Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

Clinical risk factors and Risk assessment model for Anastomotic leakage after Rectal cancer resection

BACKGROUND

Anastomotic leakage (AL) is the most serious complication after rectal cancer surgery. Risk factors associated with AL have been documented in previous studies; however, the consensus is still lacking. In this retrospective study, we aimed to identify risk factors for AL after rectal cancer resection and to create an accurate and effective tool for predicting the risk of this complication.

METHODS

The study cohort comprised of 276 patients with rectal cancer who had undergone anterior resection between 2015 and 2020. Twenty-four selected variables were assessed by univariate and multivariate logistic regression analyses to identify independent risk factors of AL. A risk assessment model for predicting the risk of AL was established on the basis of the regression coefficients of each identified independent risk factor.

RESULTS

Anastomotic leakage occurred in 20 patients (7.2%, 20/276). Multivariate analysis identified the following variables as independent risk or protective factors of AL: perioperative ileus ( P < 0.001, odds ratio [OR] = 14.699), tumor size ≥5 cm ( P = 0.025, OR = 3.925), distance between tumor and anal verge <7.5 cm ( P = 0.045, OR = 3.512), obesity ( P = 0.032, OR = 7.256), and diverting stoma ( P = 0.008, OR = 0.143). A risk assessment model was constructed and patients were allocated to high-, medium-, and low-risk groups on the basis of risk model scores of 5-7, 2-4, and 0-1, respectively. The incidences of AL in these three groups were 61.5%, 11.9%, and 2.0%, respectively ( P < 0.001).

CONCLUSIONS

Our risk assessment model accurately and effectively identified patients at high risk of AL and could be useful in aiding decision-making aimed at minimizing adverse outcomes associated with leakage.

Risk of anastomotic leakage with two-row versus three-row manual circular staplers in colorectal anastomosis: a U.S. cohort study

PURPOSES

To compare the risk of anastomotic leak (AL) between Ethicon manual circular staplers (two-row) versus Medtronic EEA™ circular stapler with Tri-Staple™ technology (three-row) and between Medtronic EEA™ circular stapler with DST™ Series technology (two-row) versus Tri-Staple™ technology.

METHODS

A retrospective cohort study was conducted in adult patients who underwent a left-sided colorectal surgery 2019-2022 in U.S. Premier Healthcare Database to assess the risk of AL within 30 days post-index procedure. The study devices were Ethicon manual circular staplers, Medtronic EEA™ circular stapler with DST™ technology, and Medtronic EEA™ circular stapler with Tri-Staple™ technology.

RESULTS

Across 447 hospitals, the cumulative incidences (95% confidence intervals [CI]) of AL within 30 days post-index procedure were 7.78% (6.91-8.74%) among 8337 patients in the Ethicon manual circular stapler cohort, 7.54% (6.87-8.27%) among 7928 patients in the Medtronic EEA™ circular stapler with DST™ technology cohort, and 8.19% (6.57-10.07%) among 1306 patients in the Medtronic EEA™ circular stapler with Tri-Staple™ technology cohort. Comparative analyses revealed no difference comparing Ethicon manual circular staplers with Medtronic EEA™ circular staplers with Tri-Staple™ technology (risk ratio [RR], 0.72; 95% CI, 0.52-1.01) or comparing Medtronic EEA™ circular staplers with DST™ technology to Tri-Staple™ technology (RR, 0.75; 95% CI, 0.53-1.06).

CONCLUSION

In this analysis of a large cohort of patients undergoing a left-sided colorectal surgery from a U.S. hospital database, the risk of AL observed with manual two-row circular staplers was similar to that seen with three-row devices. This study affirms the safety of manual two-row circular staplers in colorectal anastomosis.

Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis

INTRODUCTION

anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy.

METHODS

the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05.

RESULTS

cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35).

CONCLUSIONS

important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.

Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group

AIM

Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.

METHODS

The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured.

RESULTS

A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection.

CONCLUSIONS

While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.

