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Yi X, Yang H, Li H, Feng X, Liao W, Lin J, Chen Z, Diao D, Ouyang M. Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients. Surg Endosc 2024:10.1007/s00464-024-11149-3. [PMID: 39160312 DOI: 10.1007/s00464-024-11149-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/04/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVE To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes. METHODS A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared. RESULTS For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05). CONCLUSION Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.
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Affiliation(s)
- Xiaojiang Yi
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Huaguo Yang
- First Department of General Surgery, Luzhou Hospital of Traditional Chinese Medicine, Luzhou, 646000, Sichuan, China
| | - Hongming Li
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Xiaochuang Feng
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Weilin Liao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Jiaxin Lin
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Zhifeng Chen
- Department of Hepatobiliary Gastrointestinal Thyroid Surgery, Meizhou Hospital of Traditional Chinese Medicine, Meizhou, 514000, Guangdong, China
| | - Dechang Diao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China.
| | - Manzhao Ouyang
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China.
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Duhoky R, Piozzi GN, Rutgers MLW, Mykoniatis I, Siddiqi N, Naqvi S, Khan JS. An Institutional Shift from Routine to Selective Diversion of Low Anastomosis in Robotic TME Surgery for Rectal Cancer Patients Using the KHANS Technique: A Single-Centre Cohort Study. J Pers Med 2024; 14:725. [PMID: 39063979 PMCID: PMC11278481 DOI: 10.3390/jpm14070725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
(1) Background: In recent years, there has been a change in practice for diverting stomas in rectal cancer surgery, shifting from routine diverting stomas to a more selective approach. Studies suggest that the benefits of temporary ileostomies do not live up to their risks, such as high-output stomas, stoma dysfunction, and reoperation. (2) Methods: All rectal cancer patients treated with a robotic resection in a single tertiary colorectal centre in the UK from 2013 to 2021 were analysed. In 2015, our unit made a shift to a more selective approach to temporary diverting ileostomies. The cohort was divided into a routine diversion group treated before 2015 and a selective diversion group treated after 2015. Both groups were analysed and compared for short-term outcomes and morbidities. (3) Results: In group A, 63/70 patients (90%) had a diverting stoma compared to 98/135 patients (72.6%) in group B (p = 0.004). There were no significant differences between the groups in anastomotic leakages (11.8% vs. 17.8%, p = 0.312) or other complications (p = 0.117). There were also no significant differences in readmission (3.8% vs. 2.6%, p = 0.312) or reoperation (3.8% vs. 2.6%, p = 1.000) after stoma closure. After 1 year, 71.6% and 71.9% (p = 1.000) of patients were stoma-free. One major reason for the delay in stoma reversal was the COVID-19 pandemic, which only occurred in group B (0% vs. 22%, p = 0.054). (4) Conclusions: A more selective approach to diverting stomas for robotic rectal cancer patients does not lead to more complications or leaks and can be considered in the treatment of rectal cancer tumours.
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Affiliation(s)
- Rauand Duhoky
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
- School of Computing, Faculty of Technology, University of Portsmouth, Portsmouth PO1 2UP, UK
| | - Guglielmo Niccolò Piozzi
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
| | - Marieke L. W. Rutgers
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
| | - Ioannis Mykoniatis
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
| | - Najaf Siddiqi
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
| | - Syed Naqvi
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
| | - Jim S. Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, UK; (R.D.); (G.N.P.)
- Faculty of Science and Health, University of Portsmouth, Portsmouth PO1 2UP, UK
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Fu Z, Li S, Zang L, Dong F, Cai Z, Ma J. Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model. Sci Rep 2023; 13:18906. [PMID: 37919401 PMCID: PMC10622418 DOI: 10.1038/s41598-023-46225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 10/30/2023] [Indexed: 11/04/2023] Open
Abstract
Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid-low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15-5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20-4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid-low rectal cancer patients.
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Affiliation(s)
- Zhanwei Fu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Shuchun Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Feng Dong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China.
| | - Junjun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197 Ruijin Er Road, Shanghai, 200025, People's Republic of China.
