after Low Anterior Resection? A Meta-analysis of Randomized Trials and Meta-Regression of the Risk Factors of Leakage and Complications in Non-Diverted Patients. J Gastrointest Surg 2022; 26:2368-2379. [PMID: 35915378 DOI: 10.1007/s11605-022-05427-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a potentially life-threatening complication after low anterior resection (LAR). This meta-analysis aimed to compare outcomes of LAR with and without diverting stoma and to determine factors associated with AL in non-diverted patients. METHODS This was a PRISMA-compliant systematic review of electronic databases (PubMed, Scopus, and Web of Science). Randomized controlled trials comparing LAR with and without diverting stoma were included. Main outcome measures were AL, complications, and operation time in the two groups and risk factors of AL in non-diverted patients. RESULTS Nine randomized control trials (RCTs) (946 patients; 53.2% male) were included. The diverting stoma group had lower odds of complications (OR: 0.61, 95%CI: 0.461-0.828; p < 0.001), AL (OR: 0.362, 95%CI: 0.236-0.555; p < 0.001, I2 = 0), abscess (OR: 0.392, 95%CI: 0.174-0.883; p < 0.024, I2 = 0), and reoperation (OR: 0.352, 95%CI: 0.222-0.559, p < 0.001, I2 = 0) than the no-diversion group. Both groups had comparable odds of bowel obstruction, surgical site infection, and perioperative mortality. The weighted mean operation time in the diverting stoma group was longer than the no-diversion group (WMD: 34.804, 95%CI: 14.649-54.960, p < 0.001). Factors significantly associated with AL in non-diverted patients were higher body mass index (BMI), ASA ≥ 3, lower tumor height, neoadjuvant therapy, open surgery, end-to-end anastomosis, and longer operation time. CONCLUSIONS Non-diverted patients with increased body mass index, high American Society of Anesthesiologists scores, low rectal cancers, received neoadjuvant therapy, underwent open surgery, end-to-end anastomosis, and longer operation times were at a higher risk of AL after LAR.
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Plastiras A, Korkolis D, Frountzas M, Theodoropoulos G. The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients. Discov Oncol 2022; 13:52. [PMID: 35751713 PMCID: PMC9233722 DOI: 10.1007/s12672-022-00518-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this review was to collect all available literature data analysing the effects of the anastomotic leak (AL) on post-sphincter preserving rectal cancer surgery bowel and urogenital function as well as to quality of life (QoL) dimensions. METHODS A literature search of the PubMed and Embase electronic databases was conducted by two independent investigators and all studies using either functional parameters or QoL as a primary or secondary endpoint after a rectal cancer surgery AL were included. RESULTS Amongst the 13 identified studies focusing on the post-AL neorecto-anal function, 3 case-matched studies,3 comparative studies and 1 population-based study supported the deleterious effects of the AL on bowel function, with disturbances of the types of high bowel movement frequency, urgency and increased incontinent episodes to predominate. At one case-matched study the Low Anterior Resection Syndrome (LARS) score was inferior in the AL patients. At limited under-powered studies, urinary frequency, reduced male sexual activity and female dyspareunia may be linked to a prior AL. According to two QoL-targeted detailed studies, QoL disturbances, such as physical and emotional function difficulties may persist up to 3 years after the AL occurrence. CONCLUSIONS AL may have adverse effects on postoperative pelvic function and QoL in rectal cancer patients. As evidenced by this literature review, the limited reports on this intriguing topic may trigger the initiative for planning and undertaking larger, multicentre studies on rectal cancer patients with varying degrees of AL severity.
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Affiliation(s)
- Aris Plastiras
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Dimitrios Korkolis
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Maximos Frountzas
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece
| | - George Theodoropoulos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece.
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Collard MK, Rullier E, Panis Y, Manceau G, Benoist S, Tuech JJ, Alves A, Laforest A, Mege D, Cazelles A, Beyer-Berjot L, Christou N, Cotte E, Lakkis Z, O'Connell L, Parc Y, Piessen G, Lefevre JH. Nonmetastatic ypt0 rectal cancer after neoadjuvant treatment and total mesorectal excision: Lessons from a retrospective multicentric cohort of 383 patients. Surgery 2022; 171:1193-1199. [PMID: 35078629 DOI: 10.1016/j.surg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision. METHODS All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored. RESULTS Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124). CONCLUSION The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.
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Affiliation(s)
- Maxime K Collard
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | - Eric Rullier
- Department of Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Université de Paris, Faculté de Médecine, Paris, France
| | - Stéphane Benoist
- Department of Digestive Surgery, Kremlin-Bicêtre Hospital, France
| | | | - Arnaud Alves
- Department of Digestive Surgery, Rouen Hospital, France
| | - Anais Laforest
- Department of Digestive Surgery, Montsouris Institut, Paris, France
| | - Diane Mege
- Department of Digestive Surgery, Aix Marseille Univ, APHM, Timone University Hospital, Marseille, France
| | | | | | - Niki Christou
- Department of Digestive Surgery, Limoges Hospital, Limoges, France
| | - Eddy Cotte
- Department of Digestive Surgery, Hopital Lyon Sud, Lyon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, Jean Minoz Hospital, Besançon, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Yann Parc
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France
| | | | - Jérémie H Lefevre
- Department of Digestive Surgery, Saint Antoine Hospital, Sorbonne University Paris, France.
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