The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery

Effect of preoperative frailty on postoperative infectious complications and prognosis in patients with colorectal cancer: a propensity score matching study

BACKGROUND

Few studies have explored the impact of preoperative frailty on infectious complications in patients with a diagnosis of colorectal cancer (CRC). Therefore, this study aimed to investigate the effect of preoperative frailty on postoperative infectious complications and prognosis in patients with CRC using propensity score matching (PSM).

METHODS

This prospective single-centre observational cohort study included 245 patients who underwent CRC surgery at the Department of Gastrointestinal Surgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University between August 2021 to May 2023. Patients were categorised into two groups: frail and non-frail. They were matched for confounders and 1:1 closest matching was performed using PSM. Rates of infectious complications, intensive care unit (ICU) admission, 30-day mortality, and 90-day mortality, as well as postoperative length of hospital stay, total length of hospital stay, and hospital costs, were compared between the two groups. Binary logistic regression using data following PSM to explore independent factors for relevant outcome measures.

RESULTS

After PSM, each confounding factor was evenly distributed between groups, and 75 pairs of patients were successfully matched. The incidence of intra-abdominal infectious complications was significantly higher in the frail group than in the non-frail group (10.7% vs. 1.3%, P < 0.05). There were no significant differences in ICU admission rate, postoperative length of hospital stay, total length of hospital stay, hospital costs, 30-day mortality rate, or 90-day mortality rate between the two groups (P > 0.05). Our logistic regression analysis result showed that preoperative frailty (OR = 12.014; 95% CI: 1.334-108.197; P = 0.027) was an independent factor for intra-abdominal infection.

CONCLUSIONS

The presence of preoperative frailty elevated the risk of postoperative intra-abdominal infectious complications in patients undergoing CRC surgery. Therefore, medical staff should assess preoperative frailty in patients with CRC early and provide targeted prehabilitation interventions.

Two-row, three-row or powered circular stapler, which to choose when performing colorectal anastomosis? A systematic review and meta-analysis

PURPOSE

Three types of circular staplers can be used to perform a colorectal anastomosis: two-row (MCS), three-row (TRCS) and powered (PCS) devices. The objective of this meta-analysis has been to provide the existing evidence on which of these circular staplers would have a lower risk of presenting a leak (AL) and/or anastomotic bleeding (AB).

METHODS

An in-depth search was carried out in the electronic bibliographic databases Embase, PubMed and SCOPUS. Observational studies were included, since randomized clinical trials comparing circular staplers were not found.

RESULTS

In the case of AL, seven studies met the inclusion criteria in the PCS group and four in the TRCS group. In the case of AB, only four studies could be included in the analysis in the PCS group. The AL OR reported for PCS was 0.402 (95%-confidence interval (95%-CI): 0.266-0.608) and for AB: 0.2 (95% CI: 0.08-0.52). The OR obtained for AL in TRCS was 0.446 (95%-CI: 0.217 to 0.916). Risk difference for AL in PCS was - 0.06 (95% CI: - 0.07 to - 0.04) and in TRCS was - 0.04 (95%-CI: - 0.08 to - 0.01). Subgroup analysis did not report significant differences between groups. On the other hand, the AB OR obtained for PCS was 0.2 (95% CI: 0.08-0.52). In this case, no significant differences were observed in subgroup analysis.

CONCLUSION

PCS presented a significantly lower risk of leakage and anastomotic bleeding while TRCS only demonstrated a risk reduction in AL. Risk difference of AL was superior in the PCS than in TRCS.

Score prediction of anastomotic leak in colorectal surgery: a systematic review

OBJECTIVE

Predicting the risk of anastomotic leak (AL) is of importance when defining the optimal surgical strategy in colorectal surgery. Our objective was to perform a systematic review of existing scores in the field.

METHODS

We followed the PRISMA checklist (S1 Checklist). Medline, Cochrane Central and Embase were searched for observational studies reporting on scores predicting AL after the creation of a colorectal anastomosis. Studies reporting only validation of existing scores and/or scores based on post-operative variables were excluded. PRISMA 2020 recommendations were followed. Qualitative analysis was performed.

RESULTS

Eight hundred articles were identified. Seven hundred and ninety-one articles were excluded after title/abstract and full-text screening, leaving nine studies for analysis. Scores notably included the Colon Leakage Score, the modified Colon Leakage Score, the REAL score, www.anastomoticleak.com and the PROCOLE score. Four studies (44.4%) included more than 1.000 patients and one extracted data from existing studies (meta-analysis of risk factors). Scores included the following pre-operative variables: age (44.4%), sex (77.8%), ASA score (66.6%), BMI (33.3%), diabetes (22.2%), respiratory comorbidity (22.2%), cardiovascular comorbidity (11.1%), liver comorbidity (11.1%), weight loss (11.1%), smoking (33.3%), alcohol consumption (33.3%), steroid consumption (33.3%), neo-adjuvant treatment (44.9%), anticoagulation (11.1%), hematocrit concentration (22.2%), total proteins concentration (11.1%), white blood cell count (11.1%), albumin concentration (11.1%), distance from the anal verge (77.8%), number of hospital beds (11.1%), pre-operative bowel preparation (11.1%) and indication for surgery (11.1%). Scores included the following peri-operative variables: emergency surgery (22.2%), surgical approach (22.2%), duration of surgery (66.6%), blood loss/transfusion (55.6%), additional procedure (33.3%), operative complication (22.2%), wound contamination class (1.11%), mechanical anastomosis (1.11%) and experience of the surgeon (11.1%). Five studies (55.6%) reported the area under the curve (AUC) of the scores, and four (44.4%) included a validation set.

CONCLUSION

Existing scores are heterogeneous in the identification of pre-operative variables allowing predicting AL. A majority of scores was established from small cohorts of patients which, considering the low incidence of AL, might lead to miss potential predictors of AL. AUC is seldom reported. We recommend that new scores to predict the risk of AL in colorectal surgery to be based on large cohorts of patients, to include a validation set and to report the AUC.