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Zheng XC, Su JB, Zheng JJ. Risk assessment of rectal anastomotic leakage (RAREAL) after DIXON in non-emergency patients with rectal cancer. BMC Gastroenterol 2023; 23:343. [PMID: 37789294 PMCID: PMC10548611 DOI: 10.1186/s12876-023-02982-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
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.
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Affiliation(s)
- Xue-Cong Zheng
- Department of General Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, 362000, China.
| | - Jin-Bo Su
- Endocrine Department, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, 362000, China
| | - Jin-Jie Zheng
- Department of General Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, 362000, China
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5
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Yu L, Wu W, Xia S, Li Y, Xu Z. Visceral obesity and anastomotic leakage rates in colorectal cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1224196. [PMID: 37671054 PMCID: PMC10476096 DOI: 10.3389/fonc.2023.1224196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/02/2023] [Indexed: 09/07/2023] Open
Abstract
Background Numberous studies have heatedly discussed whether obesity is a risk factor for anastomotic leakage (AL) because of the increasing number of colorectal cancer (CRC) cases and high incidence of CRC in patients with obesity. Objective We aimed to explore the relationship between visceral obesity(VO) and AL after CRC surgery. The databases of Pubmed, Embase, and the Cochrane Library were searched for relevant data and articles published until November 1, 2022. We identified the difference in the incidence of AL after CRC surgery between patients with and without VO. The quality of included studies was evaluated using the Newcastle- Ottawa Scale, and odds ratio (OR) and 95% CI were used to assess the association between VO and AL. Results This meta-analysis included 7 studies with 2,136 patients. The OR of patients with VO versus those without VO was 2.15 (95%CIs = 1.46-3.15, test for heterogeneity: P = 0.29, I2 = 18%) based on the fixed-effect model in seven studies. Notably, the difference between the two groups was statistically significant (Z = 3.91 P < 0.0001). Patients with VO in the colon cancer group exhibited a higher incidence of AL (OR = 2.88, 95% CIs = 1.38-5.99, test for heterogeneity: P = 0.27, I2 = 20%) than those in the rectal cancer group (OR = 2.74, 95% CIs = 1.13-6.65, test for heterogeneity: P = 0.20, I2 = 38%). In the studies in the relevant literature, heterogeneity was low. Regarding patients with VO, four Asian studies reported increased morbidity due to AL (OR = 2.79, 95% CIs = 1.35-5.78, test for heterogeneity: P = 0.35, I2 = 9%) compared with three non-Asian studies. Conclusions Our findings confirmed the significant relationship between VO and AL. Thus, VO could be considered a reliable risk factor of surgery for colon cancer.
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Affiliation(s)
| | - Wenjiang Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
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Vignali A, Gozzini L, Gasparini G, Calef R, Rosati R, Elmore U. Impact of powered circular stapler on anastomotic leak after anastomosis to the rectum: a propensity score matched study. Int J Colorectal Dis 2023; 38:211. [PMID: 37561203 DOI: 10.1007/s00384-023-04506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE The aim of the present study is to assess the impact of Echelon Circular™ powered stapler (PCS) on left-sided colorectal anastomotic leaks and to compare results to conventional circular staplers (CCS). METHODS A single center cohort study was carried out on 552 consecutive patients, who underwent laparoscopic colorectal resection and anastomosis to the rectum between December 2017 and September 2022. Patients who underwent powered circular anastomosis to the rectum were matched to those who had a conventional stapled anastomosis using a propensity score matching. Main outcomes were anastomotic leak (AL) rate, anastomotic bleeding, and postoperative outcomes. RESULTS After adjusting cases with propensity score matching, two new groups of patients were generated: 145 patients in the PCS and 145 in the CCS. The two groups were homogeneous with respect to demographics and comorbidities on admission. Overall, AL occurred in 21 (7.3%) patients. No significant differences were observed with respect to AL (5.5% in PCS vs 9% in CCS; p = 0.66), fistula severity (p = 0.60) or reoperation rate (p = 0.65) in the two groups in study. A higher rate of anastomotic bleeding was observed in the CCS vs PCS (5.5% vs 0.7%, p = 0.03). At univariate analysis performed after propensity score matching, stapler diameter ≥ 31mm and age ≥ 70 years were the only variable significantly associated with anastomotic leak (p = 0.001 and p = 0.031; respectively). CONCLUSIONS The powered circular stapler has no impact on AL, while it could affect bleeding rate at the anastomotic site.
