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Qiu W, Liu J, He K, Hu G, Mei S, Guan X, Wang X, Tian J, Tang J. Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study. Surg Endosc 2024; 38:5446-5456. [PMID: 39090199 DOI: 10.1007/s00464-024-11085-2] [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: 11/07/2023] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated. AIM Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR. MATERIAL AND METHODS A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL). RESULTS After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029). CONCLUSIONS Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.
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Affiliation(s)
- Wenlong Qiu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Junguang Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Kunshan He
- Key Laboratory of Molecular Imaging Chinese Academy of Sciences, Beijing Key Laboratory of Molecular Imaging. Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, Beijing, 100000, China
| | - Gang Hu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Jie Tian
- Key Laboratory of Molecular Imaging Chinese Academy of Sciences, Beijing Key Laboratory of Molecular Imaging. Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, Beijing, 100000, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China.
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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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Hung HY, Huang SH, Tsai TY, You JF, Hsieh PS, Lai CC, Tsai WS, Tsai KY. Comparative analysis of short- and long-term outcomes in laparoscopic versus open surgery for colorectal cancer patients undergoing hemodialysis. Langenbecks Arch Surg 2024; 409:250. [PMID: 39136795 PMCID: PMC11322266 DOI: 10.1007/s00423-024-03440-7] [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: 01/07/2024] [Accepted: 08/06/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE Although minimally invasive colorectal surgery has been proven to have a shorter hospital stay and fewer short-term complications than open surgery, the advantages of laparoscopic surgery for colorectal cancer patients undergoing hemodialysis have not been validated. This study compared the outcomes of open and laparoscopic approaches in these patients. MATERIALS AND METHODS Between January 2007 and December 2020, we retrospectively analyzed the clinical data of 78 hemodialysis patients who underwent curative-intent, elective colorectal surgery. Patients were divided into two groups according to the surgical method: open and laparoscopic. RESULTS Postoperative morbidity (p = 0.480) and mortality (p = 0.598) rates and length of hospital stay (28.8 vs. 27.5 days, p = 0.830) were similar between the groups. However, laparoscopic surgery patients had a shorter return to clear liquid, full liquid, or soft food time than open surgery patients (p < 0.001, p = 0.007, and p = 0.002, respectively). Disease-free survival and long-term cancer-specific survival rates were also similar between the two groups (p = 0.353 and p = 0.201, respectively). Multivariate analysis revealed that intraoperative blood transfusion was a risk factor for severe complications and mortality (OR 6.055; p = 0.046), and the odds ratio (OR) of laparoscopic surgery was not significantly greater than that of open surgery (OR = 0.537, p = 0.337). CONCLUSION Although laparoscopic surgery did not result in hemodialysis patients having a shorter postoperative hospital stay, our results suggest that the laparoscopic approach is as safe as open surgery for hemodialysis patients and may be beneficial for shortening the return time to food intake.
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Affiliation(s)
- Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- Division of Colon and Rectal Surgery, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 236043, Taiwan (R.O.C.)
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shu-Huan Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Tzong-Yun Tsai
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Cheng-Chou Lai
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Kun-Yu Tsai
- Division of Colon and Rectal Surgery, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist, New Taipei City, 236043, Taiwan (R.O.C.).
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
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Su Y, Li Y, Zhang H, Yang W, Liu M, Luo X, Liu L. Machine learning model for prediction of permanent stoma after anterior resection of rectal cancer: A multicenter study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108386. [PMID: 38776864 DOI: 10.1016/j.ejso.2024.108386] [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: 01/24/2024] [Revised: 04/23/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The conversion from a temporary to a permanent stoma (PS) following rectal cancer surgery significantly impacts the quality of life of patients. However, there is currently a lack of practical preoperative tools to predict PS formation. The purpose of this study is to establish a preoperative predictive model for PS using machine learning algorithms to guide clinical practice. METHODS In this retrospective study, we analyzed clinical data from a total of 655 patients who underwent anterior resection for rectal cancer, with 552 patients from one medical center and 103 from another. Through machine learning algorithms, five predictive models were developed, and each was thoroughly evaluated for predictive performance. The model with superior predictive accuracy underwent additional validation using both an independent testing cohort and the external validation cohort. The Shapley Additive exPlanations (SHAP) approach was employed to elucidate the predictive factors influencing the model, providing an in-depth visual analysis of its decision-making process. RESULTS Eight variables were selected for the construction of the model. The support vector machine (SVM) model exhibited superior predictive performance in the training set, evidenced by an AUC of 0.854 (95 % CI:0.803-0.904). This performance was corroborated in both the testing set and external validation set, where the model demonstrated an AUC of 0.851 (95%CI:0.748-0.954) and 0.815 (95%CI:0.710-0.919), respectively, indicating its efficacy in identifying the PS. CONCLUSIONS The model(https://yangsu2023.shinyapps.io/psrisk/) indicated robust predictive performance in identifying PS after anterior resection for rectal cancer, potentially guiding surgeons in the preoperative stratification of patients, thus informing individualized treatment plans and improving patient outcomes.
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Affiliation(s)
- Yang Su
- Department of Gastrointestinal Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Yanqi Li
- Department of Gastrointestinal Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Heng Zhang
- Department of Gastrointestinal Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, 441100, Xiangyang, China.
| | - Wangshuo Yang
- Department of Gastrointestinal Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Mengdie Liu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Xuelai Luo
- Department of Gastrointestinal Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
| | - Lu Liu
- Department of Gastrointestinal Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
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5
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Cheng Y, Tian Z, Gao S, Zhao S, Li R, Zhou J, Sun Q, Wang D. A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis. Surg Endosc 2024; 38:3661-3671. [PMID: 38777891 DOI: 10.1007/s00464-024-10885-w] [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: 03/02/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection. METHODS A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort. RESULTS 72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer. CONCLUSION We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.
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Affiliation(s)
- Yifan Cheng
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Zhen Tian
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Shuyang Gao
- Northern Jiangsu People's Hospital Affiliated to Dalian Medical University, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Ruiqi Li
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Qiannan Sun
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Daorong Wang
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, China.
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, 225001, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China.
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.
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Hain E, Lefèvre JH, Ricardo A, Lee S, Zaghiyan K, McLemore E, Sherwinter D, Rhee R, Wilson M, Martz J, Maykel J, Marks J, Marcet J, Rouanet P, Maggiori L, Komen N, De Hous N, Lakkis Z, Tuech JJ, Attiyeh F, Cotte E, Sylla P. SafeHeal Colovac Colorectal Anastomosis Protection Device evaluation (SAFE-2) pivotal study: an international randomized controlled study to evaluate the safety and effectiveness of the Colovac Colorectal Anastomosis Protection Device. Colorectal Dis 2024; 26:1271-1284. [PMID: 38750621 DOI: 10.1111/codi.17012] [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: 06/05/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 06/28/2024]
Abstract
AIM Although proximal faecal diversion is standard of care to protect patients with high-risk colorectal anastomoses against septic complications of anastomotic leakage, it is associated with significant morbidity. The Colovac device (CD) is an intraluminal bypass device intended to avoid stoma creation in patients undergoing low anterior resection. A preliminary study (SAFE-1) completed in three European centres demonstrated 100% protection of colorectal anastomoses in 15 patients, as evidenced by the absence of faeces below the CD. This phase III trial (SAFE-2) aims to evaluate the safety and effectiveness of the CD in a larger cohort of patients undergoing curative rectal cancer resection. METHODS SAFE-2 is a pivotal, multicentre, prospective, open-label, randomized, controlled trial. Patients will be randomized in a 1:1 ratio to either the CD arm or the diverting loop ileostomy arm, with a recruitment target of 342 patients. The co-primary endpoints are the occurrence of major postoperative complications within 12 months of index surgery and the effectiveness of the CD in reducing stoma creation rates. Data regarding quality of life and patient's acceptance and tolerance of the device will be collected. DISCUSSION SAFE-2 is a multicentre randomized, control trial assessing the efficacy and the safety of the CD in protecting low colorectal anastomoses created during oncological resection relative to standard diverting loop ileostomy. TRIAL REGISTRATION NCT05010850.
