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Wilson MZ, Stewart DB. Construction of a Coloanal Anastomosis vs Closure of a Diverting Ileostomy. JAMA Surg 2024; 159:996-997. [PMID: 38985497 DOI: 10.1001/jamasurg.2024.2234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Affiliation(s)
- Matthew Z Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David B Stewart
- Department of Surgery, Southern Illinois University, Springfield
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Mukai T, Matsui S, Sakurai T, Yamaguchi T, Akiyoshi T, Fukunaga Y. Short-term outcomes of the "minimal skin incision and no stoma" procedure in needlescopic intersphincteric resection and delayed coloanal anastomosis for low rectal cancer. Tech Coloproctol 2024; 28:110. [PMID: 39150556 DOI: 10.1007/s10151-024-02979-3] [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] [Received: 02/23/2024] [Accepted: 07/12/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Needlescopic surgery is a minimally invasive procedure that uses thin trocars with 3-mm diameter. We used Turnbull-Cutait pull-through and delayed coloanal anastomosis in needlescopic surgery to avoid diverting ileostomy during intersphincteric resection for low rectal cancer. In this study, we aim to assess the diverting ileostomy avoidance rate and technical safety of this "minimal skin incision and no stoma" procedure. METHODS This single-center retrospective study was conducted at the Cancer Institute Hospital, a tertiary referral center in Japan. Between January 2017 and December 2020, 11 patients underwent needlescopic intersphincteric resection with diverting ileostomy (NSI group), and 19 patients underwent needlescopic intersphincteric resection with delayed coloanal anastomosis (NSD group) for low rectal cancer. Data regarding patient backgrounds and short-term outcomes, including diverting ileostomy avoidance rate, pathological results, and postoperative defecatory function, were compared between the groups. RESULTS There were no statistically significant differences between the NSI and NSD groups with respect to patient background, operation time (239 min versus 220 min, p = 0.68), estimated blood loss (45 g versus 25 g, p = 0.29), R0 resection rate (100% versus 100%, p = 1.00), and length of postoperative hospital stay (16 days versus 17 days, p = 0.42). The diverting ileostomy avoidance rate was 94.4% in the NSD group. The LARS and Wexner scores 12 months after surgery were not significantly different between the two groups. CONCLUSIONS Needlescopic intersphincteric resection and delayed coloanal anastomosis can be safely performed in selected patients with a high rate of diverting ileostomy avoidance and comparable short-term outcomes.
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Affiliation(s)
- T Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan.
| | - S Matsui
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Sakurai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - T Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Y Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital of JFCR, Tokyo, Japan
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Bendib H, Anou A, Hachlaf R, Oukrine H, Djelali N, Chekman C. Modified delayed coloanal anastomosis following TME for mid and low rectal cancer: 19 consecutive patients from a single center. Updates Surg 2024:10.1007/s13304-024-01936-x. [PMID: 38976219 DOI: 10.1007/s13304-024-01936-x] [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: 06/18/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024]
Abstract
Surgery and management of rectal cancer have made significant progress in recent decades. However, there is still no coloanal anastomosis technique that offers a good compromise between functionality and low morbidity. The aim of this study is to evaluate the safety and efficiency of the modified delayed coloanal anastomosis (mDCA). In this retrospective study, we analyzed the morbi-mortality as well as functional outcomes of 19 patients treated with mDCA, out of 73 colorectal cancer patients treated at our institution from September 2021 to June 2023. The inclusion criteria were cancer of the mid and low rectum (tumor less than 10 cm from the anal verge). Morbidity represented by complications of Clavien-Dindo grade III or higher was estimated at 5.2%. Only one patient experienced an asymptomatic anastomotic leak (AL) grade A. Ischemia of the colonic stump occurred in one patient, taken back to the OR on the 5th postoperative day. No stump retraction was noted. Anastomotic stenosis appeared in one patient (5.2%) during the 90-day postoperative period, and was treated by instrumental dilation. Perioperative mortality was nil. The mean St Marks incontinence score at 90 days was 13.2 points. At the 3-month follow-up, 15 patients (78.9%) had major low anterior resection syndrome (LARS), three (15.7%) had minor LARS, and one patient (5.2%) had no LARS. None of the patients had a diversion loop ileostomy. The mDCA, by decreasing the rate of AL, without the need for diversion ileostomy, might be an interesting alternative to the conventional immediate coloanal anastomosis (ICA), for restoring the GI tract after proctectomy for cancer.
