A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study

Predicting the response to neoadjuvant chemoradiation for rectal cancer using nomograms based on MRI tumour regression grade

PURPOSE

This study aimed to develop nomograms that combine clinical factors and MRI tumour regression grade to predict the pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy.

METHODS

The retrospective study included 204 patients who underwent neoadjuvant chemoradiotherapy and surgery between January 2013 and December 2021. Based on pathological tumour regression grade, patients were categorized into four groups: complete pathological response (pCR, n=45), non-complete pathological response (non-pCR; n=159), good pathological response (pGR, n=119), and non-good pathological response (non-pGR, n=85). The patients were divided into a training set and a validation set in a 7:3 ratio. Based on the results of univariate and multivariate analyses in the training set, two nomograms were respectively constructed to predict complete and good pathological responses. Subsequently, these predictive models underwent validation in the independent validation set. The prognostic performances of the models were evaluated using the area under the curve (AUC).

RESULTS

The nomogram predicting complete pathological response incorporates tumour length, post-treatment mesorectal fascia involvement, white blood cell count, and MRI tumour regression grade. It yielded an AUC of 0.787 in the training set and 0.716 in the validation set, surpassing the performance of the model relying solely on MRI tumour regression grade (AUCs of 0.649 and 0.530, respectively). Similarly, the nomogram predicting good pathological response includes the distance of the tumour's lower border from the anal verge, post-treatment mesorectal fascia involvement, platelet/lymphocyte ratio, and MRI tumour regression grade. It achieved an AUC of 0.754 in the training set and 0.719 in the validation set, outperforming the model using MRI tumour regression grade alone (AUCs of 0.629 and 0.638, respectively).

CONCLUSIONS

Nomograms combining MRI tumour regression grade with clinical factors may be useful for predicting pathological response of mid-low locally advanced rectal cancer to neoadjuvant chemoradiotherapy. The proposed models could be applied in clinical practice after validation in large samples.

Low anterior resection with transanal transection and single-stapled anastomosis: technical aspects and initial results

BACKGROUND

Rectal cancer (RC) is a surgical challenge due to its technical complexity. The double-stapled (DS) technique, a standard for colorectal anastomosis, has been associated with notable drawbacks, including a high incidence of anastomotic leak (AL). Low anterior resection with transanal transection and single-stapled (TTSS) anastomosis has emerged to mitigate those drawbacks.

METHODS

Observational study in which it described the technical aspects and results of the initial group of patients with medium-low RC undergoing elective laparoscopic total mesorectal excision (TME) and TTSS.

RESULTS

Twenty-two patients were included in the series. Favourable postoperative outcomes with a median length of stay of 5 days and an AL incidence of 9.1%. Importantly, all patients achieved complete mesorectal excision with tumour-free margins, and no mortalities were reported.

CONCLUSION

TTSS emerges as a promising alternative for patients with middle and lower rectal tumours, offering potential benefits in terms of morbidity reduction and oncological integrity compared with other techniques.

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

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.

Predictors for temporary stomas non-closure among non-metastatic rectal cancer patients undergoing curative resection: a retrospective analysis

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.

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

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.

Preoperative stoma site marking reduces postoperative stoma-related complications in emergency surgery: A single center retrospective cohort study

BACKGROUND AND OBJECTIVE

Stoma site marking is an important factor in reducing stoma-related complications, thereby influencing the long-term quality of life in the elective setting. The impact of preoperative stoma site marking in emergency stoma creation is largely unknown. We aimed to determine whether preoperative stoma site marking in emergency stoma creation reduces stoma-related complications.

METHODS

Patients who underwent emergency stoma creation at our hospital between 2009 and 2022 were examined by reviewing our prospective database and retrospective chart review. Subjects were classified into the "marking (+)" or "marking (-)" group according to stoma site marking (194 and 151 patients, respectively). The changes in the frequency of stoma marking over time and the effects of stoma marking on stoma-related complications were analyzed.

RESULTS

The overall frequency of grade 2 or higher stoma-related complications was lower in the marking (+) group than in the marking (-) group (24% versus 36%, p = 0.010). Stoma site marking was associated with fewer soma site bleeding (2% versus 10%, p < 0.001), and the frequency of peristomal dermatitis was also lower (10%) in the marking (+) group (versus 18%, p = 0.042). Moreover, the lack of stoma site marking was an independent risk factor for overall stoma-related complications (adjusted odds ratio: 1.69, p = 0.034).