Hartmann's procedure in rectal cancer surgery is often an intraoperative decision: a retrospective multicenter study

PURPOSE

This study aimed to investigate patient-related factors predicting the selection of rectal cancer patients to Hartmann's procedure as well as to investigate how often, and on what grounds, anterior resection is intraoperatively changed to Hartmann's procedure.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry regarding patients with rectal cancer operated upon from January 1 2007 to June 30 2017 in the county of Skåne were retrospectively reviewed. Data were expanded with further details from medical charts. A univariable analysis was performed to investigate variables associated with unplanned HP and significant variables included in a multivariable logistic regression analysis.

RESULTS

Altogether, 1141 patients who underwent Hartmann's procedure (275 patients, 24%), anterior resection (491 patients, 43%), or abdominoperineal resection (375 patients, 33%) were included. Patients undergoing Hartmann's procedure were significantly older and had more frequently comorbidity. The decision to perform Hartmann's procedure was made preoperatively in 209 (76%) patients, most commonly because of a comorbidity (27%) or oncological reasons (25%). Patient preference was noted in 8% of cases. In 64 cases (23%), the decision was made intraoperatively, most often due to anastomotic difficulties (60%) and oncological reasons (22%). Anastomotic difficulties were most often reported due to technical difficulties, a low tumor or neoadjuvant radiotherapy. Male gender was a significant risk factor for undergoing unplanned Hartmann's procedure.

CONCLUSIONS

The decision to perform Hartmann's procedure was frequently made intraoperatively. Hartmann's procedure should be considered and discussed preoperatively in old and frail patients, especially in the presence of mid-rectal cancer and/or male gender, since these factors increase the risk of intraoperative anastomotic difficulties.

Risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma: A systematic review and meta-analysis

BACKGROUND

To further define the risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma.

METHODS

Records from five English databases and four Chinese databases. Odds ratios (OR) and 95 % confidence intervals (CI) were used to indicate the risk of inclusion of risk factors. The non-closure stoma rate used the risk difference (RD) and 95 % CI. Risk factors were evaluated for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age ≥60 years[OR:1.57, 95%CI(1.44,1.72)], Tumor IV stage[OR:4.21, 95%CI(2.29,7.74)], American Society of Anesthesiologists (ASA)≥3[OR:1.48, 95%CI(1.33,1.65)], Neoadjuvant chemoradiotherapy[OR:1.41, 95%CI(1.09,1.82)],Open surgery[OR:1.45, 95%CI(1.09,1.93)], Postoperative chemotherapy[OR:1.37, 95%CI(1.03,1.82)], Anastomotic leakage[OR:4.61, 95%CI(2.86, 7.44)], Local recurrence[OR:7.16, 95%CI(4.70, 10.91)]. The rate of non-closure stoma after anterior resection for rectal cancer was: 0.20, 95 % CI (0.17, 0.23). The quality of evidence for stage IV tumors and anastomotic leakage was moderate, and other risk factors were low to very low.

CONCLUSIONS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age≥60 years, Tumor IV stage, ASA≥3, Neoadjuvant chemoradiotherapy, Open surgery, Postoperative chemotherapy, Anastomotic leakage, Local recurrence, and one in five anterior resection patients with a temporary stoma fails to close.

The role of tissue adhesives and sealants in colorectal anastomotic healing-a scoping review

PURPOSE

Anastomotic leakage (AL) after colorectal resection is a serious postoperative complication with grave consequences for patients. Despite several efforts to reduce its incidence, AL is still seen among 2-20% of colorectal cancer patients receiving an anastomosis. The use of tissue adhesives and sealants as an extra layer of protection around the anastomosis has shown promising results. We conducted a scoping review to provide an overview of the current knowledge on the effect of tissue adhesives and sealants on colorectal anastomosis healing, as well as their effect on the postoperative outcome.

METHODS

The databases of PubMed, Embase, and Cochrane Library were systematically searched on 14/10/2022. Studies addressing the use of a tissue adhesive or tissue sealant applied around a colorectal anastomosis, with the goal to prevent AL or to decrease AL-related complications, were included. We presented an overview of the available studies and summarized their results narratively.

RESULTS

Seven studies were included out of the 846 screened. All authors reported the rate of AL in their interventions group. Five of the studies found a decreased rate of AL compared to the control group. One study had no incidences of AL, while the last study had a seemingly low rate of AL but no comparison group. Information on secondary outcomes was sparingly reported, but the results hinted at a positive effect.

CONCLUSION

Tissue adhesives and sealants might have a beneficial effect on colorectal anastomosis healing. The literature is sparse, and this review has shown the need for further clinical studies.

Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR

OBJECTIVES

To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications.

BACKGROUND

DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA).

METHODS

All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included.

RESULTS

Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up.

CONCLUSIONS

DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.

Establishment and application of three predictive models of anastomotic leakage after rectal cancer sphincter-preserving surgery

BACKGROUND

Anastomotic leakage (AL) occurs frequently after sphincter-preserving surgery for rectal cancer and has a significant mortality rate. There are many factors that influence the incidence of AL, and each patient's unique circumstances add to this diversity. The early identification and prediction of AL after sphincter-preserving surgery are of great significance for the application of clinically targeted preventive measures. Developing an AL predictive model coincides with the aim of personalised healthcare, enhances clinical management techniques, and advances the medical industry along a more precise and intelligent path.

AIM

To develop nomogram, decision tree, and random forest prediction models for AL following sphincter-preserving surgery for rectal cancer and to evaluate the predictive efficacy of the three models.

METHODS

The clinical information of 497 patients with rectal cancer who underwent sphincter-preserving surgery at Jincheng People's Hospital of Shanxi Province between January 2017 and September 2022 was analyzed in this study. Patients were divided into two groups: AL and no AL. Using univariate and multivariate analyses, we identified factors influencing postoperative AL. These factors were used to establish nomogram, decision tree, and random forest models. The sensitivity, specificity, recall, accuracy, and area under the receiver operating characteristic curve (AUC) were compared between the three models.