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Affiliation(s)
- Elisabeth Hain
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jérémie H Lefèvre
- Department of Digestive Surgery, Sorbonne University, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sang Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Karen Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elisabeth McLemore
- Department of Colon and Rectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Danny Sherwinter
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Rebecca Rhee
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Matthew Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Joseph Martz
- Division of Colon and Rectal Surgery, Western Region Northwell/Lenox Hill Hospital, New York, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
| | - Jorge Marcet
- Division of Colon and Rectal Surgery, Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Philippe Rouanet
- Department of Colorectal Surgery, Institut du Cancer de Montpellier, Montpellier, France
| | - Leon Maggiori
- Department of Visceral and Digestive Surgery, Saint Louis Hospital, AP-HP, Paris, France
| | - Niels Komen
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Nicolas De Hous
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Jean-Jacques Tuech
- Department of Abdominal Surgery, Antwerp University Hospital Wilrijkstraat 10, Edegem, Belgium
| | - Fadi Attiyeh
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eddy Cotte
- Digestive and Oncological Surgery, Hopital Lyon Sud, Oullins-Pierre-Bénite, France
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hsu CC, Tsai WS, Tsai TY, You JF, Yeh CY, Hsieh PS, Tang R, Huang SH. Predictors for temporary stomas non-closure among non-metastatic rectal cancer patients undergoing curative resection: a retrospective analysis. World J Surg Oncol 2024; 22:124. [PMID: 38715036 PMCID: PMC11075260 DOI: 10.1186/s12957-024-03403-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop a predictive model for stoma non-closure in rectal cancer patients who underwent curative-intent low anterior resection. METHODS Consecutive patients diagnosed with non-metastatic rectal cancer between January 2005 and December 2017, who underwent low anterior resection, were retrospectively included in the Chang Gung Memorial Foundation Institutional Review Board. A comprehensive evaluation and analysis of potential risk factors linked to stoma non-closure were performed. RESULTS Out of 956 patients with temporary stomas, 10.3% (n = 103) experienced non-closure primarily due to cancer recurrence and anastomosis-related issues. Through multivariate analysis, several preoperative risk factors significantly associated with stoma non-closure were identified, including advanced age, anastomotic leakage, positive nodal status, high preoperative CEA levels, lower rectal cancer presence, margin involvement, and an eGFR below 30 mL/min/1.73m2. A risk assessment model achieved an AUC of 0.724, with a cutoff of 2.5, 84.5% sensitivity, and 51.4% specificity. Importantly, the non-closure rate could rise to 16.6% when more than two risk factors were present, starkly contrasting the 3.7% non-closure rate observed in cases with a risk score of 2 or below (p < 0.001). CONCLUSION Prognostic risk factors associated with the non-closure of a temporary stoma include advanced age, symptomatic anastomotic leakage, nodal status, high CEA levels, margin involvement, and an eGFR below 30 mL/min/1.73m2. Hence, it is crucial for surgeons to evaluate these factors and provide patients with a comprehensive prognosis before undergoing surgical intervention.
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Affiliation(s)
- Chia-Chien Hsu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzong-Yun Tsai
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Chien-Yuh Yeh
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Reiping Tang
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Shu-Huan Huang
- Division of Colon and Rectal Surgery, Colorectal Section, Department of Surgery Chang, Gung Memorial Hospital, Linko, No.5, Fuxing St., Guishan Dist, Taoyuan City, 33305, Taiwan.
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8
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He F, Tang C, Yang F, Chen D, Xiong J, Zou Y, Zhao D, Qian K. Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis. World J Surg Oncol 2024; 22:94. [PMID: 38610000 PMCID: PMC11010286 DOI: 10.1186/s12957-024-03363-z] [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: 01/22/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Temporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer. MATERIALS AND METHODS We conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer. RESULTS A total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure. CONCLUSION We identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.
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Affiliation(s)
- Fan He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chenglin Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Fuyu Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Defei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Junjie Xiong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yu Zou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dongqin Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Kun Qian
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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9
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Cui Y, Song M, Tie J, Li S, Wang H, Zhang Y, Geng J, Liu Z, Teng H, Sui X, Zhu X, Cai Y, Li Y, Wang W. Clinicopathological factors predict residual lymph node metastasis in locally advanced rectal cancer with ypT0-2 after neoadjuvant chemoradiotherapy. J Cancer Res Clin Oncol 2024; 150:176. [PMID: 38575793 PMCID: PMC10995092 DOI: 10.1007/s00432-024-05662-0] [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: 01/09/2024] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Residual lymph node metastases (RLNM) remained a great concern in the implementation of organ-preserving strategies and led to poor prognosis in locally advanced rectal cancer (LARC). In this study, we aimed to identify the clinicopathological factors correlated with RLNM in LARC patients with ypT0-2 after neoadjuvant chemoradiotherapy (NCRT). METHODS We retrospectively analyzed 417 patients histologically diagnosed middle-low LARC after NCRT and total mesorectal excision (TME), whose pathological staging was ypT0-2. All patients received pelvic magnetic resonance imaging (MRI) before NCRT. The radiation doses were 50-50.6 Gy for the planning gross tumor volume and 41.8-45 Gy for the planning target volume, respectively. A nomogram for predicting RLNM was constructed using a binary logistic regression. Nomogram performance was assessed by receiver operating characteristic (ROC) curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). RESULTS After surgery, 191 patients (45.8%) were ypT0, 43 patients (10.3%) were ypT1 and 183 patients (43.9%) were ypT2, and a total of 49 patients (11.8%) were found the presence of RLNM. Multivariable analyses identified MRI-defined mesorectal fascia (MRF)-positive, high-grade histopathology at biopsy, advanced ypT-category, and the presence of perineural invasion (PNI) as the predictive factors. The nomogram, incorporating all these predictors, showed good discrimination and calibration efficacy, with the areas under the ROC curve of 0.690 (95% CI: 0.610-0.771). Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. CONCLUSION The nomogram model can predict RLNM in patients with ypT0-2 tumors. It can help select suitable patients for performing organ-preserving strategies after NCRT.
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Affiliation(s)
- Yujun Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jian Tie
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Shuai Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhiyan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Huajing Teng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xin Sui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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10
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Burghgraef TA, Geitenbeek RTJ, Broekman M, Hol JC, Hompes R, Consten ECJ. Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study. Surg Endosc 2024; 38:105-115. [PMID: 37932600 PMCID: PMC10776460 DOI: 10.1007/s00464-023-10517-9] [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: 06/26/2023] [Accepted: 10/08/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The surgical resection of rectal carcinoma is associated with a high risk of permanent stoma rate. Primary anastomosis rate is suggested to be higher in robot-assisted and transanal total mesorectal excision, but permanent stoma rate is unknown. METHODS Patients undergoing total mesorectal excision for MRI-defined rectal cancer between 2015 and 2017 in 11 centers highly experienced in laparoscopic, robot-assisted or transanal total mesorectal excision were included in this retrospective study. Permanent stoma rate, stoma-related complications, readmissions, and reoperations were registered. A multivariable regression analysis was performed for permanent stoma rate, stoma-related complications, and stoma-related reoperations. RESULTS In total, 1198 patients were included. Permanent stoma rate after low anterior resection (with anastomosis or with an end colostomy) was 40.1% in patients undergoing laparoscopic surgery, 21.3% in patients undergoing robot-assisted surgery, and 25.6% in patients undergoing transanal surgery (P < 0.001). Permanent stoma rate after low anterior resection with an anastomosis was 17.3%, 11.8%, and 15.1%, respectively. The robot-assisted and transanal techniques were independently associated with a reduction in permanent stoma rate in patients who underwent a low anterior resection (with anastomosis or with an end colostomy) (OR 0.39 [95% CI 0.25, 0.59] and OR 0.35 [95% CI 0.22, 0.55]), while this was not seen in patients who underwent a restorative low anterior resection. 45.4% of the patients who had a stoma experienced stoma-related complications, 4.0% were at least once readmitted, and 8.9% underwent at least one reoperation. CONCLUSIONS The robot-assisted and transanal techniques are associated with a lower permanent stoma rate in patients who underwent a low anterior resection.
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Affiliation(s)
- T A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - R T J Geitenbeek
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - M Broekman
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - J C Hol
- Department of Surgery, Amsterdam UMC, VUmc, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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11
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Zhou L, Qin Z, Wang L. Risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107120. [PMID: 37907017 DOI: 10.1016/j.ejso.2023.107120] [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: 07/28/2023] [Revised: 10/07/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND To further define the risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma. METHODS Records from five English databases and four Chinese databases. Odds ratios (OR) and 95 % confidence intervals (CI) were used to indicate the risk of inclusion of risk factors. The non-closure stoma rate used the risk difference (RD) and 95 % CI. Risk factors were evaluated for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age ≥60 years[OR:1.57, 95%CI(1.44,1.72)], Tumor IV stage[OR:4.21, 95%CI(2.29,7.74)], American Society of Anesthesiologists (ASA)≥3[OR:1.48, 95%CI(1.33,1.65)], Neoadjuvant chemoradiotherapy[OR:1.41, 95%CI(1.09,1.82)],Open surgery[OR:1.45, 95%CI(1.09,1.93)], Postoperative chemotherapy[OR:1.37, 95%CI(1.03,1.82)], Anastomotic leakage[OR:4.61, 95%CI(2.86, 7.44)], Local recurrence[OR:7.16, 95%CI(4.70, 10.91)]. The rate of non-closure stoma after anterior resection for rectal cancer was: 0.20, 95 % CI (0.17, 0.23). The quality of evidence for stage IV tumors and anastomotic leakage was moderate, and other risk factors were low to very low. CONCLUSIONS Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age≥60 years, Tumor IV stage, ASA≥3, Neoadjuvant chemoradiotherapy, Open surgery, Postoperative chemotherapy, Anastomotic leakage, Local recurrence, and one in five anterior resection patients with a temporary stoma fails to close.
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Affiliation(s)
- Lu Zhou
- Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Zuming Qin
- The Second Xiangya Hospital of Central South University, Changsha, China
| | - Ling Wang
- Peking University People's Hospital, Beijing, China.