Fatores de risco pré-operatórios associados à fístula anastomótica após colectomia para câncer colorretal: revisão sistemática e metanálise

RESUMO Objetivo: fístula anastomótica (FA) após colectomia para câncer colorretal (CCR) é complicação grave. Esta revisão sistemática e meta-análise avaliou os fatores de risco pré-operatórios para FA em pacientes submetidos à colectomia. Métodos: a pesquisa bibliográfica abrangeu 15 anos e 9 meses (1 de janeiro de 2005 - 19 de outubro de 2020), sendo utilizadas as plataformas PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC e Web of Science. O critério de inclusão foram estudos transversais, coorte e caso-controle em fatores de risco pré-operatórios para FA (desfecho). A escala Newcastle-Ottawa foi usada para avaliação de viés dos estudos. A metanálise envolveu o cálculo dos efeitos de tratamento para cada estudo individualmente incluindo odds ratio (OR), risco relativo (RR) e intervalo de confiança de 95% (IC95%) com construção de modelo de efeitos aleatórios, para avaliar o impacto de cada variável (p<0,05). Resultados: foram selecionados 39 estudos transversais, 21 coortes e quatro casos-controle. A metanálise identificou 14 fatores de risco para FA em pacientes com CCR após colectomia, que são sexo masculino (RR=1,56; IC 95%=1,40-1,75), tabagismo (RR=1,48; IC 95%=1,30-1,69), alcoolismo (RR=1,35; IC 95%=1,21-1,52), diabetes mellitus (RR=1,97; IC 95%=1,44-2,70), doenças pulmonares (RR=2,14; IC 95%=1,21-3,78), doença pulmonar obstrutiva crônica (RR=1,10; IC 95%=1,04-1,16), doença coronariana (RR=1,61; IC 95%=1,07-2,41), doença renal crônica (RR=1,34; IC 95%=1,22-1,47), altas notas na escala ASA (RR=1,70; IC 95%=1,37-2,09), cirurgia abdominal prévia (RR=1,30; IC 95%=1,04-1,64), cirurgia de emergência (RR=1,61; IC 95%=1,26-2,07), quimioterapia neoadjuvante (RR=2,16; IC 95%=1,17-4,02), radioterapia (RR=2,36; IC 95%=1,33-4,19) e quimiorradioterapia (RR=1,58; IC 95%=1,06-2,35). Conclusões: importantes fatores de risco pré-operatórios para FA colorretais em pacientes com CCR foram identificados com base nas melhores pesquisas baseadas em evidências e esse conhecimento deve influenciar decisões relacionadas ao tratamento.

Outcomes on diverting ostomy formation and reversal after low anterior resection in the older more advanced rectal cancer patient

BACKGROUND

To decrease morbidity caused by anastomotic leakages after a low anterior resection (LAR) with primary anastomosis, a diverting ostomy is often created. Reversal of a diverting ostomy is associated with morbidity, which may result in non-reversal, particularly in the elderly. This study aimed to describe the diverting ostomy-related outcomes in elderly patients with more advanced rectal cancer after LAR.

MATERIALS AND METHODS

All rectosigmoid and rectal cancer patients ≥70 years who underwent LAR with primary anastomosis between 2006 and 2019 in the Catharina Hospital (Eindhoven, The Netherlands) were included for analyses. Reversal rates, ostomy-related complications, morbidity and mortality after ostomy reversal, and definitive ostomy rates were evaluated.

RESULTS

In total 164 patients were included, of which 150 (91.5%) underwent primary or secondary ostomy creation. Ostomy-related complications were reported in 34.7% (95%-CI 27.1-42.9%). In total, 72.5% (95%-CI 64.2-79.7%) reversed their diverting ostomy. Non-reversal was mostly due to relapsing disease (52.6%). Median time to ostomy reversal was 3.2 months (IQR 2.3-5.0). No or minor complications after ostomy reversal were observed in 84.0% (95%-CI 75.3-90.6%). Over time, ostomy recreation was performed in 15.0% (95%-CI 8.6-23.5%), and ultimately 65.8% (95%-CI 57.8-73.2%) were ostomy-free after the median follow-up of 3.8 years.

CONCLUSION

Although most elderly successfully reversed their diverting ostomy after LAR with limited morbidity, attention should be paid for the risk of non-reversal and ostomy recreation over time. Preoperative patient counselling is important in every individual to be able to decide if LAR with primary anastomosis or a permanent end colostomy is preferred.