CONCLUSIONS

Preoperative stoma site marking was associated with stoma-related complications in emergency surgery. The clinical significance of our attempt is worth validating with prospective studies.

Abandonment of Routine Radiotherapy for Nonlocally Advanced Rectal Cancer and Oncological Outcomes

Importance

Neoadjuvant short-course radiotherapy was routinely applied for nonlocally advanced rectal cancer (cT1-3N0-1M0 with >1 mm distance to the mesorectal fascia) in the Netherlands following the Dutch total mesorectal excision trial. This policy has shifted toward selective application after guideline revision in 2014.

Objective

To determine the association of decreased use of neoadjuvant radiotherapy with cancer-related outcomes and overall survival at a national level.

Design, Setting, and Participants

This multicenter, population-based, nationwide cross-sectional cohort study analyzed Dutch patients with rectal cancer who were treated in 2011 with a 4-year follow-up. A similar study was performed in 2021, analyzing all patients that were surgically treated in 2016. From these cohorts, all patients with cT1-3N0-1M0 rectal cancer and radiologically unthreatened mesorectal fascia were included in the current study. The data of the 2011 cohort were collected between May and October 2015, and the data of the 2016 cohort were collected between October 2020 and November 2021. The data were analyzed between May and October 2022.

Main Outcomes and Measures

The main outcomes were 4-year local recurrence and overall survival rates.

Results

Among the 2011 and 2016 cohorts, 1199 (mean [SD] age, 68 [11] years; 430 women [36%]) of 2095 patients (57.2%) and 1576 (mean [SD] age, 68 [10] years; 547 women [35%]) of 3057 patients (51.6%) had cT1-3N0-1M0 rectal cancer and were included, with proportions of neoadjuvant radiotherapy of 87% (2011) and 37% (2016). Four-year local recurrence rates were 5.8% and 5.5%, respectively (P = .99). Compared with the 2011 cohort, 4-year overall survival was significantly higher in the 2016 cohort (79.6% vs 86.4%; P < .001), with lower non-cancer-related mortality (13.8% vs 6.3%; P < .001).

Conclusions and Relevance

The results of this cross-sectional study suggest that an absolute 50% reduction in radiotherapy use for nonlocally advanced rectal cancer did not compromise cancer-related outcomes at a national level. Optimizing clinical staging and surgery following the Dutch total mesorectal excision trial has potentially enabled safe deintensification of treatment.

Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study

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.

Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis

To prevent anastomotic leakage and other postoperative complications after laparoscopic rectal cancer surgery, a protective ileostomy is often used. However, the necessity of performing ileostomy after laparoscopic rectal cancer remains controversial. The aim of this meta-analysis was to assess the benefit of ileostomy on wound infection after laparoscopic rectal cancer. The Cochrane Library, EMBASE, Web of Science, and PubMed were used to retrieve all related documents up to September 2023. Completion of the trial literature was submitted once the eligibility and exclusion criteria were met and the literature quality assessment was evaluated. This study compared the post-operative post-operative complications of an ileostomy with that of non-ileostomy in a laparoscope. We used Reman 5.3 to analyse meta-data. Controlled studies were evaluated with ROBINS-I. The meta-analyses included 525 studies, and 5 publications were chosen to statistically analyse the data according to the classification criteria. There was no statistically significant difference in the rate of postoperative wound infections among ostomate and nonostomate (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.66, 4.84; p = 0.25). In 5 trials, the incidence of anastomotic leak was increased after surgery in nonostomate patients (OR, 0.26; 95% CI, 0.12, 0.57; p = 0.0009). Two studies reported no significant difference in the length of operation time when nonstomal compared to stomal operations in patients with rectal cancer (mean difference, 0.87; 95% CI, -2.99, 4.74; p = 0.66). No significant difference was found in the rate of wound infection and operation time after operation among the two groups, but the incidence of anastomosis leak increased after operation. Protective ileostomy after laparoscopic rectal cancer was effective in reducing the risk of anastomotic leakage in patients, and we found no additional risk of infection. We cautiously conclude that protective ileostomy is active and necessary for patients with a high risk of anastomotic leakage after surgery, which needs to be further confirmed by high-quality studies with larger samples.

