Neoadjuvant chemoradiotherapy for rectal carcinoma: effects on anastomotic leak rate and postoperative bladder dysfunction after non-emergency sphincter-preserving anterior rectal resection

Effects of Neoadjuvant Radiotherapy on Postoperative Complications in Rectal Cancer: A Meta-Analysis

Objective

Neoadjuvant radiotherapy (nRT) is an important treatment approach for rectal cancer. The relationship, however, between nRT and postoperative complications is still controversial. Here, we conducted a meta-analysis to evaluate such concerns.

Methods

The electronic literature from 1983 to 2021 was searched in PubMed, Embase, and Web of Science. Postoperative complications after nRT were included in the meta-analysis. The pooled odds ratio (OR) was calculated by the random-effects model. Statistical analysis was conducted by Review Manager 5.3 and STATA 14.

Results

A total of 23,723 patients from 49 studies were included in the meta-analysis. The pooled results showed that nRT increased the risk of anastomotic leakage (AL) compared to upfront surgery (OR = 1.23; 95% CI, 1.07-1.41; p=0.004). Subgroup analysis suggested that both long-course (OR = 1.20, 95% CI 1.03-1.40; p=0.02) and short-course radiotherapy (OR = 1.25, 95% CI, 1.02-1.53; p=0.04) increased the incidence of AL. In addition, nRT was the main risk factor for wound infection and pelvic abscess. The pooled data in randomized controlled trials, however, indicated that nRT was not associated with AL (OR = 1.01; 95% CI 0.82-1.26; p=0.91).

Conclusions

nRT may increase the risk of AL, wound infection, and pelvic abscess compared to upfront surgery among patients with rectal cancer.

Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: a systematic review and meta-analysis

The level of ligation of the inferior mesenteric artery (IMA) is a critical factor that can influence outcomes. The aim of this meta-analysis was to compare outcomes following high or low ligation of IMA. A systematic search was performed for relevant articles published between 2000 and 2020. Meta-analysis was performed using fixed-effects or random-effects models; 31 studies were included. Results show significantly lower rates of anastomotic leak, postoperative morbidity and urinary dysfunction with low ligation compared with high ligation. Though recurrence rates were similar, 5-year overall survival was longer in the low ligation group. Low ligation of IMA decreases anastomotic leak rates and overall morbidity. Addition of IMA nodal clearance to low ligation appears to improve overall survival in colorectal cancer.

T stage-dependent lymph node and distant metastasis and the accuracy of lymph node assessment in rectal cancer

Objective

To analyze data obtained in a representative number of patients with primary rectal cancer with respect to lymph node diagnostics and related tumor stages.

Methods

In pT2-, pT3-, and pT4 rectal cancer lesions, the impact of investigated lymph nodes on the frequency of pN+ status, the cumulative risk of metachronous distant metastases, and overall survival was studied by means of a prospective multicenter observational study over a defined period of time.

Results

From 2000 to 2011, the proportion of surgical specimens with ≥ 12 investigated lymph nodes increased significantly, from 73.6% to 93.2% (p < 0.001; the number of investigated lymph nodes from 16.2 to 20.8; p < 0.001). Despite this, the percentage of pN+ rectal cancer lesions varied only non-significantly (39.9% to 45.9%; p = 0.130; median, 44.1%). For pT2-, pT3-, and pT4 rectal cancer lesions, there was an increasing proportion of pN+ findings correlating significantly with the number of investigated lymph nodes up to n = 12 investigated lymph nodes. Only in pT3 rectal cancer was there a significant increase in pN+ findings in case of > 12 lymph nodes (p = 0.001), but not in pT2 (p = 0.655) and pT4 cancer lesions (p = 0.256). For pT3pN0cM0 rectal cancer, the risk of metachronous distant metastases and overall survival did not depend on the number of investigated lymph nodes.

Conclusion

In rectal cancer, at least n = 12 lymph nodes are to be minimally investigated. The investigation of fewer lymph nodes is associated with a higher risk of false-negative pN0 findings. In particular, in pT3 rectal cancer, the investigation of more than 12 lymph nodes lowers the risk of false-negative pN0 findings. An upstaging effect by the investigation of a possibly maximal number of lymph nodes could not be detected.