In-hospital economic burden of anastomotic leakage after colorectal anastomosis surgery: a real-world cost analysis in Italy

BACKGROUND

Anastomotic leakage (AL) is a severe complication of colorectal surgery. We aimed to quantify inpatient costs and key cost contributors associated with AL in a single Italian center.

RESEARCH DESIGN AND METHODS

Electronic records for adults who had undergone colorectal surgery with anastomosis (January 2015 - December 2016), were retrospectively reviewed. Patients with AL were identified using clinical signs and/or imaging findings and/or intraoperative findings. Available data included patient, clinical, and procedural characteristics, healthcare resource utilization, and inpatient costs. Multivariate models were used to adjust for potential confounders.

RESULTS

AL occurred in 12.3% of patients (N = 317). Mean adjusted inpatient cost was 108% higher (p < 0.001) for patients with AL versus no AL (€14,711; 95% CI: 12,113; 17,866 versus €7,089; 95% CI: 6,623; 7,587). Key cost contributors were ward stay, disposables, operating room, and hospital consultations. Mean losses (reimbursement minus costs) were €2,041/patient with AL. AL extended mean length of stay by 9 days and increased odds of reoperation and ICU stay (all p < 0.001).

CONCLUSIONS

Patients with AL place considerable economic and resource burden on healthcare systems and hospital reimbursement rates do not cover treatment costs. This study highlights an unmet need for novel techniques to reduce the burden of AL.

A Diagnostic Nomogram for Predicting the Risk of Anastomotic Leakage in Elderly Patients With Rectal Cancer: A Single-center Retrospective Cohort Study

BACKGROUND

Laparoscopic resection for rectal cancer has been gaining popularity over the past 2 decades. Whether elderly patients had more benefits from laparoscopy-assisted anterior resection (LAR) need further investigation when comparing with open anterior resection (OAR).

OBJECTIVES

This study aimed to evaluate the clinical outcomes and prognosis of LAR in elderly patients (65 y and above) with rectal cancer and investigate the factors associated with the anastomotic leakage (AL). Besides, the study sought to create a nomogram for precise prediction of AL after anterior resection for rectal cancer.

MATERIALS AND METHODS

A total of 343 rectal cancer patients over 65 years old who underwent LAR or OAR at a single center between January 2013 to January 2021 were retrospectively reviewed. Univariate analysis was conducted to explore potential risk factors for AL, and a nomogram for AL was created based on the multivariate logistic regression model.

RESULTS

A total of 343 patients were included in this study, 271 patients in LAR group and 72 patients in OAR group. Most of the variables were comparable between the 2 groups. The mean operative time was longer in the LAR group than that in the OAR group (191.66±58.33 vs. 156.85±53.88 min, P<0.0001). The LAR group exhibited a significantly lower intraoperative blood loss than the OAR group (85.17±50.03 vs. 131.67±79.10 mL; P<0.0001). Moreover, laparoscopic surgery resulted in shorter postoperative hospital stay, lower rates of diverting stoma and receiving sphincter sparing surgery in comparison with open surgery. The overall rates of complications were 25.1% and 40.3% in the LAR and OAR groups (P=0.011), respectively. And the reoperation rates in the OAR group (0%) was lower than in the LAR group (1.5%), but the difference did not reach statistical significance (P=0.300). Sex, location of tumor, diverting stoma and combined organ resection were identified as independent risk factors for AL based on multivariate analysis. Such factors were selected to develop a nomogram. After a median follow-up of 37.0 months, our study showed no significant difference in overall survival or disease free survival between the 2 groups for treatment of rectal cancer.

CONCLUSIONS

This study suggests that LAR is an alternative minimally invasive surgical procedure in patients above 65 years with better short-term outcomes and acceptable long-term outcomes compared with OAR. In addition, our nomogram has satisfactory accuracy and clinical utility may benefit for clinical decision-making.

Is water-soluble contrast enema examination for integrity of rectal anastomosis necessary prior to ileostomy reversal?

Background and Aim

Routine use of water-soluble contrast enema (WSCE) to assess anastomotic integrity is debated. This study aimed to evaluate the role of WSCE to assess anastomotic integrity following anterior resections (AR) with defunctioning stoma prior to reversal and identify factors to limit its selective use.