Anastomotic leakage and functional outcomes following total mesorectal excision with delayed and immediate colo-anal anastomosis for rectal cancer: Two single-arm phase II trials

BACKGROUND

Anastomotic leakage (AL) remains a major cause of morbidity following total mesorectal excision (TME). A diverting ileostomy reduces the risk of AL but impairs quality of life (QoL). Delayed colo-anal anastomosis (DCAA) may be an alternative to immediate colo-anal anastomosis (ICAA) without creation of a diverting ileostomy.

STUDY DESIGN

Patients with T3 or N+ rectal tumours were treated with neoadjuvant chemoradiation and TME. To evaluate DCAA or ICAA with diverting ileostomy, a two multicenter single-arm phase II trials was designed. The primary endpoint was the rate of AL requiring a diverting ileostomy up to 30 days postoperatively. Secondary endpoints were 30-day postoperative complications, 1- and 2-year disease-free survival; QoL at baseline, 6 months and anorectal function measured by the low anterior resection syndrome questionnaire and Wexner score at baseline, 6 months and a late assessment at median 8 years following surgery.

RESULTS

AL requiring diverting ileostomy occurred in one patient (2.1%; 95% confidence interval (CI) [0; 11.1]) in the DCAA group and in five patients (8.6%; 95%CI [3.2; 21.0]) in the ICAA group. Thirty-day postoperative complications occurred in 13 patients (27.1%) in the DCAA group and in 10 patients (19.2%) in the ICAA group. Short and long-term functional outcomes showed similar patterns.

CONCLUSION

These two single-arm phase II trials showed that DCAA has low rates of AL requiring a diverting ileostomy and acceptable long-term functional results. DCAA seems a good choice to restore bowel continuity.

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort

OBJECTIVE

To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).

BACKGROUND

AL after RC resection often results in a permanent stoma.

METHODS

This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.

RESULTS

This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).

CONCLUSIONS

The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.

Risk factors for ischemia/necrosis of the colonic stump after proctectomy and delayed coloanal anastomosis

INTRODUCTION

Delayed coloanal anastomosis (DCAA) is a two-stage procedure. DCAA has been increasingly reused in recent years in the management of rectal cancer. Such increased use of DCAA has highlighted the complications associated with this procedure. We aimed to evaluate the risk and risk factors of ischemia/necrosis of the colonic stump between the two stages of DCAA.

PATIENTS AND METHODS

All patients who underwent a proctectomy with a DCAA were included in this retrospective single-centre study from November 2012 to June 2022. Two groups of patients were defined: patients with a well vascularized colonic stump (well vascularized group) and those who experienced ischemia or necrosis of the colonic stump (ischemic group). The primary endpoint was the rate of ischemia or necrosis of the colonic stump and an evaluation of the associated risk factors.

RESULTS

During the study period, 43 patients underwent DCAA. Amongst them, 32 (75%) had a well-vascularized colonic stump (well-vascularized group) and 11 (25%) ischemia of the colonic stump (ischemic group). Relative to patients in the well-vascularized group, those in the ischemic group were more often men (81.8% vs 40.6%, p = 0.034), had a higher BMI (29.2 kg/m2 vs 25.7 kg/m2, p = 0.03), were more frequently diabetic (63.6% vs 21.9%, p = 0.01) and more frequently had had preoperative radiotherapy (100% vs 53.1%, p = 0.008). On the preoperative CT scan, the interspinous diameter was shorter in the ischemic group (9.4 ± 1.01 cm vs 10.6 ± 1.01 cm, p = 0.001), the intertuberosity diameter was shorter (9.2 ± 1.18 cm vs 11.9 ± 1.18 cm, p < 0.0001), and the length of the anal canal was longer (31.9 ± 3 mm vs 27.4 ± 3.2 mm, p < 0.0001).

CONCLUSION

This study highlights clear risk factors for ischemia/necrosis of the colonic stump after proctectomy with DCAA.

Protective ileostomy after low anterior resection for extraperitoneal rectal cancer: does the reversal surgery timing affect closure failure?