Can we better predict readmission for dehydration following creation of a diverting loop ileostomy: development and validation of a prediction model and web-based risk calculator

BACKGROUND

Dehydration is the most common morbidity following creation of a diverting loop ileostomy (DLI). We aimed to develop and validate a prediction model and web-based risk calculator for readmission for dehydration following DLI creation.

METHODS

After institutional review board approval, we retrospectively reviewed the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Adult patients (> 18 years) who underwent DLI with a resection for colorectal cancer, inflammatory bowel disease, or diverticulitis were identified. Patient demographics, operative and postoperative data were collected. The final prediction model, developed in 60% of the cohort (training set) and which modeled the 30-day cumulative incidence of readmission for dehydration, was selected using highest area under the receiver operating curve (AUC) criterion. Model calibration was assessed with the Hosmer-Lemeshow goodness-of-fit test. The model was then assessed in validation and test sets, using 20% of the cohort for each.

RESULTS

Of 25,638 patients in the ACS-NSQIP database who met inclusion criteria, 15,222 patients were randomly selected for the training set. The incidence of readmission for dehydration in this cohort was 2.1%. The final model with the highest AUC retained 12 candidate variables: age, sex, smoking status, diabetes, hypertension, American Society of Anesthesiologists score, type of admission, underlying diagnosis, procedure performed, operative time, index admission length of stay, and major morbidity. The model demonstrated good discrimination (AUC 0.76, 95% CI 0.74-0.79) and the Hosmer-Lemeshow goodness-of-fit test confirmed good calibration (p = 0.50). Five-thousand and seventy-three patients were available for the validation and test sets, respectively, and the model remained strong in both the validation and test sets (AUCs of 0.73 and 0.73, respectively). The prediction model was then converted into a web-based risk calculator.

CONCLUSIONS

A prediction model and web-based risk calculator for readmission for dehydration after DLI creation was developed and validated, demonstrating good predictive capabilities.

Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure

Background

Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure.

Methods

The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia.

Results

The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538).

Conclusion

A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.

Tolerability, Safety, and Outcomes of Neoadjuvant Chemoradiotherapy With Capecitabine for Patients Aged ≥ 70 Years With Locally Advanced Rectal Cancer

INTRODUCTION

In studies of colorectal cancer, the elderly have been frequently underrepresented because comorbid conditions and functional status often lead to study exclusion. For elderly patients with an indication for neoadjuvant chemoradiotherapy (nCRT), physicians usually decide using clinical factors whether nCRT should be offered. The aim of the present retrospective study was to assess the tolerability of nCRT with capecitabine and the surgical outcomes in patients aged ≥ 70 years with locally advanced rectal cancer.

PATIENTS AND METHODS

Data from 1372 rectal cancer patients diagnosed from 2002 to 2012 at 4 Dutch hospitals were used. Patients aged ≥ 70 years were included if they had received nCRT, and their data were analyzed for treatment deviations, postoperative complications, mortality, disease-free survival (DFS), and overall survival (OS). The data were stratified into 3 age groups (ie, 70-74, 75-79, and ≥ 80 years).

RESULTS

We identified 447 patients aged ≥ 70 years. Of these patients, 42 had received nCRT, and 37 (88%) had completed nCRT. Radiation dermatitis, fatigue, and diarrhea were reported in 62%, 57%, and 43% of the 42 patients, respectively. Of the 42 patients, 40 (95%) underwent surgery, 1 patient refused resection, and 1 patient died during nCRT of severe mucositis due to dihydropyrimidine dehydrogenase deficiency. The postoperative complication rate was 30%, and the 30-day mortality rate was 0%. A pathologic complete response was found in 7.5%. The 2- and 5-year DFS and OS rates were 58.5% and 40.7% and 81.0% and 58.2%, respectively.

CONCLUSION

The results of the present multicenter study have shown that if selected on clinical factors, nCRT with capecitabine is safe and well tolerated in elderly patients. No negative effect on surgical outcome was measured, and the beneficial effect (pathologic complete response, DFS, and OS) seemed comparable to that for younger age groups. We believe that elderly patients should not be excluded from nCRT on the basis of age only.

Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis

AIM

The aim was to evaluate the association of neoadjuvant therapy with increases in the incidence of anastomotic leakage (AL) after middle and low rectal anterior resection.

METHOD

The electronic databases of PubMed, Web of Science, Scopus and Ovid were searched between 1980 and 2015. The random effects model was used to model the pooled data to determine the odds ratio with 95% confidence interval. Heterogeneity was evaluated using the Q test and I² statistics. Subgroup, sensitivity and meta-regression analysis was conducted to explore heterogeneity.

RESULTS

Neoadjuvant therapy was not shown to increase the incidence of postoperative AL as demonstrated by an OR of 1.16 [95% CI 0.99-1.36; P = 0.07 (random effects model)]. The subgroup analysis of neoadjuvant radiotherapy using the random effects model suggested that it did not increase the rate of postoperative AL (OR = 1.24, 95% CI 0.97-1.58; P = 0.08). The subgroup analysis of neoadjuvant chemoradiotherapy indicated that the rate of postoperative AL again did not increase with an OR = 1.06 [95% CI 0.86-1.30; P = 0.59 (random effects model)]. The interval to surgery after neoadjuvant therapy and preoperative radiotherapy (short or long course) was not associated with an increased incidence of postoperative AL.

CONCLUSION

Neoadjuvant therapy does not appear to increase the incidence of postoperative AL after anterior resection for mid and low rectal cancer. In addition, neither the interval to surgery after neoadjuvant therapy nor the radiotherapy regimen increases the rate of postoperative AL.

A prospective study of sexual and urinary function before and after total mesorectal excision

PURPOSE

Although rectal cancer is a very common malignancy and has an improved cure rate in response to oncological treatment, research on rectal cancer survivors' urogenital function remains limited. In this study, urogenital dysfunction after surgical rectal cancer treatment was measured and possible predisposing factors that may have an impact on the development of this disorder were discussed.

METHODS

One hundred eight patients undergoing curative rectal cancer surgery from January 2008 to December 2014 were questioned using questionnaires: male urinary function was assessed using the International Prostatic Symptom Score (IPSS) questionnaire, for sexual function-International Index of Erectile Function (IIEF). The Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire and the Female Sexual Function Index (FSFI) were used for female urogenital function assessment prior to the operation and 6 months postoperatively.

RESULTS

A total of 67.0 % of male (36) and 33.0 % (18) of female patients who completed the questionnaire were included in the study. Preoperatively, male urinary dysfunction was 80.1 % and postoperatively-88.9 %. In female patients, preoperative urinary dysfunction was seen in 75.0 % patients, postoperatively-78.0 %. Erectile dysfunction was seen in 41.7 % males preoperatively and in 63.9 % postoperatively. A total of 83.3 % of female patients had sexual dysfunction preoperatively and 94 % postoperatively.

CONCLUSION

Sexual and urinary problems after surgery for rectal cancer are common. Preoperative genitourinary dysfunction is not uncommon in patients older than 60 years as well. Female patients reported higher rates of sexual dysfunction than males. These results point out the importance of sexual and urinary (dys)function in survivors of rectal cancer. More attention should be drawn to this topic for clinical and research purposes.

Surgery for rectal cancer after high-dose radiotherapy for prostate cancer: is sphincter preservation relevant?

AIM

The feasibility and outcome of sphincter-saving resection for rectal cancer were assessed in patients previously treated by high-dose radiotherapy for prostate cancer.

METHOD

Between 2000 and 2012, 1066 patients underwent rectal excision for rectal cancer. Of these, 236 were treated by conventional radiotherapy (45 Gy) and sphincter-saving resection (Group A) and 12 were treated by external-beam radiotherapy (EBRT) for prostate cancer (70 Gy) and sphincter-saving resection (Group B) of whom five had a metachronous and seven a synchronous cancer. The end-points were surgical morbidity, pelvic sepsis, reoperation and definitive stoma.

RESULTS

Tumour characteristics were similar in both groups. Surgical morbidity (67% vs 25%, P = 0.004), anastomotic leakage (50% vs 10%, P = 0.001, and reoperation (50% vs 17%, P = 0.011) were significantly higher in Group B. Multivariate analyses showed that EBRT for prostate cancer was the only independent factor for anastomotic leakage (OR = 5.12; 95% CI 1.45-18.08; P = 0.011) and definitive stoma (OR = 10.56; 95% CI 3.02-39.92; P < 0.001).