Methods

This retrospective study evaluated all WSCE performed over a 7-year period at a high-volume colorectal unit. Risk factors for radiological abnormality/leak, including malignancy, chemoradiotherapy, and immediate postoperative complications, were recorded. A gastrointestinal specialist radiologist and surgeon validated all WSCEs reported as abnormal.

Results

Of the 486 WSCE studies identified, 92 were excluded (repeat studies (n = 51), pediatric cases [n = 2], no AR [n = 39]). A total of 394 WSCE studies were evaluated (260 cancer; 134 noncancer patients); 14% (37/260) of cancer patients and 8% (10/134) of noncancer patients had abnormal studies (P = 0.072). Of the 37 abnormal studies in cancer patients, 73% (27/37) radiological leaks were found, and 41% (n = 11/27) of these patients had postoperative complications. Of the 10 abnormal studies in noncancer patients, 20% (2/10) radiological leaks were found, but none of these patients had postoperative complications. Overall leak rates were 7% (29/394), and rates were significantly higher in cancer patients than noncancer patients (10 vs 2%, P = 0.005).

Conclusion

Routine use of WSCE may not be necessary prior to reversal. WSCE should be selectively used in event of postoperative leak or complications. Noncancer resections are less likely demonstrate a leak.

Influence of Visceral Fat in the Outcomes of Colorectal Cancer

AIM

To determine the relationship of visceral fat (VF) with the surgical outcome of the patients with colorectal cancer (CRC) submitted to curative surgery.

METHODS

Retrospective analysis of all patients submitted to CRC surgery during 3 years with a minimum of 5 years of follow-up. We assessed the length of hospital stay, complications, pathologic reports, surgical re-interventions and hospital re-admissions, relapses, survival time and disease-free time. VF was calculated based on patients' pre-operative CT-scan. The patients were divided into quartiles according to the VF area. Linear regression models and logistic regression models were used to establish a relationship between VF and all data collected.

RESULTS

The study included 199 patients (129 with colon cancer [CC] and 70 with rectal cancer). The average area of VF was 115.7 cm2. Patients with CRC revealed a direct relationship between VF and postoperative complications (p = 0.043), anastomotic leakage (p = 0.009) and re-operation (p = 0.005). The subgroup of patients with CC had an inverse association between VF and lymph nodes harvested (p = 0.027). Survival analyses did not reveal significant differences.

CONCLUSION

VF has an influence on postoperative complications, anastomotic leakage and re-operation. A negative influence of VF on lymph nodes harvested was observed on CC patients.

The outcome of transanal endoscopic microsurgery in obese patients

BACKGROUND

The prevalence of obesity is as high as one-third of the adult population in the ultrasound. Obese patients operated for rectal cancer are less likely to undergo sphincter-preserving surgery, and have an increased morbidity and mortality. We aim to report the outcomes of transanal-endoscopic-microsurgery (TEM) in obese patients with benign and malignant neoplasms.

MATERIALS AND METHODS

An analysis was carried out of all patients undergoing TEM at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed in respect to BMI; a dichotomous variable was created categorizing the patients in this retrospective case series as either obese (BMI≥30) or nonobese (BMI<30).

RESULTS

Of the 158 patients who underwent TEM during the study period, 51 (32%) were obese and 107 (68%) were nonobese. No significant differences were found in terms of patients' demographics and tumor characteristics. There were no significant differences in operative time [105 min (range: 75-170) and 98 (range: 56-170), respectively, P=0.2], hospital length of stay [3 days (range: 2-6) and 4 (range: 2-12), respectively, P=0.48], or complication rates (20 and 23%, respectively, P=0.68).

CONCLUSION

TEM is a safe procedure for rectal neoplasms in the obese population. We found no difference in surgical time and completeness of specimen resection, and no increase in complications or length of stay in the hospital in obese versus nonobese patients. As for selected high risk patients, the TEM may be of benefit in obese patients with T1/T2N0M0 rectal cancer.

The Role of Temporary Fecal Diversion

The use of temporary fecal diversion is of great importance to tenuous anastomosis, immunosuppressed patient, or actively infected patient. Its use protects newly constructed intestinal anastomoses from being the culprit of pelvic sepsis or systemic illness. Thus, potential morbidity and mortality can be averted. However, its appropriate or optimal use is often debated. We herein discuss the evidence for when to best use a diverting stoma for colorectal, coloanal, and ileoanal anastomoses. We also discuss the importance of considering a temporary diverting stoma in the setting of high-dose immunosuppression (e.g., transplant patients or inflammatory bowel disease), active infection, or upon creation of ileal pouch-anal anastomosis. Lastly, we discuss the advantages and disadvantages of a loop ileostomy versus colostomy for temporary diversion of fecal contents.