Loop ileostomy is commonly performed after LAR with TME to temporarily protect the anastomosis. Usually, defunctioning stoma is closed after 1-6 months, although sometimes it becomes definitive de facto. The aim of this study is to investigate the long-term risk of no-reversal of protective ileostomy after LAR for middle-low rectal cancer and the predictive risk factors. A retrospective analysis of a consecutive cohort of patients who underwent curative LAR with covering ileostomy for extraperitoneal rectal cancer in two colorectal units was performed. A different policy for scheduling stoma closure was applied between centers. All the data were collected through an electronic database (Microsoft Excel®). Descriptive statistical analysis was performed using Fisher's exact and Student's t test. Multivariate logistic regression analysis was conducted. Two-hundred twenty-two patients were analysed: reversal procedure was carried out in 193 patients, in 29 cases stoma was never closed. The mean interval time from index surgery was 4.9 months (Center1: 3 vs. Center2: 7.8). At the univariate analysis, mean age and tumor stage were significantly higher in the "no-reversal" group. Unclosed ostomies were significantly lower in Center 1 than Center 2 (8% vs. 19.6%). At the multivariate analysis female gender, anastomotic leakage and Center 2 had significant higher risk of unclosed ileostomy. Currently, no clinical recommendations have been established and the policy of scheduling stoma reversal is variable. Our study suggests that an established protocol could avoid closure delay, decreasing permanent stomas. Consequently, ileostomy closure should be weighed as standardized step in cancer therapeutic pathway.

Outcomes of redo for failed colorectal or coloanal anastomoses: a systematic review and meta-analysis

PURPOSE

This study aimed to review the outcomes of redo procedures for failed colorectal or coloanal anastomoses.

METHODS

A systematic review was performed using the PubMed, Embase, Cochrane, and LILACS databases. The inclusion criteria were adult patients undergoing colectomy with primary colorectal or coloanal anastomosis and studies that assessed the postoperative results. The protocol is registered in PROSPERO (No. CRD42021267715).

RESULTS

Eleven articles met the eligibility criteria and were selected. The studied population size ranged from 7 to 78 patients. The overall mortality rate was 0% (95% confidence interval [CI], 0%-0.01%). The postoperative complication rate was 40% (95% CI, 40%-50%). The length of hospital stay was 13.68 days (95% CI, 11.3-16.06 days). After redo surgery, 82% of the patients were free of stoma (95% CI, 75%-90%), and 24% of patients (95% CI, 0%-39%) had fecal incontinence. Neoadjuvant chemoradiotherapy (P=0.002) was associated with a lower probability of being free of stoma in meta-regression.

CONCLUSION

Redo colorectal and coloanal anastomoses are strategies to restore colonic continuity. The decision to perform a redo operation should be based on a proper evaluation of the morbidity and mortality risks, the probability of remaining free of stoma, the quality of life, and a functional assessment.

Determination of Factors Related to the Reversal and Perioperative Outcomes of Defunctioning Ileostomies in Patients Undergoing Rectal Cancer Surgery: A Regression Analysis Model

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.

Risk Factors for Radical Rectal Cancer Surgery with a Temporary Stoma Becoming a Permanent Stoma: A Pooling Up Analysis

Purpose: The aim of this study was to find out the potential risk factors for the formation of a permanent stoma (PS) for rectal cancer patients with a temporary stoma (TS) after surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for eligible studies until November 14, 2022. The patients were divided into the PS group and the TS group. Odds ratio (ORs) and 95% confidence intervals (CIs) were pooled up for describing dichotomous variables. Stata SE 16 was performed for data analysis. Results: After pooling up the data, a total of 14 studies involving 14,265 patients were included in this study. The outcomes showed that age (OR = 1.03, 95% CI = 0.96 to 1.10, I2 = 1.42%, P = .00 < .1), surgery type (P = .00 < .1), tumor stage (P = .00 < .1), preoperative chemoradiotherapy (P = .00 < .1), preoperative radiotherapy (P = .01 < .1), neoadjuvant therapy (P = .00 < .1), American Society of Anesthesiologists (ASA) score of ≥3 (P = .00 < .1), anastomotic leakage (P = .01 < .1), local recurrence (P = .00 < .1), and distant recurrence (P = .00 < .1) were associated with the patient with PS. However, sex (P = .15 > .1), previous abdominal surgery (P = .84 > .1), adjuvant chemotherapy (P = .87 > .1), and defunctioning stoma (P = .1) had little association with PS. Conclusion: Patients who were elderly, had advanced tumor stages, had a high ASA score, and underwent neoadjuvant therapy should be informed of the high risk of PS before surgery. Meanwhile, those who underwent rectal cancer surgery with a TS should beware of anastomotic leakage, local recurrences, and distant recurrences, which could increase the risk of PS.