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Affiliation(s)
- Andrea Vignali
- Department of Coloproctology and Inflammatory Bowel Disease, Vita e Salute University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Lorenzo Gozzini
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | - Giulia Gasparini
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | - Riccardo Calef
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e salute University, Milan, Italy
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Catarci M, Guadagni S, Masedu F, Ruffo G, Viola MG, Borghi F, Baldazzi G, Scatizzi M. Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts. Int J Surg 2023; 109:2312-2323. [PMID: 37195782 PMCID: PMC10442086 DOI: 10.1097/js9.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. MATERIALS AND METHODS A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026). CONCLUSION The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.
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Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Rome
- General Surgery Unit, “C.&G. Mazzoni” Hospital, Ascoli Piceno
| | | | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila
| | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella (VR)
| | - Massimo G. Viola
- General Surgery Unit, Cardinale G. Panico Hospital, Tricase (LE)
| | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO)
- General & Oncologic Surgery Unit, Department of Surgery, Santa Croce e Carle Hospital, Cuneo
| | - Gianandrea Baldazzi
- General Surgery Unit, ASST Ovest Milanese, Legnano (MI)
- General Surgery Unit, ASST Nord Milano, Sesto San Giovanni (MI)
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Firenze, Italy
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Zhang HQ, Xu L, Wang ZL, Shao Y, Chen Y, Lu YF, Fu Z. The effect of reinforcing sutures and trans-anal drainage tube on the outcome of laparoscopic resection for rectal cancer: propensity score‑matched analysis. Langenbecks Arch Surg 2023; 408:289. [PMID: 37515648 DOI: 10.1007/s00423-023-03027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES Laparoscopic resection for rectal cancer is currently the predominant treatment modality for rectal tumors, with an ongoing focus on reducing the incidence of postoperative complications. In an effort to decrease the occurrence of anastomotic leakage, two additional steps worth considering are reinforcing the anastomosis with a barbed suture and retaining an anal drain as part of the procedure. The results of the operation were analyzed by comparing them to cases where the anastomosis was performed with a stapler alone. METHODS This study retrospectively analyzed patients who underwent laparoscopic radical rectal cancer surgery between July 2020 and March 2023. The patients were categorized into three cohorts based on the postoperative management following instrumented anastomosis: cohort A, the instrumented anastomosis alone group; cohort B, the reinforced suture group; and cohort C, the reinforced suture and indwelling transanal drainage tube group. Propensity score matching was performed twice in a 1:1 ratio, comparing cohort B to cohort A and cohort C to cohort B. The objective was to compare the benefits and drawbacks among the different groups in terms of operative time, postoperative outcomes and operative costs. RESULTS 529 patients with laparoscopic resection for rectal cancer were eligible for inclusion. the instrumented anastomosis alone group, reinforced suture group and the reinforced suture and indwelling transanal drainage tube group were performed in 205 patients, 198 patients and 126 patients, respectively. Cohort A and Cohort B differed in three variables after PSM: total operative time (p = 0.018), postoperative hospital stay (p < 0.001) and incidence of anastomotic leakage (p = 0.038). Cohort B had a longer total operative time, shorter postoperative hospital stay and a lower incidence of anastomotic leakage. Similarly, cohort C had less postoperative drainage (P = 0.01) and a longer postoperative hospital stay (P = 0.003) when cohort B and cohort C were matched for propensity scores. There was no significant difference in the cost of surgery between the three cohorts. CONCLUSIONS The incorporation of barbed suture reinforcement significantly reduces the occurrence of postoperative anastomotic leakage in rectal cancer surgeries. On the other hand, although trans-anal drainage was used as an additional measure to the reinforcement suture of the anastomosis, the utilization of trans-anal drainage tubes does not demonstrate a significant improvement in surgical outcomes.