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.

Strategies of laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer

For advanced proximal gastric cancer (GC), splenic hilar (No. 10) lymph nodes (LN) are crucial links in lymphatic drainage. According to the 14^th edition of the Japanese GC treatment guidelines, a D2 lymphadenectomy is the standard surgery for advanced GC, and No. 10 LN should be dissected for advanced proximal GC. In recent years, the preservation of organ function and the use of minimally invasive technology are being accepted by an increasing number of clinicians. Laparoscopic spleen-preserving splenic hilar LN dissection has become more accepted and is gradually being used in operations. However, because of the complexity of splenic hilar anatomy, mastering the strategies for laparoscopic spleen-preserving splenic hilar LN dissection is critical for successfully completing the operation.

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.

Preoperative risk information and patient involvement in surgical treatment for rectal and sigmoid cancer

AIM

Surgery for rectal and sigmoid cancer is a model setting for investigating preoperative information provision and shared decision making (SDM), as the decision consists of a trade-off between the pros and cons of different treatment options. The aim of this study was to explore surgeons' opinion on the preoperative information that should be given to rectal and sigmoid cancer patients and to evaluate what is actually communicated. In addition, we assessed surgeons' attitudes towards SDM and compared these with patient involvement.

METHOD

A questionnaire was sent to Dutch surgeons with an interest in gastroenterology. Preoperative consultations were recorded. A checklist was used to code the information that surgeons communicated to the patients. The OPTION-scale was used to measure patient involvement.

RESULTS

Questionnaires were sent to 240 surgeons, and 103 (43%) responded. They stated that information on anastomotic leakage and its consequences, the benefits and risks of a defunctioning stoma and the impact of a stoma on quality of life were necessary preoperative information. In practice, patients were inconsistently informed of these items. Most participants agreed to using SDM in their consultations. However, in practice, most patients were offered only one treatment option and little SDM was seen. The mean OPTION-score was low (7/100).

CONCLUSION

Insufficient information is given to patients with rectal and sigmoid cancer to guide them on their preferred surgical option. Information should be given on all treatment options, together with their complications and outcome, before any decision is made.

Colorectal anastomotic leakage: Aspects of prevention, detection and treatment

All colorectal surgeons are faced from time to time with anastomotic leakage after colorectal surgery. This complication has been studied extensively without a significant reduction of incidence over the last 30 years. New techniques of prevention, by innovative anastomotic techniques should improve results in the future, but standardization and “teachability” should be guaranteed. Risk scoring enables intra-operative decision-making whether to restore continuity or deviate. Early detection can lead to reduction in delay of diagnosis as long as a standard system is used. For treatment options, no firm evidence is available, but future studies could focus on repair and saving of the anastomosis on the one hand or anastomotical breakdown and definitive colostomy on the other hand.

Management of distal rectal cancer: results from a national survey

Owing to the complexity of distal rectal cancer its management requires a multidisciplinary approach. The diagnosis and the response after neoadjuvant chemoradiotherapy are not easy to assess and therefore the surgical approach is heterogeneous. The purpose of this survey is to evaluate the experiences of members of the Italian Society of Surgery in diagnosis and treatment strategies for rectal cancer and compare it with international practice. A questionnaire was devised comprising 18 questions with 11 sub-items making a total of 29 questions and submitted online to all the 2,500 members of the SIC starting from July 2010. The survey was completed in June 2011. The overall response rate was 17.8 % (444). The majority of the Italian surgeons' responses were in line with the international consensus reflecting the complex management of distal rectal cancer. Other opinions, especially those on staging, diverge from the common view of MRI being the gold standard in the assessment of loco-regional diffusion of the disease and on the superiority of FDG PET-CT versus CT for systemic staging. The timing for the re-staging and for surgery following neoadjuvant chemoradiotherapy does not reflect the international opinion. Italian surgeons are also exposed to the common difficulties encountered internationally in the management of distal rectal cancer. Probably, the implementation of an Italian rectal cancer registry and of many national and international multicentre studies may improve the management of rectal cancer in Italy.