CONCLUSION

High-dose radiotherapy for prostate cancer increases morbidity from rectal surgery and the risk of a permanent stoma. This suggests that a delayed coloanal anastomosis or a Hartmann procedure should be proposed as an alternative to low anterior resection in this population.

Utility of indocyanine-green fluorescent imaging during robot-assisted sphincter-saving surgery on rectal cancer patients

BACKGROUND

There have been few studies describing the use of indocyanine green (ICG) fluorescent imaging during robot-assisted (RA) sphincter-saving operations (SSOs) and assessing its potential role in reducing anastomotic leak (AL).

METHODS

A consecutive cohort of 436 rectal cancer patients who underwent curative RA SSOs were prospectively enrolled during 2010-2014, including 123 patients with ICG imaging (ICG⁺ group) and 313 patients without ICG imaging (ICG^- group).

RESULTS

ICG imaging appeared to be helpful in identifying competent perfusion of the bowel adjacent to the anastomosis in 13 patients (10.6%) who might be susceptible to bowel ischaemia, including restrictive mesocolon. AL was remarkably greater in the ICG^- group compared with the ICG⁺ group (5.4% vs 0.8%; p = 0.031).

CONCLUSIONS

ICG imaging during RA SSO provides accurate real-time knowledge of the perfusion status at or near the anastomosis, specifically reducing AL in patients who may incur bowel ischaemia. Copyright © 2015 John Wiley & Sons, Ltd.

Surgeon perspectives on the use and effects of neoadjuvant chemoradiation in the treatment of rectal cancer: a comprehensive review of the literature

BACKGROUND

Despite screening initiatives, rectal cancer remains one of the most prevalent malignancies diagnosed in patients worldwide with a high mortality. The introduction of neoadjuvant therapy has resulted in a paradigm shift in the treatment and outcomes of rectal cancer. Surgeons play an intricate role in the pre-operative, operative, and post-operative management of these patients.

PURPOSE

The purpose of this comprehensive literature review was to summarize the evolution of the use chemotherapy and radiation and the process of differentiation into specific neoadjuvant chemoradiation protocols in the treatment of locally advanced rectal cancer. This will provide a concise summary for practicing surgeons of the current evidence for neoadjuvant chemoradiation as well as the various implications of therapy on operative outcomes.

CONCLUSION

The initial benefit of adjuvant therapy in the treatment of rectal cancer patients became evident with prospective studies demonstrating improvements in various oncologic survival outcomes. Due to the improved compliance and reduced toxicity, as well as the potential for tumor down-staging and sphincter preservation, neoadjuvant approaches became the preferred method of administering chemotherapy and radiation. Furthermore, a subgroup of patients has been shown to present with complete clinical response to neoadjuvant therapy. This has resulted in the development of the non-operative "watch and wait" approach, which has initiated discussions on changing the interval from the completion of neoadjuvant therapy to surgical resection. The continued development of the multidisciplinary approach will only further improve our ability to provide patients with the best possible oncologic outcomes.

Radiation dose does not influence anastomotic complications in patients with esophageal cancer treated with neoadjuvant chemoradiation and transhiatal esophagectomy

Background

Neoadjuvant chemoradiation might increase anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. The aim of this study was to determine the influence of radiation dose on the incidence of leakage and stenosis.

Methods

Fifty-three patients with esophageal cancer received neoadjuvant chemoradiation (23 × 1.8 Gy) (combined with Paclitaxel and Carboplatin) followed by a transhiatal esophagectomy between 2009 and 2011. On planning CT, the future anastomotic region was determined and the mean radiation dose, V20, V25, V30, V35 and V40 were calculated. Logistic regression analysis was conducted to examine determinants of anastomotic leakage and stenosis.

Results

Anastomotic leaks occurred in 13 of 53 patients (25.5%) and anastomotic stenosis occurred in 24 of 53 patients (45.3%). Median follow-up was 20 months. Logistic regression analysis showed that mean dose, V20-V40, age, co-morbidity, method of anastomosis, operating time and interval between last radiotherapy treatment and surgery were not predictors of anastomotic leakage and stenosis.