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Affiliation(s)
- Hong-Qiang Zhang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Xu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen-Ling Wang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Shao
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Chen
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yun-Fei Lu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zan Fu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going? Curr Oncol 2023; 30:3111-3137. [PMID: 36975449 PMCID: PMC10047700 DOI: 10.3390/curroncol30030236] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.
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10
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Surgical Outcomes, Long-Term Recurrence Rate, and Resource Utilization in a Prospective Cohort of 165 Patients Treated by Transanal Total Mesorectal Excision for Distal Rectal Cancer. Cancers (Basel) 2023; 15:cancers15041190. [PMID: 36831531 PMCID: PMC9954312 DOI: 10.3390/cancers15041190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
A transanal total mesorectal excision (taTME) is a smart alternative to a conventional TME. However, worrisome reports of a high recurrence and complications triggered a moratorium in a few countries. This study assessed the outcomes and resource utilization of a taTME. Consecutive patients with distal rectal cancer treated by a taTME were prospectively included. Outcomes were reported as the median and interquartile range (IQR). One hundred sixty-five patients (67% male and 33% female) with a tumor 7 cm (IQR 5-10) from the anal verge were followed for 50 months (IQR 32-79). The resection margins were threatened in 25% of the patients, while 75% of the patients received neoadjuvant radiochemotherapy. A good mesorectal dissection and clear margins were achieved in 96% of the specimens, and 27 lymph nodes (IQR 20-38) were harvested. Ninety-day major morbidity affected 36 patients (21.8%), including 12 with anastomotic leakages (7.2%). A recurrence occurred locally in 9 patients (5.4%), and 44 patients had a distant metastasis (26.7%). The five-year disease-free survival and overall survival were 67% and 90%, respectively. A multivariate analysis found a long operation and frailty predicted an anastomotic leak, while a positive distal margin and lymph nodes predicted a local recurrence and distant metastasis. A two-team taTME saved 102 min of operative time and EUR 1385 when compared to a one-team approach. Transanal total mesorectal excision produced sound surgical quality and excellent oncologic outcomes.
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Kitaguchi D, Wakabayashi M, Hasegawa H, Ando K, Ikeda K, Tsukada Y, Nishizawa Y, Ito M. Single-stapling technique versus hand-sewn anastomosis in inter-sphincteric resection with transanal total mesorectal excision (Super SST): protocol for a multicentre randomized clinical trial. BJS Open 2023; 7:6987137. [PMID: 36638066 PMCID: PMC9838806 DOI: 10.1093/bjsopen/zrac160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Currently, hand-sewn anastomosis is the standard procedure for inter-sphincteric resection (ISR); however, distal purse-string suturing during transanal total mesorectal excision (TaTME) has allowed a single-stapling technique (SST). Although it was originally intended for cases requiring anastomosis of 2 cm or more above the anorectal junction (ARJ), SST could be safely performed in ISR. The aim of this trial is to determine the superiority of SST over hand-sewn anastomosis in ISR with TaTME. METHODS The Super SST trial is a multicentre randomized clinical trial comparing stapled and hand-sewn anastomoses in ISR with TaTME. The trial will recruit patients scheduled for TaTME with anastomosis below the ARJ, who will be allocated 1:1 to receive either hand-sewn or stapled anastomosis. The primary endpoint is anastomosis-related complications within 30 postoperative days. Secondary endpoints include all early and late complications, operating time, reoperation, mortality rate, length of postoperative hospital stay, readmission, incidence of anal pain and rectal mucosal prolapse, length of temporary stoma retention, the proportion of patients with a temporary stoma at 1 year after surgery, and anorectal function at 1 year after surgery. CONCLUSION This trial will provide important clinical insights for new and promising anastomotic options for patients with very low rectal cancer. Registration number: UMIN000047818 (https://www.umin.ac.jp/ctr/index-j.htme).