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Affiliation(s)
- Hani Bendib
- Department of Oncologic Surgery, Debussy Clinic, Pierre & Marie Curie Center, Faculty of Medicine, Algiers 1 University, Algiers, Algeria.
| | - Abdelkrim Anou
- Department of Oncologic Surgery, CLCC Blida, Faculty of Medicine, Blida 1 University, Blida, Algeria
| | - Razika Hachlaf
- Department of Oncologic Surgery, Debussy Clinic, Pierre & Marie Curie Center, Faculty of Medicine, Algiers 1 University, Algiers, Algeria
| | - Hind Oukrine
- Department of Oncologic Surgery, Debussy Clinic, Pierre & Marie Curie Center, Faculty of Medicine, Algiers 1 University, Algiers, Algeria
| | - Nabil Djelali
- Department of Oncologic Surgery, Debussy Clinic, Pierre & Marie Curie Center, Faculty of Medicine, Algiers 1 University, Algiers, Algeria
| | - Chemseddine Chekman
- Department of Oncologic Surgery, Debussy Clinic, Pierre & Marie Curie Center, Faculty of Medicine, Algiers 1 University, Algiers, Algeria
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Pompeu BF, Pasqualotto E, Pigossi BD, Marcolin P, de Figueiredo SMP, Bin FC, Formiga FB. Turnbull-Cutait pull-through coloanal anastomosis versus standard coloanal anastomosis plus diverting ileostomy for low anterior resection: a meta-analysis and systematic review. Langenbecks Arch Surg 2024; 409:187. [PMID: 38888662 DOI: 10.1007/s00423-024-03379-9] [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: 04/27/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained popularity in the effort to offer patients a reconstructive option. In this context, we aimed to compare both techniques. METHODS PubMed, Cochrane, and Scopus were searched for studies published until January 2024. Odds ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p-values inferior to 0.10 and I2 >25% considered significant. Statistical analysis was conducted in RStudio version 4.1.2 (R Foundation for Statistical Computing). Registered number CRD42024509963. RESULTS One randomized controlled trial and nine observational studies were included, comprising 1,743 patients, of whom 899 (51.5%) were submitted to TCA and 844 (48.5%) to CAA. Most patients had rectal cancer (52.2%), followed by megacolon secondary to Chagas disease (32.5%). TCA was associated with increased colon ischemia (OR 3.54; 95% CI 1.13 to 11.14; p < 0.031; I2 = 0%). There were no differences in postoperative complications classified as Clavien-Dindo ≥ IIIb, anastomotic leak, pelvic abscess, intestinal obstruction, bleeding, permanent stoma, or anastomotic stricture. In subgroup analysis of patients with cancer, TCA was associated with a reduction in anastomotic leak (OR 0.55; 95% CI 0.31 to 0.97 p = 0.04; I2 = 34%). CONCLUSION TCA was associated with a decrease in anastomotic leak rate in subgroups analysis of patients with cancer.
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Affiliation(s)
- Bernardo Fontel Pompeu
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil.
- USCS - University of São Caetano do Sul, Rua Santo Antônio, 50 - Centro, São Caetano do Sul, SP, 09521-160, Brazil.
| | | | | | | | | | - Fang Chia Bin
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
| | - Fernanda Bellotti Formiga
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
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Seow-En I, Wu J, Tan IEH, Zhao Y, Seah AWM, Wee IJY, Ying-Ru Ng Y, Kwong-Wei Tan E. Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost. Surg Laparosc Endosc Percutan Tech 2024; 34:54-61. [PMID: 37987634 PMCID: PMC10829900 DOI: 10.1097/sle.0000000000001247] [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: 05/27/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA. METHODS This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs. RESULTS Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002). CONCLUSIONS TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.