Modified pull-through coloanal anastomosis to avoid permanent stomas and reduce postoperative complications for lower rectal tumors

BACKGROUND

We performed pull-through hand-sewn coloanal anastomosis immediately after sphincter-preserving ultralow anterior resection (ULAR) [pull-through ultra (PTU)] to avoid permanent stoma and reduce postoperative complications of lower rectal tumors. This study aimed to compare the clinical outcomes of PTU versus non-PTU (stapled or hand-sewn coloanal anastomosis with diverting stoma) after sphincter-preserving ULAR for lower rectal tumors.

METHODS

This retrospective cohort study analyzed prospectively maintained data from 100 consecutive patients who underwent PTU (n = 29) or non-PTU (n = 71) after sphincter-preserving ULAR for rectal tumors between January 2011 and March 2023. In PTU, hand-sewn coloanal anastomosis was immediately performed using 16 stitches of 4-0 monofilament suture during primary surgery. The clinical outcomes were assessed. The primary outcomes were rates of permanent stomas and overall postoperative complications.

RESULTS

The PTU group was significantly less likely to require a permanent stoma than the non-PTU group (P < 0.01). None of the patients in the PTU group required permanent stoma and the rate of overall complications was significantly lower in the PTU group (P = 0.01). The median operative time was comparable between the two groups (P = 0.33) but the median operative time during the second stage was significantly shorter in the PTU group (P < 0.01). The rates of anastomotic leakage and complications of Clavien-Dindo grade III were comparable between the two groups. Diverting ileostomy was performed in two patients with an anastomotic leak in the PTU group. The PTU group was significantly less likely to require a diverting ileostomy than those in the non-PTU group (P < 0.01). The composite length of hospital stay was significantly shorter in the PTU group (P < 0.01).

CONCLUSIONS

PTU via immediate coloanal anastomosis for lower rectal tumors is a safe alternative to the current sphincter-preserving ULAR with diverting ileostomy for patients who wish to avoid a stoma.

Comparative short-term and survival outcomes of three specimen extraction techniques in laparoscopic low rectal cancer surgery: does it affect ileostomy closure?

INTRODUCTION

This study aimed to compare the short-term and survival outcomes in laparoscopic low rectal cancer surgery with three different specimen extraction techniques, and whether it affects loop ileostomy closure.

MATERIALS AND METHODS

A consecutive series of patients with low rectal cancer who underwent laparoscopic low anterior resection plus protective loop ileostomy (LAR-PLI) were enrolled. Three main techniques, namely specimen extraction through auxiliary incision (EXAI), specimen extraction through stoma incision (EXSI), and specimen eversion and extra-abdominal resection (EVER), were employed. The postoperative short-term and survival outcomes of the three techniques and the impact on loop ileostomy closure were compared.

RESULTS

In all, 254 patients were enrolled in this study: 104 (40.9%) in the EXAI group, 104 (40.9%) in the EXSI group, and 46 (18.1%) in the EVER group. For primary surgery, EXAI group had significantly longer operative time (P < 0.001), more intraoperative bleeding (P < 0.001), longer length of abdominal incision (P<0.001), longer time to first flatus (P < 0.001), longer time to first defecation (P < 0.001), longer time to first eat (P < 0.001), and longer postoperative hospital stays (P = 0.005) than the EXSI and EVER groups. The primary postoperative complication rate in the EXAI and EVER group was significantly higher than in the EXSI group (P = 0.005). In loop ileostomy closure, EXAI group had significantly longer operative time (P = 0.001), more bleeding volume, and longer postoperative hospital stays (P < 0.001) than the EXSI and EVER groups. For survival outcomes, the 3-year local recurrence-free survival (LRFS) is 92.6% for all patients. The 3-year LRFS for patients in EXAI, EXSI, and EVER were 90.1%, 95.4%, and 92.7%, with P = 0.476.