RESULTS

AL occurred in 10.26% of the 497 patients with rectal cancer. The nomogram model had an AUC of 0.922, sensitivity of 0.745, specificity of 0.966, accuracy of 0.936, recall of 0.987, and accuracy of 0.946. The above indices in the decision tree model were 0.919, 0.833, 0.862, 0.951, 0.994, and 0.955, respectively and in the random forest model were 1.000, 1.000, 1.000, 0.951, 0.994, and 0.955, respectively. The DeLong test revealed that the AUC value of the decision-tree model was lower than that of the random forest model (P < 0.05).

CONCLUSION

The random forest model may be used to identify patients at high risk of AL after sphincter-preserving surgery for rectal cancer owing to its strong predictive effect and stability.

Risk assessment of rectal anastomotic leakage (RAREAL) after DIXON in non-emergency patients with rectal cancer

BACKGROUND

The routine establishment of a diverting stoma (DS) remains controversial in every patient undergoing Dixon operation. We aimed to establish a model for the risk assessment of rectal anastomotic leak (RAREAL) after Dixon in non-emergency patients with rectal cancer, using routinely available variables, by which surgeons could individualize their approach to DS.

METHODS

323 patients who underwent Dixon operation for rectal cancer from January 2015 to December 2018 were taken as the model group for retrospective study. Univariable and multivariable logistic regression analysis was used to determine the independent risk factors associated with anastomotic leakage. We constructed the RAREAL model. 150 patients who underwent Dixon operation due to rectal cancer from January 2019 to December 2020 were collected according to the uniform criteria as a validation group to validate the RAREAL model.

RESULTS

In the model group, multivariable analysis identified the following variables as independent risk factors for AL: HbA1c (odds ratio (OR) = 4.107; P = 0.044), Left colic artery (LCA) non preservation (OR = 4.360; P = 0.026), Tumor distance from the anal margin (TD) (OR = 6.373; P = 0.002). In the model group, the area under the curve (AUC) of the receiver operating characteristic (ROC) for evaluating AL with RAREAL was 0.733, and when RAREAL score = 2.5, its sensitivity, specificity and Youden index were 0.385, 0.973, 0.358, respectively. The AUC was 0.722 in the validation group and its sensitivity and specificity were 0.333 and 0.985, respectively, when RAREAL score = 2.5.

CONCLUSION

The RAREAL score can be used to assess the risk of AL after Dixon operation for rectal cancer, and prophylactic DS should be proactively done when the score is greater than 2.5.

Outcomes following anastomotic leak from rectal resections, including bowel function and quality of life

PURPOSE

Anastomotic leak (AL) is an uncommon but potentially devastating complication after rectal resection. We aim to provide an updated assessment of bowel function and quality of life after AL, as well as associated short- and long-term outcomes.

METHODS

A retrospective audit of all rectal resections performed at a colorectal unit and associated private hospitals over the past 10 years was performed. Relevant demographic, operative, and histopathological data were collected. A prospective survey was performed regarding patients' quality of life and fecal continence. These patients were matched with nonAL patients who completed the same survey.

RESULTS

One hundred patients (out of 1,394 resections) were included. AL was contained in 66.0%, not contained in 10.0%, and only anastomotic stricture in 24.0%. Management was antibiotics only in 39.0%, percutaneous drainage in 9.0%, operative abdominal drainage in 19.0%, transrectal drainage in 6.0%, combination of percutaneous drainage and transrectal drainage in 2.0%, and combination abdominal/transrectal drainage in 1.0%. The 1-year stoma rate was 15.0%. Overall, mean Fecal Incontinence Severity Instrument scores were higher for AL patients than their matched counterparts (8.06±10.5 vs. 2.92±4.92, P=0.002). Patients with an AL had a mean EuroQol visual analogue scale (EQ-VAS) of 76.23±19.85; this was lower than the matched mean EQ-VAS for non-AL patients of 81.64±18.07, although not statistically significant (P=0.180).

CONCLUSION

The majority of AL patients in this study were managed with antibiotics only. AL was associated with higher fecal incontinence scores in the long-term; however, this did not equate to lower quality of life scores.

Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers

(1) Background: A widely accepted algorithm for the management of colorectal anastomotic leakage (CAL) is difficult to establish. The present study aimed to evaluate the current clinical practice on the management of CAL among the German CHIR-Net centers. (2) Methods: An online survey of 38 questions was prepared using the International Study Group of Rectal Cancer (ISREC) grading score of CAL combined with both patient- and surgery-related factors. All CHIR-Net centers received a link to the online questionary in February 2020. (3) Results: Most of the answering centers (55%) were academic hospitals (41%). Only half of them use the ISREC definition and grading for the management of CAL. A preference towards grade B management (no surgical intervention) of CAL was observed in both young and fit as well as elderly and/or frail patients with deviating ostomy and non-ischemic anastomosis. Elderly and/or frail patients without fecal diversion are generally treated as grade C leakage (surgical intervention). A grade C management of CAL is preferred in case of ischemic bowel, irrespective of the presence of an ostomy. Within grade C management, the intestinal continuity is preserved in a subgroup of patients with non-ischemic bowel, with or without ostomy, or young and fit patients with ischemic bowel under ostomy protection. (4) Conclusions: There is no generally accepted therapy algorithm for CAL management within CHIR-Net Centers in Germany. Further effort should be made to increase the application of the ISREC definition and grading of CAL in clinical practice.

Systematic review of preoperative and intraoperative colorectal Anastomotic Leak Prediction Scores (ALPS)

OBJECTIVE

To systematically review preoperative and intraoperative Anastomotic Leak Prediction Scores (ALPS) and validation studies to evaluate performance and utility in surgical decision-making. Anastomotic leak (AL) is the most feared complication of colorectal surgery. Individualised leak risk could guide anastomosis and/or diverting stoma.

METHODS

Systematic search of Ovid MEDLINE and Embase databases, 30 October 2020, identified existing ALPS and validation studies. All records including >1 risk factor, used to develop new, or to validate existing models for preoperative or intraoperative use to predict colorectal AL, were selected. Data extraction followed CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies guidelines. Models were assessed for applicability for surgical decision-making and risk of bias using Prediction model Risk Of Bias ASsessment Tool.