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Baloyiannis I, Perivoliotis K, Mamaloudis I, Bompou E, Sarakatsianou C, Tzovaras G. Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model. J Gastrointest Cancer 2023; 54:782-790. [PMID: 36063314 DOI: 10.1007/s12029-022-00862-8] [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] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Defunctioning ileostomies are often performed during rectal cancer surgery. However, stomas are sometimes associated with complications, while 20-30% of them are never reversed. Additionally, ileostomy closure can have associated morbidity, with rates as high as 45%, with the respective literature evidence being scarce and conflicting. Thus, we evaluated the stoma reversal outcomes and the risk factors for non-closure after rectal cancer surgery. METHODS This is a retrospective analysis of a prospectively collected database of all patients who had a defunctioning ileostomy at the time of resection for rectal cancer. All operations were performed by the same surgical team. A multivariable regression model was implemented. RESULTS In this study, 129 patients (male: 68.2%, female: 31.8%) were included. Ileostomy formation was associated with a total of 31% complication rate. Eventually 73.6% of the stomas were reversed at a mean time to closure of 26.6 weeks, with a morbidity of 13.7%. Non-reversal of ileostomy was correlated with neoadjuvant CRT (OR: 0.093, 95% CI: 0.012-0.735), anastomotic leakage (OR: 0.107, 95% CI: 0.019-0.610), and lymph node yield (OR: 0.946, 95% CI: 0.897-0.998). Time to reversal was affected by the N status, the LNR, the need for adjuvant chemotherapy, and the histologic grade. CONCLUSION In patients with rectal cancer resections, defunctioning stoma closure rate and time to closure were associated with several perioperative and pathological outcomes.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Konstantinos Perivoliotis
- Department of Surgery, General Hospital of Volos, Polymeri 134, 38222, Volos, Greece.
- University of Thessaly, Viopolis, 41500, Larissa, Greece.
- Department of Surgery, University Hospital of Larissa, Viopolis, 41110, Larissa, Greece.
| | - Ioannis Mamaloudis
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Effrosyni Bompou
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - Chamaidi Sarakatsianou
- Department of Anesthesiology, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece
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13
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Martellucci J, Balestri R, Brusciano L, Iacopini V, Puccini M, Docimo L, Cianchi F, Buccianti P, Prosperi P. Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer. Colorectal Dis 2023; 25:1686-1693. [PMID: 37461265 DOI: 10.1111/codi.16657] [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: 10/23/2022] [Revised: 05/06/2023] [Accepted: 06/01/2023] [Indexed: 08/17/2023]
Abstract
AIM Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. METHODS All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. RESULTS During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. CONCLUSION The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.
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Affiliation(s)
- Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | | | - Luigi Brusciano
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Veronica Iacopini
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Marco Puccini
- General Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - Ludovico Docimo
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Fabio Cianchi
- Digestive Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Piero Buccianti
- General Surgery Unit, Cisanello University Hospital, Pisa, Italy
| | - Paolo Prosperi
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
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14
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Xia S, Wu W, Ma L, Luo L, Yu L, Li Y. Transanal drainage tube for the prevention of anastomotic leakage after rectal cancer surgery: a meta-analysis of randomized controlled trials. Front Oncol 2023; 13:1198549. [PMID: 37274258 PMCID: PMC10235681 DOI: 10.3389/fonc.2023.1198549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/09/2023] [Indexed: 06/06/2023] Open
Abstract
Background Anastomotic leakage (AL) is a serious complication of anterior resection for rectal cancer. The use of transanal drainage tubes (TDT) during surgery to prevent AL remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of TDT in reducing AL. Methods Relevant data and studies published from inception until November 1, 2022, were retrieved from PubMed, Embase, and Cochrane Library databases to compare the incidence of AL after anterior resection for rectal cancer with and without TDT. Results This meta-analysis included 5 RCTs comprising 1385 patients. The results showed that the intraoperative use of TDT could not reduce the incidence of AL after rectal cancer surgery (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.52-1.59; p = 0.75). A subgroup analysis of different degrees of AL revealed that TDT did not reduce the incidence of postoperative grade B AL (RR, 1.18; 95% CI, 0.67-2.09; p = 0.56) but decreased the incidence of grade C AL (RR, 0.28; 95% CI: 0.12-0.64; p = 0.003). Further, TDT did not reduce the incidence of AL in patients with rectal cancer and a stoma (RR, 2.40; 95% CI, 1.01-5.71; p = 0.05). Conclusion TDT were ineffective in reducing the overall incidence of AL, but they might be beneficial in reducing the incidence of grade C AL in patients who underwent anterior resection. However, additional multicenter RCTs with larger sample sizes based on unified control standards and TDT indications are warranted to validate these findings.
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Affiliation(s)
- Shijun Xia
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Wenjiang Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Lijuan Ma
- Shenzhen Traditional Chinese Medicine Anorectal Hospital, Futian, Shenzhen, China
| | - Lidan Luo
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Linchong Yu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
| | - Yue Li
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Futian, Shenzhen, China
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15
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Liu C, Zhang J, Li L, Zhang L, Shang L, Ma Y. Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study. Langenbecks Arch Surg 2023; 408:151. [PMID: 37055576 PMCID: PMC10102083 DOI: 10.1007/s00423-023-02886-5] [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: 09/20/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Protective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision. METHODS A retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured. RESULTS Univariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure. CONCLUSION Compared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.
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Affiliation(s)
- Chao Liu
- Department of Laser Cosmetic Clinic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jizhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Li Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Liang Shang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yan Ma
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
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16
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Sheng N, Yan J, Wang Z, Wu Z. Nomogram for predicting the probability of permanent stoma in patients with acute obstructive colorectal cancer. Langenbecks Arch Surg 2023; 408:121. [PMID: 36920537 DOI: 10.1007/s00423-023-02859-8] [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: 01/13/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Acute obstructive colorectal cancer is a high-risk emergency among colorectal cancer (CRC). Approximately 20% of CRC patients are associated with a permanent stoma, which greatly affects the lifestyle of patients. This study aimed to investigate risk factors for predicting permanent stoma (PS) in patients with acute obstructive colorectal cancer. METHODS We retrospectively analyzed the clinical-pathological features of patients with acute obstructive colorectal cancer who underwent treatments from our hospital between January 2015 and December 2020. Univariate and multivariate logistic regression analyses were used to evaluate the risk factors for predicting PS chances of CRC patients using a nomogram method. Furthermore, the operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to assess the discrimination power of the nomogram. Calibration plot was used to evaluate nomogram's calibration. RESULTS A total of 98 patients with acute obstructive colorectal cancer were enrolled in this study, including 24 PS patients with permanent stoma and 74 non-PS patients. Multivariate analysis showed that age [odds ratio (OR): 1.068, 95% confidence interval (CI): 1.006 ~ 1.135, P = 0.032], carcinoembryonic antigen (CEA) [OR: 1.015, 95% CI: 1.003 ~ 1.028, P = 0.013], and surgical method [emergency group vs. stent group, OR: 14.066, 95% CI: 3.625 ~ 54.572, p < 0.001] were independent risk factors for PS. These risk factors were incorporated into a nomogram and showed that the AUC of the nomogram was 0.867 (95% CI: 0.782-0.951). The calibration plot got consistent with prediction for PS in the nomogram. CONCLUSION Age, CEA, and surgical method were independent risk factors for PS in patients with acute obstructive colorectal cancer. Our nomogram has favorable predictive power for PS in CRC patients.
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Affiliation(s)
- Nengquan Sheng
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Jun Yan
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zhigang Wang
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China
| | - Zhenqian Wu
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai, 200233, China.
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Thomas F, Menahem B, Lebreton G, Bouhier-Leporrier K, Dejardin O, Alves A. Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think. Front Oncol 2023; 12:1056314. [PMID: 36776358 PMCID: PMC9909408 DOI: 10.3389/fonc.2022.1056314] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Objectives This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state. Methods We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method. Results Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01). Conclusions This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.
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Affiliation(s)
- Flavie Thomas
- Centre Hospitalier Universitaire de Caen, Caen, France
| | - Benjamin Menahem
- Centre Hospitalier Universitaire de Caen, Caen, France,*Correspondence: Benjamin Menahem,
| | - Gil Lebreton
- Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Olivier Dejardin
- Institut Nationale de la Recherche Medicale (INSERM) U1086 Unité de recherche Interdisciplinaire pour la Prévention et le Traitement des Cancers, Caen, France
| | - Arnaud Alves
- Centre Hospitalier Universitaire de Caen, Caen, France
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Cao Y, Xu P, Shen Y, Wu W, Chen M, Wang F, Zhu Y, Yan F, Gu W, Lin Y. Exosomes and cancer immunotherapy: A review of recent cancer research. Front Oncol 2023; 12:1118101. [PMID: 36727049 PMCID: PMC9885269 DOI: 10.3389/fonc.2022.1118101] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/29/2022] [Indexed: 01/18/2023] Open
Abstract
As phospholipid extracellular vesicles (EVs) secreted by various cells, exosomes contain non-coding RNA (ncRNA), mRNA, DNA fragments, lipids, and proteins, which are essential for intercellular communication. Several types of cells can secrete exosomes that contribute to cancer initiation and progression. Cancer cells and the immune microenvironment interact and restrict each other. Tumor-derived exosomes (TDEs) have become essential players in this balance because they carry information from the original cancer cells and express complexes of MHC class I/II epitopes and costimulatory molecules. In the present study, we aimed to identify potential targets for exosome therapy by examining the specific expression and mechanism of exosomes derived from cancer cells. We introduced TDEs and explored their role in different tumor immune microenvironment (TIME), with a particular emphasis on gastrointestinal cancers, before briefly describing the therapeutic strategies of exosomes in cancer immune-related therapy.