CONCLUSIONS

Our single-center results found that in LAR-PLI surgery for low rectal cancer, the short-term outcomes of specimen extraction through the stoma incision or anus were better than that through the auxiliary incision, but the 3-year LRFS was no statistically different.

Early stoma closure after low anterior resection is not recommended due to postoperative complications and asymptomatic anastomotic leakage

The safety of early stoma closure after lower anterior resection (LAR) for rectal cancer remains controversial. In this study, patients scheduled to undergo LAR and stoma creation for rectal cancer were recruited. In absence of anastomotic leakage on radiological examination, closure of the diverting ileostomy was performed within 2 weeks. The primary endpoint was incidence of the colorectal anastomosis leakage after early stoma closure. Because of the slow accrual rate, the study was closed before recruitment reached the planned number of patients (n = 20). Among the 13 patients enrolled between April 2019 and March 2021, early stoma closure was performed in seven patients (53.8%). Non-clinical anastomotic leakage, leakage identified only on radiological examination, occurred in five cases, resulting in rescheduling of stoma closure. One patient did not undergo early stoma closure due to ileus. After stoma closure, colorectal anastomotic leakage manifested in one case; its incidence rate was 14.2%. Surgical site infection occurred in 42.8% of patients. This study revealed that asymptomatic anastomotic leakage occurred frequently. Considering the low rate of successful cases and the high rate of complications, early stoma closure within 2 weeks after LAR should not be performed routinely. Trial registration: (UMIN000036382 registered on 03/04/2019).

Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study

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.

A Novel Clinical Nomogram for Predicting Overall Survival in Patients with Emergency Surgery for Colorectal Cancer

BACKGROUND

Long-term survival after emergency colorectal cancer surgery is low, and its estimation is most frequently neglected, with priority given to the immediate prognosis. This study aimed to propose an effective nomogram to predict overall survival in these patients.

MATERIALS AND METHODS

We retrospectively studied 437 patients who underwent emergency surgery for colorectal cancer between 2008 and 2019, in whom we analyzed the clinical, paraclinical, and surgical parameters.

RESULTS

Only 30 patients (6.86%) survived until the end of the study. We identified the risk factors through the univariate Cox regression analysis and a multivariate Cox regression model. The model included the following eight independent prognostic factors: age > 63 years, Charlson score > 4, revised cardiac risk index (RCRI), LMR (lymphocytes/neutrophils ratio), tumor site, macroscopic tumoral invasion, surgery type, and lymph node dissection (p < 0.05 for all), with an AUC (area under the curve) of 0.831, with an ideal agreement between the predicted and observed probabilities. On this basis, we constructed a nomogram for prediction of overall survival.

CONCLUSIONS

The nomogram created, on the basis of a multivariate logistic regression model, has a good individual prediction of overall survival for patients with emergency surgery for colon cancer and may support clinicians when informing patients about prognosis.

A phase III randomized trial evaluating the quality of life impact of a tailored versus systematic use of defunctioning ileostomy following total mesorectal excision for rectal cancer-GRECCAR 17 trial protocol

AIM

The systematic use of a defunctioning ileostomy for 2-3 months postoperatively to protect low colorectal anastomosis (<7 cm from the anal verge) has been the standard practice after total mesorectal excision (TME). However, stoma-related complications can occur in 20%-60% of cases, which may lead to prolonged inpatient care, urgent reoperation and long-term definitive stoma. A negative impact on quality of life (QoL) and increased healthcare expenses are also observed. Conversely, it has been reported that patients without a defunctioning stoma or following early stoma closure (days 8-12 after TME) have a better functional outcome than patients with systematic defunctioning stoma in situ for 2-3 months.