Conclusions

A radiation dose of 23 × 1.8 Gy on the future anastomotic region has no influence on the occurrence of anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation followed by transhiatal esophagectomy.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks

BACKGROUND

Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

METHODS

A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

RESULTS

Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

CONCLUSION

Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.

Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study

AIM

Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction.

METHOD

All living female patients who underwent abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ-FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009.

RESULTS

Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties (OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions (OR = 4.77, 95% CI 1.97-11.55), dyspareunia (OR = 2.76, 95% CI 1.12-6.79), lack of desire (OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity (OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia (OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties (OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence (OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire (OR = 2.69, 95% CI 1.21-5.98), sexual inactivity (OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction (OR = 0.40, 95% CI 0.20-0.82).

CONCLUSION

Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction.

Anastomotic Leakage after Anterior Resection for Rectal Cancer with Mesorectal Excision: Incidence, Risk Factors, and Management

We investigated risk factors and prognostic implications of symptomatic anastomotic leakage after anterior resection for rectal cancer, and the influence of a diverting stoma. Our retrospective review of prospective collected data analyzed 475 patients who underwent anterior resection for rectal cancer. Uni- and multivariate analysis was made between anastomotic leakage and patient, tumor, and treatment variables, either for the overall group (n = 475) and in the midlow rectal cancer subgroup (n = 291). Overall rate of symptomatic leakage was 9 per cent (43 of 475) with no related postoperative mortality. At univariate analysis, significant factors for leak were a tumor less than 6 cm from the anal verge (13.7 vs 6.6%; P = 0.011) and intraoperative transfusions (16.9 vs 4.3%; P = 0.001). Similar results were observed in the midlow rectal cancer subgroup. At multivariate analysis, no parameter resulted in being an independent prognostic factor for risk of leakage. In patients with a leakage, a temporary enterostomy considerably reduced the need for reoperation (12.5 vs 77.8%; P < 0.0001) and the risk of a permanent stoma (18.7 vs 28.5%; P = 0.49). The incidence of anastomotic failure increases for lower tumors, whereas it is not influenced by radiotherapy. Defunctioning enterostomy does not influence the leak rate, but it mitigates clinical consequences.

Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials

Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80-1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.

Preoperative chemoradiotherapy effects on anastomotic leakage after rectal cancer resection: a propensity score matching analysis

OBJECTIVE

To assess the effects of preoperative chemoradiotherapy (CRT) on anastomotic leakage (AL) after rectal cancer resection, using propensity score matching.

BACKGROUND

Conflicting data have emerged over the last decade regarding the effect of preoperative CRT on AL.

METHODS

We reviewed 1437 consecutive patients with rectal cancer who underwent low anterior resection (LAR) at our institution between 2005 and 2012. AL evaluated as grade C was the primary endpoint, as proposed by the International Study Group of Rectal Cancer in 2010. The patients were treated with (n = 360) or without (n = 1077) preoperative CRT. The total radiation dose was 50.4 Gy in 28 fractions. Multivariate and propensity score matching analyses were used to compensate for the differences in some baseline characteristics.

RESULTS

The preoperative CRT group contained more patients with the following characteristics, older age, male sex, smoker, advanced stage tumor, lower/mid rectal tumor location, ultra-LAR, and diverting stoma, than the non-preoperative CRT group (all Ps < 0.05). Postoperative AL occurred in 91 patients (6.3%). Before propensity score matching, the incidence of AL in patients with or without preoperative CRT was 7.5% and 5.9%, respectively (P = 0.293). After propensity score matching, the 2 groups were nearly balanced except for the initial stage and the length of the surgeon's career, and the incidence of AL in patients with or without preoperative CRT was 7.5% and 8.1%, respectively (P = 0.781).

CONCLUSIONS

We did not observe that preoperative CRT increased the risk of postoperative AL after LAR in patients with rectal cancer, using propensity score matching analysis.