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Affiliation(s)
- Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masashi Wakabayashi
- Biostatistics Division, Center for Research Administration and Support, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ando
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Correspondence to: Masaaki Ito, Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan (e-mail: )
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Brisinda G, Chiarello MM, Pepe G, Cariati M, Fico V, Mirco P, Bianchi V. Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors. World J Clin Cases 2022; 10:13321-13336. [PMID: 36683625 PMCID: PMC9850997 DOI: 10.12998/wjcc.v10.i36.13321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
| | | | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Paolo Mirco
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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Teng W, Liu J, Chen M, Zang W, Wu A. BMI and pelvimetry help to predict the duration of laparoscopic resection for low and middle rectal cancer. BMC Surg 2022; 22:402. [PMID: 36404329 PMCID: PMC9677663 DOI: 10.1186/s12893-022-01840-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/06/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In rectal cancer surgery, recent studies have found associations between clinical factors, especially pelvic parameters, and surgical difficulty; however, their findings are inconsistent because the studies use different criteria. This study aimed to evaluate common clinical factors that influence the operative time for the laparoscopic anterior resection of low and middle rectal cancer. METHODS Patients who underwent laparoscopic radical resection of low and middle rectal cancer from January 2018 to December 2020 were retrospectively analyzed and classified according to the operative time. Preoperative clinical and magnetic resonance imaging (MRI)-related parameters were collected. Logistic regression analysis was used to identify factors for predicting the operative time. RESULTS In total, 214 patients with a mean age of 60.3 ± 8.9 years were divided into two groups: the long operative time group (n = 105) and the short operative time group (n = 109). Univariate analysis revealed that the male sex, a higher body mass index (BMI, ≥ 24.0 kg/m2), preoperative treatment, a smaller pelvic inlet (< 11.0 cm), a deeper pelvic depth (≥ 10.7 cm) and a shorter intertuberous distance (< 10.1 cm) were significantly correlated with a longer operative time (P < 0.05). However, only BMI (OR 1.893, 95% CI 1.064-3.367, P = 0.030) and pelvic inlet (OR 0.439, 95% CI 0.240-0.804, P = 0.008) were independent predictors of operative time. Moreover, the rate of anastomotic leakage was higher in the long operative time group (P < 0.05). CONCLUSION Laparoscopic rectal resection is expected to take longer to perform in patients with a higher BMI or smaller pelvic inlet.
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Affiliation(s)
- Wenhao Teng
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Jingfu Liu
- grid.415110.00000 0004 0605 1140Department of Blood Transfusion, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Meimei Chen
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Weidong Zang
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Aiwen Wu
- grid.412474.00000 0001 0027 0586Unit III, Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142 China
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Liu Y, Qi H, Deng C, Zhang Z, Guo Z, Li X. Advantages of ligating the rectum with gauze pad band in laparoscopic anterior resection of rectal cancer: a propensity score matched analysis. BMC Surg 2022; 22:368. [DOI: 10.1186/s12893-022-01822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
It is difficult to maintain sufficient tension throughout laparoscopic anterior resection with total mesorectal excision, which causes a decline in surgical quality. We used a soft, inexpensive gauze pad band pulling the rectal tube to analyze the effect of surgery.
Methods
A gauze pad band was positioned at the proximal of the tumor, followed by fastening the rectal tube and ligating the rectum. 233 patients undergoing laparoscopic anterior resection for mid to low rectal cancer were enrolled between January 2018 and December 2020. After propensity score matching, 63 cases were selected in gauze pad band group and 126 cases were selected in traditional group. The two groups were compared in preoperative, intraoperative, and pathological characteristics.
Results
Compared to traditional group, the median operation duration (203 min vs. 233 min, p < 0.001) and the median intraoperative bleeding (48 ml vs. 67 ml, p < 0.001) were lesser in gauze pad band group. A higher percentage of one cartridge transection of rectum (36/63 vs. 51/126, p = 0.030), shorter length of cartridges used (6.88 ± 1.27 cm vs. 7.28 ± 1.25 cm, p = 0.040), and longer distal resection margin (2.74 ± 0.76 cm vs. 2.16 + 0.68 cm, p < 0.001) were found in the gauze pad band group. The completeness of total mesorectal excision (61/63 vs. 109/126, p = 0.022), harvested lymph nodes (19 vs. 17, p < 0.001) and positive lymph nodes (1 vs. 0, p = 0.046) were higher in gauze pad band group.