Obesity and colorectal cancer

Obesity is a risk factor for colorectal cancer based on its molecular and metabolic effects on insulin and IGF-1, leptin, adipocytokines, and sex hormones. Obese men have a higher risk of colorectal cancer compared with normal weight men, but the association between obesity and rectal cancer is weaker than with colon cancer. There is a weaker association between obesity and colon cancer in women than in men, and no appreciable association between obesity and rectal cancer in women. Although obesity does not seem to have an effect on the number of lymph nodes harvested with resection, obesity does seem to be associated with more-aggressive colorectal cancers in a handful of studies. Survival and local recurrence studies are contradictory with no conclusive evidence that obesity predisposes to worse overall survival or increased recurrence in colon and rectal cancers. The literature is not definitive as far as overall morbidity and mortality rates in the obese are concerned, though obese rectal cancer patients seem to incur proportionally more morbidity and mortality. Preexisting steatosis or steatohepatitis in obese colorectal cancer patients or chemotherapy-induced liver dysfunction may lead to an increased mortality in obese patients with colorectal liver metastases. Diabetes may cause poorer response to neoadjuvant therapy in rectal cancer and contribute to higher mortality and recurrence in colon cancer.

Complications of colorectal anastomoses: leaks, strictures, and bleeding

Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.

Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality

BACKGROUND

Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer.

METHODS

A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed.

RESULTS

Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes.

CONCLUSION

We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.

Visceral obesity is associated with outcomes of total mesorectal excision for rectal adenocarcinoma

BACKGROUND AND OBJECTIVES

General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma.

METHODS

Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model.

RESULTS

Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI was associated with improved overall (P = 0.02) but not disease-free survival (P = 0.14).

CONCLUSION

Visceral obesity, measured by VFA/SFA ratio, is a better predictor of postoperative, oncologic, and survival outcomes after TME for rectal adenocarcinoma than general obesity measured by the BMI.

Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score

BACKGROUND

Anastomotic leakage following colorectal surgery still occurs all too frequently, and this complication is difficult to predict. A nonfunctional stoma may reduce the risk of clinically relevant leaks but is overtreatment for most patients. More accurate assessments of the risk of anastomotic leakage would be very helpful in tailoring treatment in colorectal surgery. Therefore, a Colon Leakage Score (CLS) was developed and tested.

MATERIAL AND METHODS

The CLS was developed based on information from the literature and expert opinions. It was tested in a retrospective cohort of consecutive patients undergoing left-sided colorectal surgery with primary anastomosis in a teaching hospital in The Netherlands.

RESULTS

In the test cohort, 10 of 121 patients who were not treated with a nonfunctional stoma experienced anastomotic leakage. The mean CLS in the leakage group was 16 versus eight in the group that did not have a leak (P < 0.01). Using receiver-operating characteristics, the area under the curve (AUC) showed that the CLS was a good predictor (AUC = 0.95, CI 0.89-1.00) of anastomotic leakage. Furthermore, logistic regression analysis with CLS as a predictor for anastomotic leakage showed an odds ratio of 1.74 (95% CI 1.32-2.28, P < 0.01).

CONCLUSIONS

The CLS can predict the risk of anastomotic leakage following left-sided colorectal surgery. After further validation, this score may help the surgeon make a more individualized, safer decision regarding whether to perform an anastomosis or make a (nonfunctional) stoma.

Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage

PURPOSE

Up to 19% of all colorectal resections develop clinically apparent insufficiencies. Insufficient perfusion of the anastomosis is recognized as an important risk factor. As tissue perfusion can be objectified intraoperatively using laser fluorescence angiography (LFA), its effect on the rate of anastomotic complications was evaluated in a retrospective matched-pairs analysis.

METHODS

Between 2003 and 2008, all anastomosis or resection margins in colorectal cancer resections were investigated intraoperatively using LFA (LFA group). Patients with colorectal cancer resections between 1998 and 2003 without LFA served as the control group. Four hundred two patients were matched for age, T-stage, type of resection and anastomosis, defunctioning stoma, administration of blood, emergency conditions, and body mass index. Statistical analysis was performed using the Fisher and the Wilcoxon tests.