RESULTS

34 studies were identified containing 31 individual ALPS (12 colonic/colorectal, 19 rectal) and 6 papers with validation studies only. Development dataset patient populations were heterogeneous in terms of numbers, indication for surgery, urgency and stoma inclusion. Heterogeneity precluded meta-analysis. Definitions and timeframe for AL were available in only 22 and 11 ALPS, respectively. 26/31 studies used some form of multivariable logistic regression in their modelling. Models included 3-33 individual predictors. 27/31 studies reported model discrimination performance but just 18/31 reported calibration. 15/31 ALPS were reported with external validation, 9/31 with internal validation alone and 4 published without any validation. 27/31 ALPS and every validation study were scored high risk of bias in model analysis.

CONCLUSIONS

Poor reporting practices and methodological shortcomings limit wider adoption of published ALPS. Several models appear to perform well in discriminating patients at highest AL risk but all raise concerns over risk of bias, and nearly all over wider applicability. Large-scale, precisely reported external validation studies are required.

PROSPERO REGISTRATION NUMBER

CRD42020164804.

Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study

BACKGROUND

Anastomotic leak after restorative surgery for rectal cancer is a major complication and may lead to worse long-term oncological and survival outcomes.

OBJECTIVE

The purpose of this study was to identify risk factors associated with anastomotic leak and to assess the perioperative and long-term oncological impact of anastomotic leak in our cohort of patients with rectal cancer.

DESIGN

A retrospective analysis was performed on data from the prospectively maintained Cabrini Monash colorectal neoplasia database. Patients who had undergone rectal cancer resection and subsequently received anastomosis between November 2009 and May 2020 were included in this study. Patient and tumor characteristics, technical risk factors, and short-term and perioperative as well as long-term oncological and survival outcomes were assessed.

SETTINGS

The study was conducted in 3 tertiary hospitals.

PATIENTS

A total of 693 patients met the inclusion criteria for this study.

MAIN OUTCOME MEASURES

Univariate analyses were performed to assess the relationship between anastomotic leak and patient and technical risk factors, as well as perioperative and long-term outcomes. Univariate and multivariate proportional HR models of overall and disease-free survival were calculated. Kaplan-Meier survival analyses assessed disease-free and overall survival.

RESULTS

Anastomotic leak rate was 3.75%. Males had an increased risk of anastomotic leak, as did patients with hypertension and ischemic heart disease. Patients who experience an anastomotic leak were more likely to require reoperation and hospital readmission and were more likely to experience an inpatient death. Disease-free and overall survival were also negatively impacted by anastomotic leaks.

LIMITATIONS

This is a retrospective analysis of data from only 3 centers with the usual limitations. However, these effects have been minimized because of the high quality and completeness of the prospective data collection.

CONCLUSIONS

Anastomotic leaks after restorative surgery negatively affect long-term oncological and survival outcomes for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/C81 .

IMPACTO DE LA FUGA ANASTOMTICA EN LOS RESULTADOS ONCOLGICOS A LARGO PLAZO TRAS CIRUGA RESTAURADORA PARA EL CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO

ANTECEDENTES:La fuga anastomótica tras una cirugía restauradora para el cáncer de recto es una complicación mayor y puede conducir a peores resultados oncológicos y de supervivencia a largo plazo.OBJETIVO:El propósito de este estudio fue identificar los factores de riesgo asociados con la fuga anastomótica y evaluar el impacto oncológico perioperatorio y a largo plazo de la fuga anastomótica en nuestra cohorte de pacientes con cáncer de recto.DISEÑO:Se realizó un análisis retrospectivo de datos obtenidos de la base de datos Cabrini Monash sobre neoplasia colorrectal la cual es mantenida prospectivamente. Se incluyeron en este estudio pacientes que fueron sometidos a una resección del cáncer de recto y que posteriormente recibieron una anastomosis entre noviembre de 2009 y mayo de 2020. Se evaluaron las características del paciente y del tumor, los factores de riesgo relacionados a la técnica, los resultados oncológicos y de supervivencia perioperatorio, así como los resultados a corto y largo plazo.AJUSTES:El estudio se realizó en tres hospitales terciarios.PACIENTES:Un total de 693 pacientes cumplieron con los criterios de inclusión para este estudio.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis univariados para evaluar la relación entre la fuga anastomótica y aquellos factores relacionados al paciente, a la técnica, así como los resultados perioperatorios y a largo plazo. Se calcularon modelos de razón de riesgo proporcional univariante y multivariante de supervivencia global y libre de enfermedad. Los análisis de supervivencia de Kaplan-Meier evaluaron la supervivencia libre de enfermedad y la supervivencia global.RESULTADOS:La tasa de fuga anastomótica fue del 3,75%. Los hombres tenían un mayor riesgo de fuga anastomótica al igual que aquellos pacientes con hipertensión y cardiopatía isquémica. Los pacientes que sufrieron una fuga anastomótica tuvieron mayores probabilidades de requerir una reintervención y reingreso hospitalario, así como también tuvieron mayores probabilidades de sufrir una muerte hospitalaria. La supervivencia libre de enfermedad y general también se vio afectada negativamente por las fugas anastomóticas.LIMITACIONES:Este es un análisis retrospectivo de datos de solo tres centros con las limitaciones habituales. Sin embargo, estos efectos han sido minimizados debido a la alta calidad y la exhaustividad de la recopilación prospectiva de datos.CONCLUSIONES:Las fugas anastomóticas después de una cirugía restauradora afectan negativamente los resultados oncológicos y de supervivencia a largo plazo para los pacientes con cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C81 . (Traducción-Dr. Osvaldo Gauto ).

Short-Term Outcomes in Patients Undergoing Virtual/Ghost Ileostomy or Defunctioning Ileostomy after Anterior Resection of the Rectum: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Anterior rectal resection (ARR) represents one of the most frequently performed methods in colorectal surgery, mainly carried out for rectal cancer (RC) treatment. Defunctioning ileostomy (DI) has long been chosen as a method to "protect" colorectal or coloanal anastomosis after ARR. However, DI does not rule out risks of more or less serious complications. A proximal intra-abdominal closed-loop ileostomy, the so-called virtual/ghost ileostomy (VI/GI), could limit the number of DIs and the associated morbidity.