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Affiliation(s)
- Yue Cao
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Peng Xu
- Department of Hematology, Soochow Hopes Hematology Hospital, Suzhou, Jiangsu, China
| | - Yangling Shen
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Wei Wu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Min Chen
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Fei Wang
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yuandong Zhu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Feng Yan
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Weiying Gu
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China,*Correspondence: Yan Lin, ; Weiying Gu,
| | - Yan Lin
- Department of Hematology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China,*Correspondence: Yan Lin, ; Weiying Gu,
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Liu Y, Zhao S, Du W, Tian Z, Chi H, Chao C, Shen W. Applying interpretable machine learning algorithms to predict risk factors for permanent stoma in patients after TME. Front Surg 2023; 10:1125875. [PMID: 37035560 PMCID: PMC10079943 DOI: 10.3389/fsurg.2023.1125875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Objective The purpose of this study was to develop a machine learning model to identify preoperative and intraoperative high-risk factors and to predict the occurrence of permanent stoma in patients after total mesorectal excision (TME). Methods A total of 1,163 patients with rectal cancer were included in the study, including 142 patients with permanent stoma. We collected 24 characteristic variables, including patient demographic characteristics, basic medical history, preoperative examination characteristics, type of surgery, and intraoperative information. Four machine learning algorithms including extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM) and k-nearest neighbor algorithm (KNN) were applied to construct the model and evaluate the model using k-fold cross validation method, ROC curve, calibration curve, decision curve analysis (DCA) and external validation. Results The XGBoost algorithm showed the best performance among the four prediction models. The ROC curve results showed that XGBoost had a high predictive accuracy with an AUC value of 0.987 in the training set and 0.963 in the validation set. The k-fold cross-validation method was used for internal validation, and the XGBoost model was stable. The calibration curves showed high predictive power of the XGBoost model. DCA curves showed higher benefit rates for patients who received interventional treatment under the XGBoost model. The AUC value for the external validation set was 0.89, indicating that the XGBoost prediction model has good extrapolation. Conclusion The prediction model for permanent stoma in patients with rectal cancer derived from the XGBoost machine learning algorithm in this study has high prediction accuracy and clinical utility.
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Affiliation(s)
- Yuan Liu
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Songyun Zhao
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Wenyi Du
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Zhiqiang Tian
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Hao Chi
- Clinical Medical College, Southwest Medical University, Luzhou, China
| | - Cheng Chao
- Department of Neurosurgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
- Correspondence: Wei Shen Chao Cheng
| | - Wei Shen
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
- Correspondence: Wei Shen Chao Cheng
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Zamaray B, Veld JV, Burghgraef TA, Brohet R, van Westreenen HL, van Hooft JE, Siersema PD, Tanis PJ, Consten ECJ, Amelung F, Bastiaenen V, van der Bilt J, Burghgraef T, Draaisma W, de Groot J, Kok N, Kusters M, Nagtegaal I, Zwanenburg E. Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:738-746. [PMID: 36641294 DOI: 10.1016/j.ejso.2022.12.008] [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: 09/27/2022] [Revised: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS. MATERIALS AND METHODS Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T0) and after resection, in patients having a stoma in situ (T1). These risk factors were used to construct a web-based prediction tool. RESULTS Of 2099 patients included in the study (T0), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T1), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T0 and T1 population. Other predictors at T0 were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T1, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T0 and an AUC of 0.81 for T1. CONCLUSIONS PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.
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Affiliation(s)
- Bobby Zamaray
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - J V Veld
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - T A Burghgraef
- Department of Surgery, Meander Hospital, Amersfoort, the Netherlands
| | - R Brohet
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands
| | | | - J E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Location AMC, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands; Department of Oncological and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E C J Consten
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands; Department of Surgery, Meander Hospital, Amersfoort, the Netherlands.
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21
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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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22
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Guo C, Fu Z, Qing X, Deng M. Prophylactic transanal drainage tube placement for preventing anastomotic leakage after anterior resection for rectal cancer: A meta-analysis. Colorectal Dis 2022; 24:1273-1284. [PMID: 35735261 DOI: 10.1111/codi.16231] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/23/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
AIM The aim was to evaluate the efficacy of transanal drainage tube (TDT) placement for preventing anastomotic leakage after low anterior resection for rectal cancer. METHOD PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to October 2021. Studies comparing outcomes following low anterior resection with or without TDT were included. The primary outcomes measured were anastomotic leakage rate, reoperation rate and anastomotic bleed rate. RESULTS Three randomized controlled trials (RCTs) and 16 observational studies (prospective or retrospective) involving 4560 patients satisfied the basic inclusion criteria. In RCTs, a TDT was associated with no statistically significant differences in anastomotic leakage (OR = 0.67, 95% CI 0.42-1.05, P = 0.08), reduction in reoperation (OR = 0.11, 95% CI 0.03-0.51, P = 0.004) and increased anastomotic bleeding rate (OR = 2.36, 95% CI 1.11-5.01, P = 0.03). In observational studies, a TDT was associated with significant reduction in anastomotic leak (OR = 0.44, 95% CI 0.30-0.64, P < 0.0001) and reoperation (OR = 0.47, 95% CI 0.33-0.69, P < 0.0001), with no statistically significant differences in anastomotic bleeding (OR = 1.30, 95% CI 0.20-8.30, P = 0.78). CONCLUSION In RCTs, a TDT for rectal cancer was correlated with no detectable differences in anastomotic leakage and with an increased risk of anastomotic bleeding. In observational studies, a TDT was correlated with reduction in anastomotic leakage and no detectable differences in anastomotic bleeding. Both RCTs and observational studies demonstrated a comparable reduction in reoperation rate with TDT. These data in aggregate indicated that TDTs may not show superiority but emphasized differences between RCT and observational data.
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Affiliation(s)
- Chenchen Guo
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Zhiwen Fu
- School of Medicine, Southeast University, Nanjing, China
| | - Xin Qing
- School of Medicine, Southeast University, Nanjing, China
| | - Mengen Deng
- School of Medicine, Southeast University, Nanjing, China
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Kuo CY, Lin YK, Wei PL, Chi-Yong Ngu J, Lee KD, Chen CL, Huang Y, Chen CC, Kuo LJ. Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for rectal cancer patients after sphincter-saving operation. Asian J Surg 2022; 46:1944-1950. [PMID: 36229306 DOI: 10.1016/j.asjsur.2022.09.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 03/18/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to identify the risk factors for permanent stoma (PS) in patients who underwent sphincter-saving operations for rectal cancer. METHODS We retrospectively reviewed 597 consecutive patients with rectal cancer from January 2012 to December 2020 at Taipei Medical University Hospital. Univariate and multivariable analyses were used to analyze risk factors for PS. RESULTS After a mean follow-up of 47.3 months (range 7-114 months), 59 patients (15.1%) were alive with a PS, including 46 patients who did not undergo reversal surgery and 13 patients who underwent stoma re-creation after reversal surgery. The mean period between primary surgery and stoma reversal was 6.0 months. Multivariate analysis revealed that the risk factors for PS were local recurrence [odd ratio (OR), 25.58; 95% confidence interval (CI), 4.428-147.761; p < 0.001], perirectal abscess [OR, 154.34; 95% CI, 15.806 - >999; p < 0.001], anastomosis site stenosis [OR, 187.081; 95% CI, 22.193 - >999; p < 0.001], perineural invasion [OR, 4.782; 95% CI, 1.22-18.736; p = 0.025], and operation time (min) [OR, 1.008; 95% CI, 1.002-1.014; p = 0.01]. CONCLUSIONS Local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, and operation time were independent risk factors for PS. Therefore, before a patient undergoes surgery for rectal cancer, surgeons should consider the possibility of the need for a PS, and patients should be informed before the operation that closure of the temporary stoma may not always be possible.
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From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies. Dis Colon Rectum 2022; 65:1135-1142. [PMID: 34840304 DOI: 10.1097/dcr.0000000000002185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Defunctioning loop ileostomies are used commonly, but there are significant morbidities. OBJECTIVE This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies. DESIGN This descriptive study is based on electronic health records and claims data. SETTINGS This study was conducted at academic and community hospitals in Ontario, Canada. PATIENTS Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included. MAIN OUTCOME MEASURES Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected. RESULTS The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%. LIMITATIONS This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions. CONCLUSIONS Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 . DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).