Conclusion
Ligation of the rectum with a gauze pad band allows for a reduction in operative time and intraoperative bleeding while increasing the rate of one cartridge transection. It also protected the quality of total mesorectal excision and membrane anatomy.
Trial registration: Not applicable.
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Yi X, Liao W, Feng X, Li H, Chen Z, Wang J, Lu X, Wan J, Lin J, Hong X, Diao D. An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area. Updates Surg 2022; 74:1645-1656. [PMID: 35596113 DOI: 10.1007/s13304-022-01282-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/20/2022] [Indexed: 12/24/2022]
Abstract
Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.
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Affiliation(s)
- Xiaojiang Yi
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Weilin Liao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaochuang Feng
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Hongming Li
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Zhaoyu Chen
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiahao Wang
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xinquan Lu
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jin Wan
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiaxin Lin
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaoyan Hong
- Department of Anesthesiology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Dechang Diao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China.
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Kondo H, Nakagawa R, Yamamoto T, Yamaguchi S. Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy complicating laparoscopic low anterior resection of rectal cancer: Case report. Int J Surg Case Rep 2022; 98:107543. [PMID: 36055169 PMCID: PMC9482925 DOI: 10.1016/j.ijscr.2022.107543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy is increasingly popular for treating internal hemorrhoids. This injectable compound incites inflammation to dampen hemorrhoidal blood flow and inflict secondary fibrosis. Herein, we detail the implications of ALTA treatment for laparoscopic low anterior resection of rectal cancer. Patient presentation A 72-year-old man receiving ALTA sclerotherapy for internal hemorrhoids thereafter required laparoscopic low anterior resection for newly discovered early rectal cancer. Observed changes of anal canal resembled those of radiochemotherapy and proved problematic. There was mural thickening and sclerosis at the planned resection site. To ensure proper removal, the bowel was compressed and stapled slowly. A two-shot resection took place (without straining), anastomosis was performed, and a covering stoma was constructed. Recovery was uneventful, allowing discharge on postoperative Day 10. The ileostomy was closed at a later time. Discussion Although little information is available on long-term rectal pathology after ALTA therapy, existing data suggest that sclerosis persists well beyond injection timeframes. Hence, caution is required in dissecting and debriding sclerotic remnants. We have identified only four earlier reports in this setting, the present case providing added perspective. Conclusion Colonoscopy is highly advisable prior to ALTA therapy. A thorough work-up before rectal surgery is also essential, documenting any past treatments for anorectal disease, especially ALTA. Rectal surgery after ALTA therapy requires caution due to mural thickening. ALTA-induced tissue fibrosis is sustained for at least 5 years. Careful preoperative histories of prior anorectal treatments are essential. Colonoscopy is strongly recommended prior to treatment of anorectal disease.
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The Risk Factors of Anastomotic Leakage After Rectal Cancer Surgery. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm-120889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Anastomotic leakage is a significant complication after colorectal anastomosis. The aim of this study was to evaluate the risk factors and preventive measures for anastomotic leakage after rectal cancer surgery. Methods: A total of 171 patients who had undergone laparoscopic and open rectal cancer resection with a double stapling participated in this study. Twelve independent variables include age, sex, obesity, smoking, ASA grading, medical diseases, preoperative radiotherapy, preoperative chemotherapy, splenic flexure mobilization, diverting ileostomy, and the number of stapler firing were analyzed. Results: The anastomotic leakage rate was 2.33% (4 of 171). The mean age of the patients was 58.33 years old while their mean body mass index (BMI) was calculated as 24.10 kg/m2. In our study, 16.3% of patients were cigarette smokers. Of the 171 rectal surgeries, 69.0% of patients were diverted by loop ileostomy and 1.16% were supported by ghost ileostomy. Of 171 patients included in this study, 17.5 % of patients required a single staple firing for rectal division. In contrast, 47.9% of patients required 2 linear staplers, others, 24.5% of patients required 3 cartridges for rectal division, and 9.9% of patients required 4 cartridges in their surgeries. There were significant differences between men and women in the number of cartridges used (P = 0.023). Conclusions: All our leakage cases were men and the higher number of stapler firings for rectal division, history of smoking; male gender, and level of anastomosis were independent risk factors for the anastomotic leak.