MATERIALS AND METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Meta-analysis was performed by use of RevMan [Computer program] Version 5.4.

RESULTS

The five included comparative studies (VI/GI or DI) covering an approximately 20-year study period (2008-2021). All included studies were observational ones and originated from European countries. Meta-analysis indicated VI/GI as significantly associated with lower short-term morbidity rates related to VI/GI or DI after primary surgery (RR: 0.21, 95% CI: 0.07-0.64, p = 0.006), fewer dehydration (RR: 0.17, 95% CI: 0.04-0.75, p = 0.02) and ileus episodes after primary surgery (RR: 0.20, 95% CI: 0.05-0.77, p = 0.02), fewer readmissions after primary surgery (RR: 0.17, 95% CI: 0.07-0.43, p = 0.0002) and readmissions after primary surgery plus stoma closure surgery (RR: 0.14, 95% CI: 0.06-0.30, p < 0.00001) than the DI group. On the contrary, no differences were identified in terms of AL after primary surgery, short-term morbidity after primary surgery, major complications (CD ≥ III) after primary surgery and length of hospital stay after primary surgery. Conclusions: Given the significant biases among meta-analyzed studies (small overall sample size and the small number of events analyzed, in particular), our results require careful interpretation. Further randomized, possibly multi-center trials may be of paramount importance in confirming our results.

Artificial intelligence assists surgeons' decision-making of temporary ileostomy in patients with rectal cancer who have received anterior resection

BACKGROUND

Due to the difficult evaluation of the risk of anastomotic leakage (AL) after rectal cancer resection, the decision to perform a temporary ileostomy is not easily distinguishable. The aim of the present study was to develop an artificial intelligence (AI) model for identifying the risk of AL to assist surgeons in the selective implementation of a temporary ileostomy.

MATERIALS AND METHODS

The data from 2240 patients with rectal cancer who received anterior resection were collected, and these patients were divided into one training and two test cohorts. Five AI algorithms, such as support vector machine (SVM), logistic regression (LR), Naive Bayes (NB), stochastic gradient descent (SGD) and random forest (RF) were employed to develop predictive models using clinical variables and were assessed using the two test cohorts.

RESULTS

The SVM model indicated good discernment of AL, and might have increased the implementation of temporary ileostomy in patients with AL in the training cohort (p < 0.001). Following the assessment of the two test cohorts, the SVM model could identify AL in a favorable manner, which performed with positive predictive values of 0.150 (0.091-0.234) and 0.151 (0.091-0.237), and negative predictive values of 0.977 (0.958-0.988) and 0.986 (0.969-0.994), respectively. It is important to note that the implementation of temporary ileostomy in patients without AL would have been significantly reduced (p < 0.001) and which would have been significantly increased in patients with AL (p < 0.05).

CONCLUSION

The model (https://alrisk.21cloudbox.com/) indicated good discernment of AL, which may be used to assist the surgeon's decision-making of performing temporary ileostomy.

Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors

BACKGROUND

Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.

AIM

To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.

METHODS

To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.

RESULTS

The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.

CONCLUSION

Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.

A preoperative prediction model for anastomotic leakage after rectal cancer resection based on 13.175 patients

INTRODUCTION

This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort.

MATERIALS AND METHODS

A development cohort was formed by using the DCRA (Dutch ColoRectal Audit), a mandatory population-based repository of all patients who undergo colorectal cancer resection in the Netherlands. Patients aged 18 years or older were included who underwent surgical resection for rectal cancer with primary anastomosis (with or without deviating ileostomy) between 2011 and 2019. Anastomotic leakage was defined as clinically relevant leakage requiring reintervention. Multivariable logistic regression was used to build a prediction model and cross-validation was used to validate the model.

RESULTS

A total of 13.175 patients were included for analysis. AL was diagnosed in 1319 patients (10%). A deviating stoma was constructed in 6853 patients (52%). The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, neo-adjuvant (chemo)radiotherapy, cT stage, distance of the tumor from anal verge, and deviating ileostomy. The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. In addition, a nomogram was developed.

CONCLUSION

The present study generated a discriminative prediction model based on preoperatively available variables. The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer.

Multicenter Study of Drain Fluid Amylase as a Biomarker for the Detection of Anastomotic Leakage After Ileal Pouch Surgery Without a Diverting Ileostomy

BACKGROUND

Anastomotic leak is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary defunctioning ileostomy does not prevent an anastomotic leak and presents inherent complications of its own. Drain fluid biomarkers have been studied in colorectal surgery but not in ileal pouch surgery.

OBJECTIVE

This study aimed to assess drain fluid amylase as a biomarker of anastomotic leak after ileal pouch surgery and without a diverting ileostomy.

DESIGN

This was a multicenter prospective observational cohort study.

SETTINGS

The study was conducted at 4 tertiary hospitals in Queensland, Australia.

PATIENTS

This study included elective patients undergoing restorative proctectomy and ileal pouch surgery.

INTERVENTIONS

Measurement of rectal tube amylase and drain fluid amylase.

MAIN OUTCOME MEASURES

The primary measure was observation of increased drain fluid amylase on the day of anastomotic leak.

RESULTS

Fifty-three patients were studied. On the day of anastomotic leak, 4 patients in the anastomotic leak group who experienced an early anastomotic leak recorded a median drain fluid amylase of 21,897 U/L compared with a median drain fluid amylase of 25 U/L for those in the no anastomotic leak group ( p < 0.0001).

LIMITATIONS

This study relies on the anastomotic leak occurring while the pelvic drain is in situ.

CONCLUSIONS

The measurement of drain fluid amylase is a sensitive biomarker of early clinical anastomotic leak in patients undergoing restorative proctectomy with an ileal pouch and when a diverting ileostomy is not incorporated. This simple, inexpensive, and noninvasive test should be considered in all patients with ileal pouches as an adjunct to the clinical diagnosis and differentiation of anastomotic leak from other postoperative complications. See Video Abstract at http://links.lww.com/DCR/B958 .Estudio multicéntrico de la amilasa del líquido de drenaje como biomarcador para la detección de fugas anastomóticas después de una cirugía de reservorio ileal sin ileostomía de derivación.