Intensified neoadjuvant radiochemotherapy for rectal cancer enhances surgical complications

BACKGROUND

Neoadjuvant radiochemotherapy has proven superior to adjuvant treatment in reducing the rate of local recurrence without impairing cancer related survival or the incidence of distant metastases. The present study aimed at addressing the effects of an intensified protocol of neoadjuvant treatment on the development of postoperative complications.

METHODS

A total of 387 patients underwent oncological resection for rectal cancer in our institution between January 2000 and December 2009. 106 patients received an intensified radiochemotherapy. Perioperative morbidity and mortality were analyzed retrospectively with special attention on complication rates after intensified radio-chemotherapy. Therefore, for each patient subjected to neoadjuvant treatment a patient without neoadjuvant treatment was matched in the following order for tumor height, discontinuous resection/exstirpation, T-category of the TNM-system, dividing stoma and UICC stage.

RESULTS

Of all patients operated for rectal cancer, 27.4% received an intensified neoadjuvant treatment. Tumor location in the matched patients were in the lower third (55.2%), middle third (41.0%) and upper third (3.8%) of the rectum. Postoperatively, surgical morbidity was higher after intensified neoadjuvant treatment. In the subgroup with low anterior resection (LAR) the anastomosis leakage rate was higher (26.6% vs. 9.7%) and in the subgroup of patients with rectal exstirpations the perineal wound infection rate was increased (42.2% vs. 18.8%) after intensified radiochemotherapy.

CONCLUSIONS

In rectal cancer the decision for an intensified neoadjuvant treatment comes along with an increase of anastomotic leakage and perineal wound infection. Quality of life is often reduced considerably and has to be balanced against the potential benefit of intensifying neoadjuvant radiochemotherapy.

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

BACKGROUND

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

OBJECTIVE

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

INTERVENTIONS

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

Effect of preoperative radio(chemo)therapy on long-term functional outcome in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

Preoperative radio(chemo)therapy (pR(C)T) significantly reduces the local recurrence risk and is therefore recommended in stage II/III rectal cancer. However, this multimodal treatment approach may be associated with late adverse effects. To determine the impact of pR(C)T on long-term anorectal, sexual, and urinary function, we performed a systematic review and meta-analysis.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched for studies reporting on long-term functional outcome after rectal cancer resection with pR(C)T. Only studies that reported anorectal, sexual, and/or urinary function after rectal cancer resection in TME-technique with pR(C)T were eligible for inclusion.

RESULTS

Twenty-five studies, including 6,548 patients, were identified. Methodological quality of the eligible studies was low. The majority of studies reported higher rates of anorectal (14/18 studies) and male sexual dysfunction (9/10 studies) after pR(C)T. Few studies examined female sexual dysfunction (n = 4). Meta-analysis revealed that stool incontinence occurred more often in irradiated patients (risk ratio (RR) = 1.67; 95 % confidence interval (CI), 1.36, 2.05; p < 0.0001) and manometric results were significantly worse after pR(C)T (mean resting pressures (weighted mean difference (WMD) = 15.04; 95 % CI, 0.77, 29.31; p = 0.04) and maximum squeeze pressures (WMD = 30.39; 95 % CI, 21.48, 39.3; p < 0.0001)). Meta-analysis of erectile dysfunction revealed no statistical significance (RR = 1.41; 95 % CI, 0.74, 2.72; p = 0.3). Six of eight studies and meta-analysis demonstrated no negative effect of pR(C)T on urinary function (RR = 1.05; 95 % CI, 0.67, 1.65; p = 0.82).

CONCLUSIONS

Although quality of studies on long-term functional outcome is limited, current evidence demonstrates that pR(C)T negatively affects anorectal function after TME.

Short-term outcomes after laparoscopic surgery following preoperative chemoradiotherapy for rectal cancer

Purpose

The safety and the feasibility of performing laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy (CRT) have not yet been established. Thus, the aim of this study was to evaluate the efficacy and the safety of laparoscopic rectal cancer surgery performed after preoperative CRT.

Methods

We enrolled 124 consecutive patients who underwent laparoscopic surgery for rectal cancer. Of these patients, 56 received preoperative CRT (CRT group), whereas 68 did not (non-CRT group). The patients who were found to have distant metastasis and open conversion during surgery were excluded. The clinicopathologic parameters were evaluated and the short-term outcomes were compared between the CRT and non-CRT groups.