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Role of transanal drainage tubes in preventing anastomotic leakage after low anterior resection: a meta-analysis of randomized controlled trials. Tech Coloproctol 2022; 26:931-939. [PMID: 35915290 DOI: 10.1007/s10151-022-02665-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND The transanal drainage tube (TDT) is thought to reduce the incidence of anastomotic leakage (AL) in patients with low anterior resection (LAR). However, results from different clinical trials are inconsistent, although nearly all meta-analyses agree on the efficacy. In contrast to results of many previous studies, 2 recent independent randomized controlled trials (RCTs) suggest that the use of TDT does not prevent AL. We performed a meta-analysis including only RCTs to compare patients with TDTs vs. those without TDTs in terms of AL rate. METHODS A systematic literature search was performed in the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov and WHO/ICTRP from inception until February 14, 2022. RCTs that evaluated the role of TDTs in AL prevention in patients who underwent LAR for rectal cancer were included. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by two authors independently, and random-effects models were implemented. The main outcome was AL, and the secondary outcome was the grade of AL. RESULTS Three RCTs were included involving a total of 1115 participants (559 patients in the TDT group and 556 in the non-TDT group). No significant difference in the AL rate was detected (RR = 0.69, 95% confidence interval (CI) 0.42-1.15, p = 0.15, I2 = 21%, very low certainty evidence). The incidence of grade C AL was possibly lower in the TDT group (RR = 0.33, 95% CI 0.11-1.01, p = 0.05, very low certainty evidence), while the rate of grade B AL was similar between the two groups (RR = 1.17, 95% CI 0.66-2.08, p = 0.59, very low certainty evidence). CONCLUSIONS The present meta-analysis suggests that TDTs are not effective in reducing the overall incidence of AL, but possibly have a potential benefit in reducing the occurrence of grade C AL in patients with LAR. Based on the current limited data and existing heterogeneity, the inclusion of larger populations and the identification of more uniform indications for TDT need to be addressed in future studies.
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Hu K, Tan K, Li W, Zhang A, Li F, Li C, Liu B, Zhao S, Tong W. The impact of postoperative complications severity on stoma reversal following sphincter-preserving surgery for rectal cancer. Langenbecks Arch Surg 2022; 407:2959-2967. [PMID: 35802267 DOI: 10.1007/s00423-022-02589-3] [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: 12/27/2021] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, the relationship between temporary stoma reversal and the severity of postoperative complications (POCs) after the index surgery based on the Clavien-Dindo classification has not yet been explored. METHODS From July 2010 to June 2016, 380 patients undergoing sphincter-preserving surgery for rectal cancer with a temporary stoma in our hospital were included. Temporary stoma nonclosure rates, disease-free survival rates, and overall survival rates were estimated utilizing the Kaplan-Meier method. RESULTS Of all the 380 patients, primary stomas were created in 335 patients and secondary stomas in 45 patients. After the index surgery, 36.6% (139/380) of patients developed at least one postoperative complication. In the first analysis, which included all the patients, 24.7% of temporary stomas remained unclosed. In the second analysis for 335 patients with a primary stoma, 23.3% were left with unclosed stomas. After the COX regression analysis, both major POCs and minor POCs were found to be independent risk factors for the permanent stoma, and there was an increasing tendency toward the risk of permanent stoma with the increase in POC severity. CONCLUSION POCs are independent predictors of permanent stoma after rectal cancer surgery. Even minor POCs may affect the outcome, while there is a clear direct relationship between POC severity and permanent stoma rates.
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Affiliation(s)
- Kang Hu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Ke Tan
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Wang Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Anping Zhang
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Chunxue Li
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Baohua Liu
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Song Zhao
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Weidong Tong
- Department of General Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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Turner GA, Clifford KA, Holloway R, Woodfield JC, Thompson‐Fawcett M. The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study. Colorectal Dis 2022; 24:854-861. [PMID: 35156285 PMCID: PMC9545668 DOI: 10.1111/codi.16095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 12/13/2022]
Abstract
AIM There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. METHOD A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. RESULTS A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). CONCLUSION Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.
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Affiliation(s)
| | - Kari A. Clifford
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Rossi Holloway
- Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - John C. Woodfield
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
| | - Mark Thompson‐Fawcett
- Department of SurgeryDunedin HospitalDunedinNew Zealand,Department of Surgical SciencesUniversity of Otago School of MedicineDunedinNew Zealand
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Dellafiore F, Caruso R, Bonavina L, Udugampolage NS, Villa G, Russo S, Vangone I, BaronI I, Di Pasquale C, Nania T, Manara DF, Arrigoni C. Risk factors and pooled incidence of intestinal stoma complications: systematic review and Meta-analysis. Curr Med Res Opin 2022; 38:1103-1113. [PMID: 35608158 DOI: 10.1080/03007995.2022.2081455] [Citation(s) in RCA: 2] [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] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The present systematic review aimed to identify, critically assess and summarize which risk factors might determine the onset of ostomy complications, describing a pooled incidence and stratified incidences by each identified risk factor. METHODS A systematic literature review with a meta-analysis of observational studies was performed by following the PRISMA statement and flow chart. The quality assessment of the included articles was performed through the Newcastle-Ottawa Scale (NOS). RESULTS Sixteen articles published between 1990 and 2018 focused on the risk factors related to intestinal stomal complications, and the performed analysis led to identifying influenceable and non-influenceable risk factors. The median of the NOS evaluation was 6 (IQR = 5.75-6). Among 10,520 included patients, the pooled incidence of stomal complications was 35%, ranging from 9% to 63%, regardless of the nature of the complications. Analysis of the sub-groups highlighted obesity and ostomy surgery performed via laparoscopy or emergency conditions have significant incidences, respectively, of 66% and 68%. CONCLUSIONS The pooled incidence of stomal complications requires greater attention for its relevant epidemiology. From the clinical point of view, patients with obesity and chronic conditions require more attention to prevent complications, possibly employing accurate educational interventions to enhance proper stoma management.
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Affiliation(s)
- Federica Dellafiore
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Division of General Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Giulia Villa
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Russo
- ItalyVascular Surgery Unit, IRCCS Policlinic San Matteo Foundation, Nursing degree course, University of Pavia, section Istituti Clinici di Pavia e Vigevano S.p.A., Pavia, Italy
| | - Ida Vangone
- Department of Oncology and Hematology-Oncology, Istituto Europeo Oncologia, Milan, Italy
| | - Irene BaronI
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Tiziana Nania
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Duilio F Manara
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Milan, Italy
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
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Hasegawa H, Tsukada Y, Wakabayashi M, Nomura S, Sasaki T, Nishizawa Y, Ikeda K, Takeshita N, Teramura K, Ito M. Impact of near-infrared fluorescence imaging with indocyanine green on structural sequelae of anastomotic leakage after laparoscopic intersphincteric resection of malignant rectal tumors. Tech Coloproctol 2022; 26:561-570. [DOI: 10.1007/s10151-022-02631-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 05/02/2022] [Indexed: 12/16/2022]
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Huang SH, Tsai KY, Tsai TY, You JF, Yeh CY, Hsieh PS, Tang R, Chiang JM, Tsai WS. Preoperative risk stratification of permanent stoma in patients with non-metastatic mid and low rectal cancer undergoing curative resection and a temporary stoma. Langenbecks Arch Surg 2022; 407:1991-1999. [DOI: 10.1007/s00423-022-02503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
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Kang SI, Kim S, Kim JH. Two-year follow-up results of the use of a fecal diverting device as a substitute for a defunctioning stoma. Int J Colorectal Dis 2022; 37:835-841. [PMID: 35238980 DOI: 10.1007/s00384-022-04117-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Our previously published clinical studies described the short-term outcomes of a newly developed intraluminal fecal diverting device (FDD). FDD was a safe and effective substitute for a defunctioning stoma. However, the long-term efficacy and safety of this device remain unknown. We investigated the long-term outcomes of the use of the FDD as a substitute for a defunctioning stoma. METHODS We examined the medical records of patients who participated in our two previous FDD clinical studies. The main outcome was the number of patients with bowel continuity for 2 years after undergoing the FDD procedure or defunctioning stoma creation. RESULTS Between May 2015 and July 2018, 85 patients were screened for inclusion in this study. Of those, 27 patients underwent a defunctioning ileostomy after proctectomy. The remaining 58 underwent the FDD procedure after proctectomy. Seventy-two patients (ileostomy group, n = 22; FDD group, n = 50) with a follow-up duration > 24 months were included in this analysis. The mean duration of fecal diversion was significantly shorter (p < 0.001) in the FDD group (3.1 [1.6-6.1] weeks) than in the ileostomy group (16.7 [10.0-31.6] weeks). However, the rate of permanent stoma creation was not statistically different between the two groups (ileostomy and FDD groups, 13.6% [3/22] and 10.0% [5/50], respectively; p = 0.693). CONCLUSIONS The FDD procedure is a feasible substitute for a defunctioning stoma after proctectomy. Multicenter large-scaled clinical studies are required to validate our results.
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Affiliation(s)
- Sung Il Kang
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea.
| | - Sohyun Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
| | - Jae Hwang Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
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Cauley CE, Kalady MF. Special Considerations of Anastomotic Leak in Patients with Rectal Cancer. Clin Colon Rectal Surg 2021; 34:426-430. [PMID: 34853565 DOI: 10.1055/s-0041-1735275] [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] [Indexed: 10/19/2022]
Abstract
Anastomotic leak in patients with rectal cancer has the potential to cause worse oncologic outcomes in addition to major morbidity and mortality risk of this dreaded complication. Anatomic location of the rectal cancer determines the ability to perform a restorative operation and the height of the anastomosis in relation to the anal canal. Clinical staging dictates the need for neoadjuvant treatment (such as chemotherapy and radiation) which may also contribute to anastomotic leak risk. In addition to oncologic outcomes, anastomotic leak can impact bowel function, the need for permanent stoma, and long-term quality of life. This study will discuss special considerations for anastomotic leak prevention and clinical implications of this complication in patients with rectal cancer.