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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. Int J Colorectal Dis 2022; 37:1335-1348. [PMID: 35538165 DOI: 10.1007/s00384-022-04171-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 02/04/2023]
Abstract
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.
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Operating on the Mesentery in Robotic Colonic Surgery—General Techniques. Clin Colon Rectal Surg 2022; 35:281-287. [PMID: 35966983 PMCID: PMC9365489 DOI: 10.1055/s-0042-1743586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
AbstractDuring colorectal surgery the mesentery is the organ on which the greatest amount of operating time is focused. It has recently gained increasing attention. This technical review focuses on the mesentery during robotic colonic procedures. Specifically, we focus upon how to access, dissect, and divide the mesentery using the robotic platform. We also touch on the management of bleeding and some specific disease etiologies.
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Zarnescu EC, Zarnescu NO, Costea R. Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery. Diagnostics (Basel) 2021; 11:diagnostics11122382. [PMID: 34943616 PMCID: PMC8700187 DOI: 10.3390/diagnostics11122382] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 12/13/2022] Open
Abstract
Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.
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Affiliation(s)
- Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-592-483
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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23
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Zhao S, Zhang L, Gao F, Wu M, Zheng J, Bai L, Li F, Liu B, Pan Z, Liu J, Du K, Zhou X, Li C, Zhang A, Pu Z, Li Y, Feng B, Tong W. Transanal Drainage Tube Use for Preventing Anastomotic Leakage After Laparoscopic Low Anterior Resection in Patients With Rectal Cancer: A Randomized Clinical Trial. JAMA Surg 2021; 156:1151-1158. [PMID: 34613330 DOI: 10.1001/jamasurg.2021.4568] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Preventing anastomotic leakage (AL) is crucial for colorectal surgery. Some studies have suggested a positive role of transanal drainage tubes (TDTs) in AL prevention after low anterior resection, but this finding is controversial. Objective To assess the effect of TDTs in AL prevention after laparoscopic low anterior resection for rectal cancer. Design, Setting, and Participants This multicenter randomized clinical trial with parallel groups (TDT vs non-TDT) was performed from February 26, 2016, to September 30, 2020. Participants included patients from 7 different hospitals in China who were undergoing laparoscopic low anterior resection with the double-stapling technique for mid-low rectal cancer; 576 patients were initially enrolled in this study, and 16 were later excluded. Ultimately, 560 patients were randomly divided between the TDT and non-TDT groups. Interventions A silicone tube was inserted through the anus, and the tip of the tube was placed approximately 5 cm above the anastomosis under laparoscopy at the conclusion of surgery. The tube was fixed with a skin suture and connected to a drainage bag. The TDT was scheduled for removal 3 to 7 days after surgery. Main Outcomes and Measures The primary end point was the postoperative AL rate within 30 days. Results In total, 576 patients were initially enrolled in this study; 16 of these patients were excluded. Ultimately, 560 patients were randomly divided between the TDT group (n = 280; median age, 61.5 years [IQR, 54.0-68.8 years]; 177 men [63.2%]) and the non-TDT group (n = 280; median age, 62.0 years [IQR, 52.0-69.0 years]; 169 men [60.4%]). Intention-to-treat analysis showed no significant difference between the TDT and non-TDT groups in AL rates (18 [6.4%] vs 19 [6.8%]; relative risk, 0.947; 95% CI, 0.508-1.766; P = .87) or AL grades (grade B, 14 [5.0%] and grade C, 4 [1.4%] vs grade B, 11 [3.9%] and grade C, 8 [2.9%]; P = .43). In the stratified analysis based on diverting stomas, there was no significant difference in the AL rate between the groups, regardless of whether a diverting stoma was present (without stoma, 12 [5.8%] vs 15 [7.9%], P = .41; and with stoma, 6 [8.3%] vs 4 [4.5%], P = .50). Anal pain was the most common complaint from patients in the TDT group (130 of 280, 46.4%). Accidental early TDT removal occurred in 20 patients (7.1%), and no bleeding or iatrogenic colonic perforations were detected. Conclusions and Relevance The results from this randomized clinical trial indicated that TDTs may not confer any benefit for AL prevention in patients who undergo laparoscopic low anterior resection for mid-low rectal cancer without preoperative radiotherapy. Trial Registration ClinicalTrials.gov Identifier: NCT02686567.