Results

The mean operation time was longer in the CRT group (294 minutes; range, 140 to 485 minutes; P = 0.004). In the non-CRT group, the tumor sizes were larger (mean, 4.0 cm; range, 1.2 to 8.0 cm; P < 0.001) and more lymph nodes were harvested (mean, 12.9; range, 0 to 35; P < 0.001). However, there was no significant difference between the two groups in time to first bowel movement, tolerance of a soft diet, length of hospital stay, and postoperative complication rate.

Conclusion

Performing laparoscopic surgery for rectal cancer after preoperative CRT may be safe and feasible if performed by a highly skilled laparoscopic surgeon. Randomized controlled trials and long-term follow-up studies are necessary to support our results.

Risk adjusted benchmarking of clinical anastomotic leakage rate after total mesorectal excision in the context of an improvement project

AIM

Anastomotic leakage (AL) after total mesorectal excision (TME) is a major adverse event. This study evaluates variability in AL between centres participating on a voluntary basis in PROCARE, a Belgian improvement project, and how further improvement of the AL rate might be achieved.

METHOD

Between January 2006 and March 2011, detailed data on 1815 patients (mean age 65.5 years, 63% male) who underwent elective TME with colo-anal reconstruction for rectal cancer were registered by 48 centres. Variability in early clinical AL rate was analysed before and after adjustment for gender, age > 60 years, American Society of Anesthesiologists score of 3 or more and body mass index > 25 kg/m(2).

RESULTS

The overall AL rate was 6.7% (95% CI 5.6%-7.9%). Early AL required reoperation in 86.8% of patients. It increased length of hospital stay from 14.7 days to 32.4 days and in-hospital mortality from 1.1% to 4.8%. Statistically significant variability in AL rate between centres was not observed, either before or after risk adjustment. Nonetheless, further improvement may be achievable in some centres by targeting the adjusted performance of better performing centres. These centres used neoadjuvant treatment, rectal irrigation, mobilization of the splenic flexure, resection of the sigmoid colon, side-to-end colo-anastomosis with or without pouch and defunctioning stoma at primary surgery in a significantly higher proportion of patients than less well performing centres.

CONCLUSION

The overall AL rate was low but needs to be interpreted with caution because of incomplete registration. Further improvement might be achieved by adopting the approach of better performing centres.

Ranking of patient and surgeons' perspectives for endpoints in randomized controlled trials--lessons learned from the POVATI trial [ISRCTN 60734227]

INTRODUCTION

Surgical trials focus mainly on mortality and morbidity rates, which may be not the most important endpoints from the patient's perspective. Evaluation of expectations and needs of patients enrolled in clinical trials can be analyzed using a procedure called ranking. Within the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized trial (POVATI), the perspectives of participating patients and surgeons were assessed as well as the influence of the surgical intervention on patients' needs.

PATIENTS AND METHODS

All included patients of the POVATI trial were asked preoperatively and postoperatively to rank predetermined outcome variables concerning the upcoming surgical procedure (e.g., pain, complication, cosmetic result) hierarchically according to their importance. Preoperatively, the surgeons were asked to do the same.

RESULTS

One hundred eighty two out of 200 randomized patients (71 females, 111 males; mean age 59 years) returned the ranking questionnaire preoperatively and 152 patients (67 females, 85 males; mean age 60 years) on the day of discharge. There were no differences between the two groups with respect to the distribution of ranking variables (p > 0.05). Thirty-five surgeons (7 residents, 6 fellows, and 22 consultants) completed the same ranking questionnaire. The order of the four most important ranking variables for both patients and surgeons were death, avoiding of postoperative complications, avoiding of intraoperative complications, and pain. Surgeons ranked the variable "cosmetic result" significantly as more important compared to patients (p = 0.034, Fisher's exact test).

CONCLUSION

Patients and surgeons did not differ in ranking predetermined outcomes in the POVATI trial. Only the variable "cosmetic result" is significantly more important from the surgeon's than from the patient's perspective. Ranking of outcomes might be a beneficial tool and can be a proper addition to RCTs.