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Affiliation(s)
- Isaac Seow-En
- Department of Colorectal Surgery, Singapore General Hospital
| | - Jingting Wu
- Department of Colorectal Surgery, Singapore General Hospital
| | | | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Ian Jun Yan Wee
- Department of Colorectal Surgery, Singapore General Hospital
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Seow-En I, Ng YYR, Tan IBH, Tan EKW. Transanal total mesorectal excision and delayed coloanal anastomosis without stoma for low rectal cancer. Tech Coloproctol 2023; 27:75-81. [PMID: 36029385 DOI: 10.1007/s10151-022-02677-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/28/2022] [Indexed: 01/12/2023]
Abstract
The management of low rectal cancer is a perennial challenge for colorectal surgeons. The benefits of transanal total mesorectal excision (TaTME) in low rectal cancer are to secure the distal margin and avoid surgical space constraints within the deep pelvis. However, anastomotic leak remains an important concern. We report our technique and results combining TaTME with delayed coloanal anastomosis (DCAA) without bowel diversion. First, the splenic flexure, left colon and rectum are laparoscopically mobilized to mid-rectum. TaTME is performed to complete the distal rectal mobilization, and the specimen is delivered transanally and transected. The abdominoperineal colonic pull-through is secured to the anal canal and hypertonic dressing is applied regularly in the ward. The handsewn DCAA is performed one week later. An accompanying video demonstrates this technique. Five consecutive patients with low rectal cancer underwent TaTME with DCAA. All had upfront surgical resection except one who underwent total neoadjuvant therapy. Mean operative duration, blood loss, and length of hospital stay was 290 (250-375) min, 142 (10-200) ml and 11.6 (10-14) days respectively. One patient (20%) suffered a postoperative complication of persistent urinary retention, requiring an indwelling urinary catheter on discharge. There were no cases of open conversion and no instances of anastomotic leakage. Two patients (40%) had minor low anterior resection syndrome (LARS) and one (20%) had major LARS. TaTME and DCAA without stoma are complimentary techniques that augment the minimally invasive effects of laparoscopic sphincter-sparing low rectal cancer surgery, with good perioperative outcomes.
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Affiliation(s)
- I Seow-En
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore.
| | - Y Y-R Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - I B H Tan
- Department of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - E K-W Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
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Shannon NB, Seow‐En I, Tan EK. Cost‐effectiveness comparison of delayed versus immediate coloanal anastomosis following ultralow anterior resection for rectal cancer. ANZ J Surg 2022; 93:963-969. [PMID: 36358002 DOI: 10.1111/ans.18148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Following ultralow anterior resection for distal rectal cancers, a coloanal anastomosis is usually created along with a defunctioning ileostomy (DI). Recent evidence suggests that abdominoperineal pull-through with delayed coloanal anastomosis (DCAA) is a viable alternative to immediate coloanal anastomosis (ICAA), minimizing the risk of anastomotic leakage and avoiding the need for stoma creation with the risk of stoma-associated morbidity. However, DCAA requires a longer initial hospitalization. We aimed to perform a cost-effectiveness analysis to compare DCAA versus ICAA for elective rectal cancer surgery. METHODS A decision tree model was used to compare the cost-effectiveness of the two strategies. Cost data were obtained from the 2019 to 2020 United Kingdom National Health Service reference costs. Model probabilities were derived from published studies. Univariate and probabilistic sensitivity analyses were used to evaluate the robustness of the results. RESULTS DCAA was the overall cheaper strategy at £13 541 compared with £14 856 for ICAA in the base case analysis. This was explained by the decreased overall costs of hospitalization/surgery, reduction in costs associated with anastomotic or stoma-related complications, specifically dehydration-induced hospital readmissions and avoidance of stoma maintenance costs. Sensitivity analysis demonstrated that DCAA remained consistently more inexpensive except when the duration of total parenteral nutrition exceeded 14 days. CONCLUSION Despite a longer index hospitalization with higher initial costs, this economic analysis demonstrates that DCAA without stoma is overall more cost-effective compared with ICAA with DI following ultralow anterior resection. Cost savings should be considered an additional benefit when selecting the DCAA approach for rectal cancer surgery.
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Affiliation(s)
| | - Isaac Seow‐En
- Department of Colorectal Surgery Singapore General Hospital Singapore
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