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Affiliation(s)
- Christy E Cauley
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew F Kalady
- Division of Colon and Rectal Surgery, The Ohio State University, Columbus, OH
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Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection. J Gastrointest Surg 2021; 25:3218-3229. [PMID: 33904057 DOI: 10.1007/s11605-021-04982-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/10/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study was to determine the risk factors for the development of a permanent stoma in laparoscopic intersphincteric resection (LS-ISR) for ultralow rectal adenocarcinoma and to develop and validate a prediction model to predict the probability of permanent stoma after surgery. METHODS A primary cohort consisting of 301 consecutive patients who underwent LS-ISR was enrolled in this study. Multivariable logistic regression analysis was used to identify risk factors and develop the nomogram. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort contained 91 consecutive patients from January 2012 to January 2019. RESULTS The permanent stoma rate was 11.3% (34/301) in the primary cohort and 18.7% (17/91) in the validation cohort. Multivariable analysis revealed that nCRT (OR, 3.195; 95% CI, 1.169-8.733; P=0.024), ASA score of 3 (OR, 5.062; 95% CI, 1.877-13.646; P=0.001), distant metastasis (OR, 14.645; 95% CI, 3.186-67.315; P=0.001), and anastomotic leakage (OR, 11.308; 95% CI, 3.650-35.035; P<0.001) were independent risk factors for permanent stoma, and a nomogram was established. The AUCs of the nomogram were 0.842 and 0.858 in the primary and validation cohorts, respectively. The calibration curves showed good calibration in both cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful. CONCLUSION We developed and validated a nomogram for ultralow rectal adenocarcinoma patients who underwent LS-ISR, and the nomogram could help surgeons identify which patients are at a higher risk of a permanent stoma after surgery.
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Warps ALK, Tollenaar RAEM, Tanis PJ, Dekker JWT. Time interval between rectal cancer resection and reintervention for anastomotic leakage and the impact of a defunctioning stoma: A Dutch population-based study. Colorectal Dis 2021; 23:2937-2947. [PMID: 34407272 DOI: 10.1111/codi.15878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/01/2023]
Abstract
AIM In the Netherlands, a selective policy of faecal diversion after rectal cancer surgery is generally applied. This study aimed to evaluate the timing, type, and short-term outcomes of reoperation for anastomotic leakage after primary rectal cancer resection stratified for a defunctioning stoma. METHOD Data of all patients who underwent primary rectal cancer surgery with primary anastomosis from 2013-2019 were extracted from the Dutch ColoRectal Audit. Primary outcomes were new stoma construction, mortality, ICU admission, prolonged hospital stay, and readmission. RESULTS In total, 10,772 rectal cancer patients who underwent surgery with primary anastomosis were included, of whom 46.6% received a primary defunctioning stoma. The reintervention rate for anastomotic leakage was 8.2% and 11.6% for patients with and without a defunctioning stoma (p < 0.001). Reintervention consisted of reoperation in 44.0% and 85.3% (p < 0.001), with a median time interval from primary resection to reoperation of seven days (IQR 4-14) vs. five days (IQR 3-13), respectively. In the presence of a defunctioning stoma, early reoperation (<5 days; n = 47) was associated with significantly more end-colostomy construction (51% vs. 33%) and ICU admission (66% vs. 38%) than late reoperation (≥5 days; n = 127). Without defunctioning stoma, early reoperation (n = 252) was associated with significantly higher mortality (4% vs. 1%), and more ICU admissions (52% vs.34%) than late reoperation (n = 302). CONCLUSIONS Early reoperations after rectal cancer resection are associated with worse outcomes reflected by a more frequent ICU admission in general, more colostomy construction, and higher mortality in patients with primary defunctioned and nondefunctioned anastomosis.
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Affiliation(s)
- Anne-Loes K Warps
- Department of Surgery, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands.,Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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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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Kim S, Kang SI, Kim SH, Kim JH. The Effect of Anastomotic Leakage on the Incidence and Severity of Low Anterior Resection Syndrome in Patients Undergoing Proctectomy: A Propensity Score Matching Analysis. Ann Coloproctol 2021; 37:281-290. [PMID: 34098631 PMCID: PMC8566143 DOI: 10.3393/ac.2021.03.15] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Proctectomy for the treatment of rectal cancer results in inevitable changes to bowel habits. Symptoms such as fecal incontinence, constipation, and tenesmus are collectively referred to as low anterior resection syndrome (LARS). Among the several risk factors that cause LARS, anastomotic leakage (AL) is a strong risk factor for permanent stoma formation. Therefore, the purpose of this study was to investigate the relationship between the severity of LARS and AL in patients with rectal cancer based on the LARS score and the Memorial Sloan Kettering Cancer Center (MSKCC) defecation symptom questionnaires. Methods We retrospectively analyzed patients who underwent low anterior resection for rectal cancer since January 2010. Patients who completed the questionnaire were classified into the AL group and control group based on medical and imaging records. Major LARS and MSKCC scores were analyzed as primary endpoints. Results Among the 179 patients included in this study, 37 were classified into the AL group. After propensity score matching, there were significant differences in the ratio of major LARS and MSKCC scores of the control group and AL group (ratio of major LARS: 11.1% and 37.8%, P < 0.001; MSKCC score: 67.29±10.4 and 56.49±7.2, respectively, P < 0.001). Univariate and multivariate analyses revealed that AL was an independent factor for major LARS occurrence and MSKCC score. Conclusion This study showed that AL was a significant factor in the occurrence of major LARS and defecation symptoms after proctectomy.
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Affiliation(s)
- Sungjin Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Il Kang
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - So Hyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae-Hwang Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Chen J, Zhang Z, Chang W, Yi T, Feng Q, Zhu D, He G, Wei Y. Short-Term and Long-Term Outcomes in Mid and Low Rectal Cancer With Robotic Surgery. Front Oncol 2021; 11:603073. [PMID: 33767981 PMCID: PMC7985529 DOI: 10.3389/fonc.2021.603073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate the risk factors for postoperative complications and anastomotic leakage after robotic surgery for mid and low rectal cancer and their influence on long-term outcomes. Methods A total of 641 patients who underwent radical mid and low rectal cancer robotic surgery at Zhongshan Hospital Fudan University from January 2014 to December 2018 were enrolled in this study. The clinicopathological factors of the patients were collected. The risk factors for short-term outcomes of complications and anastomotic leakage were analyzed, and their influences on recurrence and overall survival were studied. Results Of the 641 patients, 516 (80.5%) underwent AR or LAR procedures, while 125 (19.5%) underwent the NOSES procedure. Only fifteen (2.3%) patients had stoma diversion. One hundred and seventeen patients (17.6%) experienced surgical complications. Anastomotic leakage occurred in 44 patients (6.9%). Eleven patients (1.7%) underwent reoperation within 90 days after surgery. Preoperative radiotherapy did not significantly increase anastomotic leakage in our study (7.4% vs. 6.8%, P = 0.869). The mean postoperative hospital stay was much longer with complication (10.4 vs. 7.1 days, P<0.05) and leakage (12.9 vs. 7.4 days, P < 0.05). Multivariate analysis showed that male sex (OR = 1.855, 95% CI: 1.175–2.923, P < 0.05), tumor distance 5 cm from the anus (OR = 1.563, 95% CI: 1.016–2.404, P < 0.05), and operation time length (OR = 1.563, 95% CI: 1.009–2.421, P < 0.05) were independent risk factors for complications in mid and low rectal cancer patients. The same results for anastomotic leakage: male sex (OR = 2.247, 95% CI: 1.126–4.902, P < 0.05), tumor distance 5 cm from the anus (OR = 2.242, 95% CI: 1.197–4.202, P < 0.05), and operation time length (OR = 2.114, 95% CI: 1.127–3.968, P < 0.05). The 3-year DFS and OS were 82.4% and 92.6% with complication, 88.4% and 94.0% without complication, 88.6% and 93.1% with leakage, and 87.0% and 93.8% without leakage, respectively. The complication and anastomotic leakage showed no significant influences on long-term outcomes. Conclusion Being male, having a lower tumor location, and having a prolonged operation time were independent risk factors for complications and anastomotic leakage in mid and low rectal cancer. Complications and anastomotic leakage might have no long-term impact on oncological outcomes for mid and low rectal cancer with robotic surgery.
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Affiliation(s)
- Jingwen Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenju Chang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tuo Yi
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qingyang Feng
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dexiang Zhu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guodong He
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Metwally IH, Abdelkhalek M, Elbalka SS, Zuhdy M, Fareed AM, Eldamshity O. Clinico-epidemiologic criteria and predictors of survival of rectal cancer among Egyptians in Delta region. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Background Colorectal cancer represents a global health problem. Rectal cancer in particular is increasing and is believed to carry a unique epidemiologic and prognostic criteria.
Method We herein study retrospectively the data of 245 patients from a tertiary center in Egypt. Clinico-epidemiologic criteria and predictors of survival are analyzed.
Results The disease affects younger population without sex predilection. Prognosis is affected by age, nodal status, metastasis, and bowel obstruction.
Conclusion Rectal cancer has unique criteria in the Egyptian population. A national population based registry is recommended to delineate the nature of the disease in Egypt.