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Affiliation(s)
- Song Zhao
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Luyang Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Gao
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Gansu, China
| | - Miao Wu
- Department of Gastrointestinal and Hernia Surgery, Second People's Hospital of Yibin, Yibin, China
| | - Jianyong Zheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Fan Li
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Baohua Liu
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Zehui Pan
- Department of Colorectal and Anal Surgery, The 940th Hospital of Joint Logistics Support Force of The Chinese People's Liberation Army, Gansu, China
| | - Jian Liu
- Department of Gastrointestinal and Hernia Surgery, Second People's Hospital of Yibin, Yibin, China
| | - Kunli Du
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Xiong Zhou
- Department of Gastrointestinal Surgery, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Chunxue Li
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Anping Zhang
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - Zhizhong Pu
- Department of Gastrointestinal and Breast Surgery, The People's Hospital of Kaizhou District, Chongqing, China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University, Chongqing, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weidong Tong
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
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24
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Cheong JY, Shin SH, Kim J, Kim SH. Novel technique in atraumatic retraction for minimally invasive low anterior resection. ANZ J Surg 2021; 91:2827-2828. [PMID: 34309983 DOI: 10.1111/ans.17087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
This study describes an atraumatic minimally invasive retraction system for rectal cancer surgery.
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Affiliation(s)
- Ju Yong Cheong
- Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea.,Department of Colorectal Surgery, Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Seon Hui Shin
- Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jin Kim
- Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Seon-Hahn Kim
- Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea
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25
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Bakker N, Doodeman HJ, Dunker MS, Schreurs WH, Houdijk APJ. Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection. Langenbecks Arch Surg 2021; 406:2769-2779. [PMID: 34312719 DOI: 10.1007/s00423-021-02266-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/03/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) protocol reduces complications and length of stay (LOS) in colon cancer, but implementation in rectal cancer is different because of neo-adjuvant therapy and surgical differences. Laparoscopic resection may further improve outcome. The aim of this study was to evaluate the effects of introducing ERAS on postoperative outcome after rectal cancer resection in an era of increasing laparoscopic resections. MATERIALS AND METHODS Patients who underwent elective rectal cancer surgery from 2009 till 2015 were included in this observational cohort study. In 2010, ERAS was introduced and adherence to the protocol was registered. Open and laparoscopic resections were compared. With regression analysis, predictive factors for postoperative outcome and LOS were identified. RESULTS A total of 499 patients were included. The LOS decreased from 12.3 days in 2009 to 5.7 days in 2015 (p = 0.000). Surgical site infections were reduced from 24% in 2009 to 5% in 2015 (p = 0.013) and postoperative ileus from 39% in 2009 to 6% in 2015 (p = 0.000). Only postoperative ERAS items and laparoscopic surgery were associated with an improved postoperative outcome and shorter LOS. CONCLUSIONS ERAS proved to be feasible, safe, and contributed to improving short-term outcome in rectal cancer resections. The benefits of laparoscopic surgery may in part be explained by reaching better ERAS adherence rates. However, the laparoscopic approach was also associated with anastomotic leakage. Despite the potential of bias, this study provides an insight in effects of ERAS and laparoscopic surgery in a non-randomized real-time setting.
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Affiliation(s)
- Nathalie Bakker
- Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hiëronymus J Doodeman
- Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands
| | - Michalda S Dunker
- Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands
| | - Wilhelmina H Schreurs
- Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands
| | - Alexander P J Houdijk
- Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands. .,Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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26
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Ahmad NZ, Abbas MH, Khan SU, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. Int J Colorectal Dis 2021; 36:445-455. [PMID: 33064212 DOI: 10.1007/s00384-020-03771-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication. METHODS The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints. RESULTS A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively). CONCLUSION A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co, Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Saad Ullah Khan
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust, Poole, UK
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