ANTECEDENTES

La fuga anastomótica es el anatema de la cirugía colorrectal. El diagnóstico precoz es una transición esencial a la intervención temprana. Una ileostomía desfuncionalizante temporal no evita una fuga anastomótica y presenta sus propias complicaciones inherentes. Los biomarcadores del líquido de drenaje se han estudiado en la cirugía colorrectal, pero no en la cirugía del reservorio ileal.

OBJETIVO

El objetivo fue evaluar la amilasa del líquido de drenaje como biomarcador de fuga anastomótica después de cirugía de reservorio ileal y sin ileostomía de derivación.

DISEO

Este fue un estudio de cohorte observacional prospectivo multicéntrico.

AJUSTES

El estudio se realizó en 4 hospitales terciarios en Queensland, Australia.

PACIENTES

Se incluyeron pacientes electivos sometidos a proctectomía restauradora y cirugía de reservorio ileal.

INTERVENCIONES

Medición de la amilasa del tubo rectal y amilasa del líquido de drenaje.

PRINCIPALES MEDIDAS DE RESULTADO

La medida principal fue la observación del aumento de la amilasa en el líquido de drenaje el día de la fuga anastomótica.

RESULTADOS

Cincuenta y tres pacientes fueron estudiados. Los 4 pacientes que experimentaron una fuga anastomótica temprana registraron una mediana de amilasa en el líquido de drenaje de 21 897 U/L el día de la fuga anastomótica en comparación con una mediana de amilasa en el líquido de drenaje de 25 U/L para aquellos en el grupo sin fuga anastomótica (p < 0,0001).

LIMITACIONES

Este estudio se basa en que la anastomosis ocurre mientras el drenaje pélvico está in situ.

CONCLUSIONES

La medición de amilasa en el líquido de drenaje es un biomarcador sensible de fuga anastomótica clínica temprana en pacientes sometidos a proctectomía restauradora con reservorio ileal y cuando no se incorpora ileostomía derivativa. Esta prueba simple, económica y no invasiva se debe considerar en todos los pacientes con reservorio ileal como complemento del diagnóstico clínico y la diferenciación de la fuga anastomótica de otras complicaciones posoperatorias. Consulte Video Resumen en http://links.lww.com/DCR/B958 . (Traducción-Dr Yolanda Colorado ).

The impact of multiple firings on the risk of anastomotic leakage after minimally invasive restorative rectal cancer resection and the impact of anastomotic leakage on long-term survival: a population-based study

PURPOSE

The aim of this study was to evaluate the anastomotic leakage (AL) rate and predictors for AL following minimally invasive restorative rectal resection (RRR) among rectal cancer patients managed according to up-to-date standardized treatment. Furthermore, we explored the impact of symptomatic AL on long-term survival.

METHODS

The study cohort was rectal cancer patients undergoing minimally invasive RRR in Central Denmark Region between 2013 and 2017. Data was retrieved from a prospective clinical quality database and supplemented with data from medical records. The AL rate was calculated as the proportion of patients who developed symptomatic AL within 30 days. Predictors for AL were identified through logistic regression. The impact of AL on long-term survival was analyzed using Kaplan-Meier methods and Cox regression.

RESULTS

AL occurred in 15.1% of 604 patients. The AL rate for males was 20.1% (95% CI 16.3-24.3) and 5.0% (95% CI 2.4-9.0) for females. Odds ratio (OR) of AL in females vs. males was 0.25 (95% CI 0.12-0.51). The use of at least three firings when transecting the rectum was associated with OR of 2.71 (95% CI 1.17-6.26) for AL. The 5-year survival for patients with vs. those without AL was 76.1% (95%CI 65.1-84.0) and 83.6% (95%CI 79.8-86.7), corresponding to adjusted hazard ratio of 1.43 (95%CI 0.84-2.41).

CONCLUSION

Symptomatic AL is still a challenge in a standardized setting using minimally invasive surgery in rectal cancer patients undergoing RRR, especially in men. Multiple firings should be avoided in transection of the rectum with an endoscopic stapler. AL had a statistical non-significant negative impact on survival.

Training prediction models for individual risk assessment of postoperative complications after surgery for colorectal cancer

BACKGROUND

The occurrence of postoperative complications and anastomotic leakage are major drivers of mortality in the immediate phase after colorectal cancer surgery. We trained prediction models for calculating patients' individual risk of complications based only on preoperatively available data in a multidisciplinary team setting. Knowing prior to surgery the probability of developing a complication could aid in improving informed decision-making by surgeon and patient and individualize surgical treatment trajectories.

METHODS

All patients over 18 years of age undergoing any resection for colorectal cancer between January 1, 2014 and December 31, 2019 from the nationwide Danish Colorectal Cancer Group database were included. Data from the database were converted into Observational Medical Outcomes Partnership Common Data Model maintained by the Observation Health Data Science and Informatics initiative. Multiple machine learning models were trained to predict postoperative complications of Clavien-Dindo grade ≥ 3B and anastomotic leakage within 30 days after surgery.

RESULTS

Between 2014 and 2019, 23,907 patients underwent resection for colorectal cancer in Denmark. A Clavien-Dindo complication grade ≥ 3B occurred in 2,958 patients (12.4%). Of 17,190 patients that received an anastomosis, 929 experienced anastomotic leakage (5.4%). Among the compared machine learning models, Lasso Logistic Regression performed best. The predictive model for complications had an area under the receiver operating characteristic curve (AUROC) of 0.704 (95%CI 0.683-0.724) and an AUROC of 0.690 (95%CI 0.655-0.724) for anastomotic leakage.

CONCLUSIONS

The prediction of postoperative complications based only on preoperative variables using a national quality assurance colorectal cancer database shows promise for calculating patient's individual risk. Future work will focus on assessing the value of adding laboratory parameters and drug exposure as candidate predictors. Furthermore, we plan to assess the external validity of our proposed model.