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Affiliation(s)
- Islam H. Metwally
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
| | - Mohamed Abdelkhalek
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
| | - Saleh S. Elbalka
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
| | - Mohamed Zuhdy
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
| | - Ahmed M. Fareed
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
| | - Osama Eldamshity
- Oncology Center Mansoura University (OCMU), Surgical Oncology Unit, Mansoura, Egypt
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Li C, Qin X, Yang Z, Guo W, Huang R, Wang H, Wang H. A nomogram to predict the incidence of permanent stoma in elderly patients with rectal cancer. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:342. [PMID: 33708969 PMCID: PMC7944294 DOI: 10.21037/atm-21-29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Creation of a temporary diverting stoma during rectal cancer surgery is used widely to prevent undesirable outcomes related to anastomotic leakage (AL). The transition from temporary stoma (TS) to permanent stoma (PS) is a frequent outcome. Elderly patients may have a greater probability of PS. We aimed to identify risk factors of PS and developed a nomogram to predict the rate of PS for elderly patients. Methods We enrolled elderly patients (≥70 years) who underwent rectal cancer surgery with a TS between January 2014 and December 2017 at our hospital. We divided patients into two groups: a TS group and a PS group. We then identified the risk factors for PS and developed a nomogram to predict the possibility of PS. Results Of the 278 elderly patients who received a diverting stoma, 220 (79.14%) eventually underwent stoma reversal, and 58 (20.86%) had PS. The proportion of males in the PS group was significantly higher than that of the TS group (P=0.048). Univariate and multivariate analysis showed that American Society of Anesthesiologists (ASA) score (P<0.001), laparotomy (P=0.004), AL (P<0.001), and tumor recurrence (P<0.001) were significantly correlated with PS. These four factors were included to construct the nomogram. The consistency index of the nomogram was 0.833 and the model yielded an area under the curve of 0.833. Conclusions ASA score (≥3), laparotomy, AL, and tumor recurrence were independent risk factors for PS in elderly patients. Our nomogram exhibited moderate predictive ability.
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Affiliation(s)
- Chuangkun Li
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiusen Qin
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zifeng Yang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wentai Guo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rongkang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huaiming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Disease, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Predisposing factors and clinical impact of high-output syndrome after sphincter-preserving surgery with covering ileostomy for rectal cancer: a retrospective single-center cohort study. Int J Clin Oncol 2020; 26:118-125. [PMID: 32902781 DOI: 10.1007/s10147-020-01781-z] [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: 06/29/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Ileostomy-related high-output syndrome has become a major cause of postoperative morbidity after rectal cancer surgery. This study aimed to clarify the predisposing factors and clinical impact of high-output syndrome. METHODS Clinical parameters that were associated with high-output syndrome and clinical impact of high-output syndrome on nutritional status, electrolyte abnormality and renal dysfunction were retrospectively investigated in consecutive patients with rectal cancer undergoing resection with covering ileostomy during 2016-2017. RESULTS High-output syndrome developed in 44/195 eligible patients (22.6%). Multivariable analysis revealed that neoadjuvant (chemo)radiotherapy [odds ratio (OR): 2.4; 95% confidence interval (CI) 1.1-5.2; P = 0.02], postoperative complications (OR: 2.2; 95% CI 1.0-4.6; P = 0.049), postoperative maximal white blood cell ≥ 10,000 cells/μl (OR: 4.0; 95% CI 1.9-8.8; P = 0.0004), and postoperative maximal C-reactive protein ≥ 10 mg/dl (OR: 2.4; 95% CI 1.1-5.2; P = 0.02) were independently associated with high-output syndrome. High-output syndrome was associated with increased renal dysfunction at the time of ostomy closure (29.6% versus 11.9%, patients with high-output syndrome vs. without high-output syndrome, P = 0.008), but not with nutritional imbalance or electrolyte abnormalities. High-output syndrome (OR: 2.5; 95% CI 1.1-5.9; P = 0.03) and postoperative maximal C-reactive protein ≥ 10 mg/dl (OR: 2.4; 95% CI 1.0-5.6; P = 0.04) were independently associated with renal dysfunction at ostomy closure. CONCLUSION Preoperative (chemo)radiotherapy, postoperative inflammatory response, and postoperative complications predisposed to high-output syndrome, and it significantly impacted postoperative renal dysfunction. Active monitoring and early intervention are warranted to prevent renal dysfunction in patients with these factors.
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Niu L, Wang J, Zhang P, Zhao X. Protective ileostomy does not prevent anastomotic leakage after anterior resection of rectal cancer. J Int Med Res 2020; 48:300060520946520. [PMID: 32862745 PMCID: PMC7457655 DOI: 10.1177/0300060520946520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore whether protective ileostomy is beneficial in preventing anastomotic leakage after anterior resection of rectal cancer. METHODS A total of 347 patients underwent anterior resection of rectal cancer in our hospital. Ninety-five patients were treated with protective ileostomy (treatment group), and 252 patients were not (control group). The incidences of anastomotic leakage and permanent stoma were compared between the two groups. RESULTS The overall incidences of anastomotic leakage were 6.32% (6/95) and 8.73% (22/252) in the treatment group and control group, respectively. In the cohort of patients who underwent neoadjuvant radiotherapy, the incidence of anastomotic leakage was 5.88% (2/34) and 12.0% (3/25) in the treatment group and control group, respectively. Logistic regression showed that the incidence of anastomotic leakage was not statistically significant. However, diabetes and the anastomotic height significantly affected the occurrence of anastomotic leakage. The permanent stoma rate was 6.42% (6/95) and 5.95% (15/252) in the treatment group and control group, respectively. CONCLUSION Protective ileostomy did not show a significant advantage in reducing the incidence of postoperative anastomotic leakage in patients with rectal cancer, and it may lead to a permanent stoma.
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Affiliation(s)
- Lei Niu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jin Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaomu Zhao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients. World J Surg Oncol 2020; 18:207. [PMID: 32795302 PMCID: PMC7427951 DOI: 10.1186/s12957-020-01979-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/30/2020] [Indexed: 12/21/2022] Open
Abstract
Background One of the most severe complications of low anterior rectal resection is anastomotic leakage (AL). The creation of a loop ileostomy (LI) reduces the prevalence of AL requiring surgical intervention. However, up to one-third of temporary stomas may never be closed. The first aim of the study was to perform a retrospective assessment of the impact of LI on the risk of permanent stoma (PS) and symptomatic AL. The second aim of the study was to assess preoperative PS risk factors in patients with LI. Methods A total of 286 consecutive patients who underwent low anterior rectal resection were subjected to retrospective analysis. In 101 (35.3%) patients, diverting LI was performed due to low anastomosis, while in the remaining 185 (64.7%) patients, no ileostomy was performed. LIs were reversed after adjuvant treatment. Analyses of the effect of LI on symptomatic AL and PS were performed. Among the potential risk factors for PS, clinical factors and the values of selected peripheral blood parameters were analysed. Results PS occurred in 37.6% and 21.1% of the patients with LI and without LI, respectively (p < 0.01). Symptomatic ALs were significantly more common in patients without LI. In this group, symptomatic ALs occurred in 23.8% of patients, while in the LI group, they occurred in 5% of patients (p < 0.001). In the LI group, the only significant risk factor for PS in the multivariate analysis was preoperative plasma fibrinogen concentration (OR = 1.007, 97.5% CI 1.002–1.013, p = 0.013). Conclusions Although protective LI may reduce the incidence of symptomatic AL, it can be related to a higher risk of PS in this group of patients. The preoperative plasma fibrinogen concentration can be a risk factor for PS in LI patients and may be a useful variable in decision-making models.
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Diverting Ileostomy Duration Is the Main Determinant of Ileostomy-Related Complications after Surgical Treatment of Rectum Cancer. JOURNAL OF ONCOLOGY 2020; 2020:4186857. [PMID: 32322269 PMCID: PMC7166299 DOI: 10.1155/2020/4186857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/16/2020] [Indexed: 01/02/2023]
Abstract
Background This study aimed to investigate factors associated with the development of ileostomy complications in rectal cancer patients, including those who received neoadjuvant treatment. Methods This retrospective trial included 133 consecutive patients who underwent surgery for rectal cancer with temporary diverting ileostomy. Patients' demographic characteristics as well as the pre- and postclosure outcomes and complications were analyzed. Results In logistic regression analysis, longer duration of ileostomy emerged as a significant independent predictor of any complication during ileostomy. The respective odds ratios for 3–6 months and >6 months vs. <3 months of ileostomy duration were as follows: OR, 4.5 (95% CI, 1.2–16.7), p=0.023; and OR, 15.2 (95% CI, 3.1–75.2), p=0.001. An additional stepwise model also identified hypertension as a significant predictor. In stepwise logistic regression model, adjuvant chemoradiotherapy emerged as significant independent predictor of “any ileostomy-related complication after ileostomy closure”: OR, 4.5 (2.0–10.2), p < 0.001. Conclusion Duration of ileostomy appears to be the main determinant of ileostomy-related complications. Patients who had received neoadjuvant or adjuvant therapy had longer ileostomy duration, which may be attributed to the concerns of the surgeon or to the complications themselves.