RESULTS

Twenty-two surgical revisions were necessary due to anastomotic leakage, seven (3.5%) in the LFA group and 15 (7.5%) in the control group. Subgroup analysis revealed that in elective resections the rate of revision was 3.1% (LFA group) and 7.7% (control group) (p = 0.04, risk of revision (ROR) reduced by 60%). In patients older than 70 years, the rate of revision was 4.3% (LFA group) compared to 11.9% (control group) (p = 0.04, ROR reduced by 64%). After hand-sewn anastomosis, the rate of revision was 1.2% (LFA group) and 8.5% (control group) (p = 0.03, ROR reduced by 84%). Hospital stay was significantly reduced in the LFA group (Wilcoxon test; p = 0.01).

CONCLUSION

There was an overall reduction in the absolute revision rate of 4% in the LFA group and a significantly reduced rate of revision in the subgroup analysis of patients undergoing elective colorectal resections, in patients older than 70 years and in patients with hand-sewn anastomosis. This demonstrates that LFA is a method that may significantly reduce not only the rate of severe complications in colorectal surgery but also the hospital length of stay.

Impact of metabolic syndrome on the short-term outcomes of colorectal cancer surgery

PURPOSE

The purpose of this study was to determine the effects of metabolic syndrome on the short-term outcomes of colorectal cancer surgery.

METHODS

A prospective, observational study of colorectal cancer patients who underwent elective oncological resection was conducted between June 2007 and August 2008 at the Faculty of Medicine, Siriraj Hospital, Bangkok. Each patient received preoperative screening for metabolic syndrome using the criteria of the American Heart Association and the National Heart, Lung, and Blood Institute. Factors influencing 30-day postoperative morbidity and mortality were analyzed.

RESULTS

The study included 114 patients with colorectal cancer, with an average age of 61 years (range 29-91). Forty-two (36.8%) patients had metabolic syndrome. There was no significant difference in age, sex, tumor, or operative parameters between patients with or without metabolic syndrome. There was no postoperative mortality, and overall postoperative morbidity was 21.9%. Patients with metabolic syndrome had a higher rate of complications and a longer length of hospital stay than those without metabolic syndrome (40.5% vs 11.1%, P < .001 and 11.2 vs 8.1 day, P = .006, respectively). The presence of metabolic syndrome, tumor location, American Society of Anesthesiologists' score III, elevated blood pressure, and high triglycerides level were risk factors for postoperative complications in the univariate analysis; however, in the multivariate analysis, the presence of metabolic syndrome and rectal cancer surgery were the only 2 independent factors for the development of complications.

CONCLUSIONS

Patients with metabolic syndrome had a higher rate of postoperative complication and a longer length of hospital stay than patients without metabolic syndrome.

Body mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma

INTRODUCTION

Obesity adds to the technical difficulty of colorectal surgery and is a risk factor for postoperative complications. We hypothesized that obese patients have increased morbidity and poor oncologic outcomes after proctectomy for rectal adenocarcinoma.

METHODS

Adult patients undergoing total mesorectal excision (TME) for rectal adenocarcinoma at a tertiary referral center were retrospectively identified from a prospectively maintained database. Operative characteristics, postoperative complication rates, and oncologic outcomes were compared in patients with BMI > or = 30 kg/m(2) and BMI < 30 kg/m(2).

RESULTS

Between 1997 and 2009, 254 patients underwent proctectomy for rectal adenocarcinoma, of whom 27% were obese. There were no significant differences in demographics, comorbidities or preoperative oncologic characteristics between obese and nonobese groups. Patients with BMI > or = 30 kg/m(2) had longer operative times (p = 0.04) and higher intraoperative blood loss (p < 0.001) but comparable postoperative complication rates (p = 0.80), number of lymph nodes retrieved (p = 0.57), margin-negative resections (p = 0.44), and disease-free survival (p = 0.11). Obese patients had longer overall survival (p = 0.05). Tumor stage was the only variable associated with disease-free (p < 0.001) and overall survival (p < 0.001).

CONCLUSION

Despite increased technical difficulty of resection, obesity does not increase the risk of postoperative morbidity or adversely affect oncologic outcomes after total mesorectal excision of rectal adenocarcinoma.