Anastomotic leakage following restorative rectal cancer resection: treatment and impact on stoma presence 1 year after surgery-a population-based study

PURPOSE

Anastomotic leakage (AL) continues to be a challenge after restorative rectal resection (RRR). Various treatment options of AL are available; however, their long-term outcomes are uncertain. We explored the impact of AL on the risk of stoma presence 1 year after RRR for rectal cancer and described treatment of AL after RRR including impact on the probability of receiving adjuvant chemotherapy and stoma presence following different treatment options of AL.

METHODS

We included 859 patients undergoing RRR in Central Denmark Region between 2013 and 2019. Stoma presence was calculated as the proportion of patients with stoma 1 year after RRR. Multivariable logistic regression was conducted to estimate the impact of AL on stoma presence adjusting for potential predictors. Descriptive data of outcomes were stratified for various treatment options of AL.

RESULTS

The risk of stoma presence 1 year after surgery was 9.8% (95% CI 7.98-12.0). Predictors for having stoma 1 year after RRR were AL (OR 8.43 (95% CI 4.87-14.59)) and low tumour height (OR 3.85 (95% CI 1.22-13.21)). For patients eligible for adjuvant chemotherapy, the probability of receiving it was 42.9% (95% CI 21.8-66.0) if treated with endo-SPONGE and 71.4% (95% CI 47.8-88.7) if treated with other anastomosis preserving treatment options. The risk of having stoma 1 year after RRR was 33.9% (95% CI 21.8-47.8) for patients treated with endo-SPONGE and 13.5% (95% CI 5.6-25.8) for patients treated with other anastomosis preserving treatment options (p = 0.013).

CONCLUSION

AL is a strong predictor for stoma presence 1 year after RRR. Patients treated with endo-SPONGE seem to have worse outcomes compared to other anastomosis preserving treatment options.

Risk Nomogram Does Not Predict Anastomotic Leakage After Colon Surgery Accurately: Results of the Multi-center LekCheck Study

PURPOSE

Anastomotic leakage (AL) is a dreaded complication after colorectal surgery. Preoperatively identifying high-risk patients can help to reduce the incidence of this complication. For this reason, AL risk nomograms have been developed. The objective of this study was to test the AL risk nomogram developed by Frasson, et al. for validity and to identify risk-factors for AL.

METHODS

From the international multi-center LekCheck study database, patients who underwent colonic surgery with the formation of an anastomosis were included. Data were prospectively collected between 2016 and 2019 at 14 hospitals. Univariate and multivariable regression analyses, and area under receiver operating characteristic curve analysis (AUROC) were performed.

RESULTS

A total of 643 patients were included. The median age was 70 years and 51% were male. The majority underwent surgery for malignancies (80.7%). The overall AL rate was 9.2%. The risk nomogram was not predictive for AL in the population tested (AUROC 0.572). Low preoperative haemoglobin (p = 0.006), intraoperative hypothermia (p = 0.02), contamination of the operative field (p = 0.004), and use of epidural analgesia (p = 0.02) were independent risk-factors for AL.

CONCLUSION

The AL risk nomogram could not be validated using the international LekCheck study database. In the future, intraoperative predictive factors for AL, as identified in this study, should also be included in AL risk predictors.

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.

Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn?

PURPOSE

Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA.

METHODS

This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function.

RESULTS

A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS.

CONCLUSION

ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.

Drain fluid amylase as a biomarker for the detection of anastomotic leakage after rectal resection without a diverting ileostomy

BACKGROUND

Anastomotic leak (AL) is the anathema of colorectal surgery. Early diagnosis is an essential segue to early intervention. A temporary diverting ileostomy (TDI) does not prevent an AL and presents inherent complications of its own. Numerous drain fluid biomarkers (BM) have been studied in colorectal surgery and extravasated intraluminal substances (EILS) such as amylase have shown promise. The aim of this study was to assess drain fluid amylase (DFA) as a BM of AL after minimally invasive rectal resection without a TDI.

METHODS

A single centre prospective cohort study performed from 2018 to 2021. The primary outcome was DFA measured daily whilst the drain was in situ. Rectal tube amylase was also measured for the first two post-operative days to quantitate the intra-luminal levels of the enzyme. DFA was compared between patients who experienced AL and those who did not.

RESULTS

Of the 62 patients studied, six (9.7%) experienced AL. There was a statistically significant difference in DFA between patients who experienced AL (Median:1373.5 U/L; IQR: 306-7953) and patients who did not experience an AL (Median: 27.0 U/L; IQR: 16-38); p < 0.0001.

CONCLUSIONS

The measurement of drain fluid amylase is a highly sensitive BM of early clinical anastomotic leak in patients undergoing a rectal resection with an extraperitoneal anastomosis and when a TDI is not incorporated. This simple, inexpensive and non-invasive test should be considered in all patients as an adjunct to the clinical diagnosis and differentiation of AL from other postoperative complications.

Indocyanine Green Fluorescence in Colorectal Cancer

Fluorescence vision using indocyanine green is a surgical tool with increasing applications in colorectal cancer surgery. This tool has received acceptance in several disciplines as a potential method to improve visualization of the surgical field, improve lymph node resection and decrease the incidence of anastomotic leaks (ALs). In colorectal surgery specifically, some studies have shown that intraoperative fluorescence imaging is a safe and feasible method to evaluate anastomotic perfusion, and its use could affect the incidence of anastomotic leaks. Currently, controlled trials are carried out to validate these conclusions, as well as new indications for indocyanine green such as detection and guidance in the management of hepatic colorectal metastases, visualization of ureters and even as tumor marking and improvement the lymph node harvest of early tumors. These advances could offer great value to surgeons and patients, by improving the accuracy and results of cancer resections.

Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial

AIM

The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy.

METHODS

This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group).

RESULTS

Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17).

CONCLUSION

Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).

ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group

Background

Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date.

Methods

This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire.

Results

Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future.

Conclusion

The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

The usefulness of transanal tube for reducing anastomotic leak in mid rectal cancer: compared to diverting stoma

Purpose

Diverting stoma (DS) and transanal tube (TAT) are the 2 main procedures for reducing anastomotic leak (AL) in rectal cancer surgery. However, few studies have compared the protective effect of the 2 modalities against AL.

Methods

Total of 165 patients with mid rectal cancer, who underwent curative resection from 2012 to 2017, were included. Clinical characteristics and outcomes were compared. Risk factors for AL were identified using multivariate analysis.