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Kim S, Kim MH, Oh JH, Jeong SY, Park KJ, Oh HK, Kim DW, Kang SB. Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function. Colorectal Dis 2020; 22:399-407. [PMID: 31698537 DOI: 10.1111/codi.14898] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 10/08/2019] [Indexed: 12/24/2022]
Abstract
AIM Preoperative factors predictive of permanent stoma creation were investigated in a long-term follow-up of patients with mid or low rectal cancer. METHOD We included patients who underwent radical resection for mid or low rectal cancer with available data for preoperative anal function measured by manometry and Faecal Incontinence Severity Index questionnaire between January 2005 and December 2015 in three tertiary referral hospitals. A permanent stoma was defined as a stoma present until the patient's last follow-up visit or death. Preoperative factors that predicted permanent stoma creation were analysed. RESULTS Over a median follow-up of 57.4 months (range 12-143 months), a permanent stoma was created in 144/577 (25.0%) patients, including 89 (15.4%) who underwent abdominoperineal resection, one (0.2%) who underwent Hartmann's operation without reversal, 15 (2.6%) with a diverting ileostomy at the time of initial sphincter-preserving surgery without undergoing stoma reversal, and 39 (6.8%) who underwent permanent ileostomy formation after sphincter-preserving surgery. Patients with permanent stoma creation had a shorter tumour distance from the anal verge (P < 0.001), larger tumour size (P = 0.020) and higher preoperative Faecal Incontinence Severity Index score (P = 0.020). On multivariable analysis, tumour distance from the anal verge predicted permanent stoma formation (relative risk 0.53 per centimetre increase; 95% confidence interval 0.46-0.60; P < 0.001) but preoperative anal function did not. CONCLUSION Tumour distance from the anal verge was the only preoperative determinant of permanent stoma creation in rectal cancer patients. These data may help mid and low rectal cancer patients understand the need for permanent stoma.
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Affiliation(s)
- S Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Armed Forces Capital Hospital, Seongnam, Korea
| | - M H Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - J H Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - S-Y Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - K J Park
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - H-K Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - D-W Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - S-B Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Sun X, Han H, Qiu H, Wu B, Lin G, Niu B, Zhou J, Lu J, Xu L, Zhang G, Xiao Y. Comparison of safety of loop ileostomy and loop transverse colostomy for low-lying rectal cancer patients undergoing anterior resection: A retrospective, single institution, propensity score-matched study. Asia Pac J Clin Oncol 2020; 19:e5-e11. [PMID: 32199033 DOI: 10.1111/ajco.13322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/29/2019] [Accepted: 01/23/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION This study was to compare the prevalence of stoma-related complications and stoma reversal perioperative complications of patients with low-lying rectal cancer who received preventative loop ileostomy and those who underwent loop transverse colostomy. METHODS This retrospective single-center study analyzed the clinicopathologic and surgical data of 288 patients with pathologically proven primary rectal cancer who underwent anterior resection with either preventative loop ileostomy (n = 82) or loop transverse colostomy. To achieve comparability of a propensity score matching method was used to match patients from each group in a 1:2 ratio. Determinants of stoma-related complications were analyzed by multivariate logistic regression analysis. RESULTS Forty-nine (74.3%) patients in the loop ileostomy group experienced stoma-related complications versus 48.7% in the loop transverse colostomy group (P < 0.01). Irritant dermatitis was the most frequent complication in both groups. The loop ileostomy group had a significantly higher rate (24.24%) of stoma reversal perioperative complications than the loop transverse colostomy group. Multivariate logistic regression analysis showed that ileostomy versus loop transverse colostomy was a significant independent risk for stoma-related complications and stoma reversal perioperative complications. Furthermore, by Clavien-Dindo classification, patients receiving loop ileostomy had an overall higher rate of complications and stoma reversal perioperative complications versus those undergoing loop transverse colostomy (P < 0.01). The rate of grade II complications was significantly higher in the loop ileostomy group (43.9%) than that of loop transverse colostomy group (13.5%, P < 0.01), whereas the rate of grade I, and grade IIIa and IIIb complications and stoma reversal perioperative complications was comparable between the two groups. CONCLUSION The study has demonstrated that loop transverse colostomy is associated with significantly lower rates of stoma-related complications and stoma reversal perioperative complications compared to loop transverse colostomy.
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Affiliation(s)
- Xiyu Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huiqiao Han
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Huizhong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guole Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Beizhan Niu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaolin Zhou
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junyang Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lai Xu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guannan Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Carboni F, Valle M, Levi Sandri GB, Giofrè M, Federici O, Zazza S, Garofalo A. Transanal drainage tube: alternative option to defunctioning stoma in rectal cancer surgery? Transl Gastroenterol Hepatol 2020; 5:6. [PMID: 32190774 DOI: 10.21037/tgh.2019.10.16] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background Anastomotic leakage (AL) remains the most dreaded complication after rectal cancer surgery. The aim of this study was to evaluate the role of transanal drainage tube in reducing the incidence, severity and hospital costs respect to defunctioning stoma (DS). Methods Considering 429 patients consecutively operated for rectal adenocarcinoma, the tube was placed in 275 (Group A) and not placed in 154 (Group B) patients. A DS was created in a subgroup of 54 patients among the latter. Results The incidence of AL was significantly higher in Group B (P=0.007). In patients with DS, the incidence was higher than Group A (P=NS). Grade C complications were significantly higher in Group B (P=0.006) and Grade B complications were significantly higher in patients with DS (P=0.03). Estimated economic benefit was 4,000 Euros for each patient. Conclusions Transanal drainage tube may be a safe and effective alternative to DS in many cases. The incidence of leakage and Grade C complications are reduced albeit not significantly but Grade B complications are significantly lower. Although the AL incidence was similar in our experience, the tube allows to avoid a stoma-related consequence and the need for reversal procedure with economic benefit.
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Affiliation(s)
- Fabio Carboni
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Mario Valle
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Manuel Giofrè
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Orietta Federici
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Settimio Zazza
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alfredo Garofalo
- Department of Digestive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Tchelebi LT, Romesser PB, Feuerlein S, Hoffe S, Latifi K, Felder S, Chuong MD. Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management. Cancer Control 2020; 27:1073274820969449. [PMID: 33118384 PMCID: PMC7791447 DOI: 10.1177/1073274820969449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.
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Affiliation(s)
- Leila T. Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine,
Hershey, PA, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Sebastian Feuerlein
- Department of Diagnostic Imaging and Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, USA
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Kujtim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL,
USA
| | - Seth Felder
- Department of Gastrointestinal Oncology, Moffitt Cancer Center,
Tampa, FL, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL,
USA
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Eray İC, Rencüzoğulları A, Yalav O, Topal U, Sarıtaş AG, Dalcı K. Rektum kanser cerrahisi sonrası kalıcı ileostomi insidansı ve risk faktörleri. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.529941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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49
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Yang SU, Park EJ, Baik SH, Lee KY, Kang J. Modified Colon Leakage Score to Predict Anastomotic Leakage in Patients Who Underwent Left-Sided Colorectal Surgery. J Clin Med 2019; 8:jcm8091450. [PMID: 31547283 PMCID: PMC6780090 DOI: 10.3390/jcm8091450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022] Open
Abstract
Colon leakage score (CLS) was introduced as a clinical tool to predict anastomotic leakage (AL) in patients who underwent left-sided colorectal surgery, but its clinical validity has not been widely studied. We evaluated the clinical utility of CLS and developed a modified CLS (m-CLS). In total, 566 patients who underwent left-sided colorectal surgery were enrolled and categorized into training (n = 396) and validation (n = 170) sets via random sampling. Using CLS variables, the least absolute shrinkage and selection operator (LASSO) regression model was applied for variable selection and predictive signature building in the training set. The model's performance was validated in the validation set. The predictive powers of m-CLS and CLS were compared by the area under the receiver operating characteristic (AUROC) curve in the overall group. Twenty-three AL events (4.1%) were noted. The AL group had a significantly higher mean CLS than the No Leakage group (12.5 vs. 9.6, p = 0.001). Five clinical variables were selected and used to generate m-CLS. The predictive performance of m-CLS was similar in training and validation sets (AUROC 0.838 vs. 0.803, p = 0.724). In the overall set, m-CLS was significantly predictive of AL and performed better than CLS (AUROC 0.831 vs. 0.701, p = 0.008). In conclusion, LASSO-model-generated m-CLS could predict AL more accurately than CLS.
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Affiliation(s)
- Seung Up Yang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Eun Jung Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Seung Hyuk Baik
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
| | - Kang Young Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea.
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Neary PM, Aiello AC, Stocchi L, Shawki S, Hull T, Steele SR, Delaney CP, Holubar SD. High-Risk Ileocolic Anastomoses for Crohn's Disease: When Is Diversion Indicated? J Crohns Colitis 2019; 13:856-863. [PMID: 31329836 DOI: 10.1093/ecco-jcc/jjz004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Patients with Crohn's disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn's disease using a large international registry. METHODS We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage. RESULTS A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0-6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04. CONCLUSIONS After ileocolic resection for Crohn's disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.
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Affiliation(s)
- Peter M Neary
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Academic Surgery, University Hospital Waterford.,University College Cork, Ireland
| | | | - Luca Stocchi
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherief Shawki
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Conor P Delaney
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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