Results

The DS group had lower tumor location, higher rates of neoadjuvant concurrent chemoradiotherapy, and longer operative time than the TAT group. However, the level of the anastomosis did not show statistically significant differences (DS: 4.6 cm vs. TAT: 4.9 cm, P = 0.061). AL occurred in 14 of the 165 patients (8.5%), with 10 (10.2%) in the DS group and 4 (6.0%) in the TAT group (P = 0.405). On multivariate analysis, only low body mass index (BMI) and smoking were significantly related to AL. Neither the protection method nor neoadjuvant chemoradiotherapy demonstrated statistical differences in AL. Seven of 10 patients in the DS group who experienced AL were treated conservatively, while all 4 in the TAT group underwent reoperation.

Conclusion

TAT seems to have comparable protective effect against AL to DS. However, in AL, DS appeared to be more effective in preventing reoperation. Therefore, DS is recommended in patients with low BMI or smoking, and with an expected higher probability of morbidity or mortality in case of reoperation. In other cases, TAT may be considered as an alternative to DS.

Intra-operative fluorescence angiography is reproducible and reduces the rate of anastomotic leak after colorectal resection for cancer: a prospective case-matched study

AIM

Intra-operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left-sided colonic or low anterior resection with anastomosis for colorectal cancer.

METHODS

All patients with left-sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA-). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end-point.

RESULTS

In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra-operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788-0.998, P < 0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA- group compared to the IOFA+ group (16.7% vs 2.4%, P = 0.026) involving significantly more anastomotic dehiscence which required re-intervention (19% vs 2.4%, P = 0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA- group compared with the IOFA+ group (9.5% vs 0%, P = 0.040).

CONCLUSION

In this prospective case-matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible.

Intraoperative use of fluorescence with indocyanine green reduces anastomotic leak rates in rectal cancer surgery: an individual participant data analysis

BACKGROUND

Fluorescence imaging by means of Indocyanine green (ICG) has been applied to intraoperatively determine the perfusion of the anastomosis. The purpose of this Individual Participant Database meta-analysis was to assess the effectiveness in decreasing the incidence of anastomotic leak (AL) after rectal cancer surgery.

METHODS

We searched PubMed, Embase, Cochrane Library and ClinicalTrial.gov, EU Clinical Trials and ISRCTN registries on September 1st, 2019. We considered eligible those studies comparing the assessment of anastomotic perfusion during rectal cancer surgery by intraoperative use of ICG fluorescence compared with standard practice. We defined as primary outcome the incidence of AL at 30 days after surgery. The studies were assessed for quality by means of the ROBINS-I and the Cochrane risk tools. We calculated odds ratios (ORs) using the Individual patient data analysis, restricted to rectal lesions, according to original treatment allocation.

RESULTS

The review of the literature and international registries produced 15 published studies and 5 ongoing trials, for 9 of which the authors accepted to share individual participant data. 314 patients from two randomized trials, 452 from three prospective series and 564 from 4 non-randomized studies were included. Fluorescence imaging significantly reduced the incidence of AL (OR 0.341; 95% CI 0.220-0.530; p < 0.001), independent of age, gender, BMI, tumour and anastomotic distance from the anal verge and neoadjuvant therapy. Also, overall morbidity and reintervention rate were positively influenced by the use of ICG.

CONCLUSIONS

The incidence of AL may be reduced when ICG fluorescence imaging is used to assess the perfusion of a colorectal anastomosis. Limitations relate to the consistent number of non-randomized studies included and their heterogeneity in defining and assessing AL. Ongoing large randomized studies will help to determine the exact role of routine ICG fluorescence imaging may decrease the incidence of AL in surgery for rectal cancer.

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons

Purpose

Anastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.

Methods

A cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon’s preference for the use of diverting stomas, rectal tubes, and pelvic drains.

Results

There were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouches

Conclusion

There is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery

INTRODUCTION

The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice.

METHODS

A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting.

RESULTS

Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds.

CONCLUSIONS

This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

A Retrospective Study of Risk Factors for Symptomatic Anastomotic Leakage after Laparoscopic Anterior Resection of the Rectal Cancer without a Diverting Stoma

Background

Anastomotic leakage (AL) is a common and devastating postoperative issue for patients who have undergone anterior resection of rectal carcinoma and can lead to increased short-term morbidity and mortality. Moreover, it might be associated with a worse oncological prognosis of tumors. This study is aimed at exploring the risk factors for symptomatic AL after laparoscopic anterior resection (LAR) for rectal tumors without a preventive diverting stoma.

Materials and Methods

This case control study retrospectively reviewed the data of 496 consecutive patients who underwent LAR of the rectum without a preventive diverting stoma at the Cancer Hospital, Chinese Academy of Medical Sciences between September 2016 and September 2017. All patients were divided into an AL group and a control group based on the occurrence of postoperative symptomatic AL. Factors regarding patient-related variables, operation-related variables, and tumor-related variables were collected and assessed between the two groups through univariate and multivariate logistic regression analyses to identify independent risk factors for AL.

Results

In total, 18 (3.6%) patients developed postoperative symptomatic AL. Univariate analysis showed that a synchronous primary malignancy of the left hemicolon (P = 0.047), intraoperative chemotherapy (P = 0.003), and level of anastomosis (P = 0.033) were significantly related with AL. Multivariate analysis was subsequently performed to adjust for confounding biases and confirmed that a synchronous primary malignancy of the left hemicolon (odds ratio (OR), 12.225; 95% confidence interval (CI), 1.764-84.702; P = 0.011), intraoperative chemotherapy (OR, 3.931; 95% CI, 1.334-11.583; P = 0.013), and level of anastomosis (OR, 3.224; 95% CI, 1.124-9.249; P = 0.030) were independent risk factors for symptomatic AL for patients who received LAR for rectal neoplasms without a preventive diverting stoma.

Conclusions

Synchronous primary malignancy of the left hemicolon, intraoperative chemotherapy, and a low anastomotic level can increase the risks of postoperative symptomatic AL after LAR of the rectum without a protective diverting stoma.