METHOD

The main objective of this trial is to compare the QoL impact of a tailored versus systematic use of a defunctioning stoma after TME for rectal cancer. The primary outcome is QoL at 12 months postoperatively using the European Organization for. Research and Treatment of Cancer QoL questionnaire QLQ-C30. Among 29 centres of the French GRECCAR network, 200 patients will be recruited over 18 months, with follow-up at 1, 4, 8 and 12 months postoperatively, in an open-label, randomized, two-parallel arm, phase III superiority clinical trial. The experimental arm (arm A) will undergo a tailored use of defunctioning stoma after TME based on a two-step process: (i) to perform or not a defunctioning stoma according to the personalized risk of anastomotic leak (defunctioning stoma only if modified anastomotic failure observed risk score ≥2) and (ii) if a stoma is fashioned, whether to perform an early stoma closure at days 8-12, according to clinical (fever), biochemical (C-reactive protein level on days 2 and 4 postoperatively) and radiological postoperative assessment (CT scan with retrograde contrast enema at days 7-8 postoperatively). The control arm (arm B) will undergo systematic use of a defunctioning stoma for 2-3 months after TME for all patients, in keeping with French national and international guidelines. Secondary outcomes will include comprehensive analysis of functional outcomes (including bowel, urinary and sexual function) again up to 12 months postoperatively and a cost analysis. Regular assessments of anastomotic leak rates in both arms (every 50 randomized patients) will be performed and an independent data monitoring committee will recommend trial cessation if this rate is excessive in arm A compared to arm B.

CONCLUSION

The GRECCAR 17 trial is the first randomized trial to assess a tailored, patient-specific approach to decisions regarding defunctioning stoma use and closure after TME according to personalized risk of anastomotic leak. The results of this trial will describe, for the first time, the QoL and morbidity impact of selective use of a defunctioning ileostomy and the potential health economic effect of such an approach.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.

METHODS

Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.

RESULTS

In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424-4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.

CONCLUSIONS

The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

Organ Preservation in Rectal Cancer: An Overview of the Dutch Perspective and Recent Developments

Although current guidelines on rectal cancer treatment often recommend rectal resection with or without neoadjuvant (chemo)radiotherapy, there is growing interest in organ-preserving treatment approaches among patients and clinicians in the Netherlands. Currently, multiple ongoing studies are investigating the value of different non-operative treatment modalities to improve tumour response rates and increase the chance of successful organ preservation. Papillon contact X-ray brachytherapy is a promising treatment modality to improve the chance of organ preservation, which seems especially relevant for elderly and frail patients unable or refusing to undergo total mesorectal excision surgery. The elderly and frail patient with rectal cancer poses a significant challenge and warrants a thorough multidisciplinary approach to provide the most optimal organ-preserving treatment. In this overview, an insight into the Dutch perspectives and developments within the field of organ preservation and the set-up of a Papillon facility to complete the spectrum of organ-preserving treatment options in a tertiary referral centre for rectal cancer treatment has been provided.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

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.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Applying interpretable machine learning algorithms to predict risk factors for permanent stoma in patients after TME

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Cost‐effectiveness comparison of delayed versus immediate coloanal anastomosis following ultralow anterior resection for rectal cancer

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.

Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for rectal cancer patients after sphincter-saving operation

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.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2 years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

Single center experience with salvage surgery for chronic pelvic sepsis

Chronic pelvic sepsis eventually requires salvage surgery in half of all patients. The goal of surgery is to resolve pelvic inflammation while restoring intestinal continuity. Our salvage procedure achieves this by bringing a healthy conduit into the pelvis and creating an anastomosis beyond the source of sepsis. We aimed to review our single center experience with this procedure for the treatment of chronic pelvic sepsis. All patients requiring the procedure from 2010 to 2018 were retrospectively reviewed using a prospective database. Morbidity and mortality were evaluated, and restoration of bowel continuity at 1-year rate was the endpoint. Twenty patients were included. The main indication was pelvic sepsis after anastomotic leak (AL). The median age was 60 (42-86) years and the median BMI was 26 (18-37) kg/m². The median time carrying a stoma before the intervention was 15 months, and median time to intervention was 32 months. All patients had a diverting stoma. There were no death and overall morbidity reached 60%, and AL rate was 10%. At 1 year, 70% of the patients had their intestinal continuity restored. In expert hands, salvage surgery for chronic pelvic sepsis has acceptable morbidity rates, an acceptable rate of AL, and a bowel restoration success rate 70% at 1 year, and is a valuable option for patients failing conservative treatment.

Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates

BACKGROUND

Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC.

METHODS

A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model.

RESULTS

Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given.

CONCLUSION

EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.

The impact of postoperative complications severity on stoma reversal following sphincter-preserving surgery for rectal cancer

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.

Revised risk factors and patient characteristics for failure to close a defunctioning ileostomy following low anterior resection for locally advanced rectal cancer

BACKGROUND

Our clinical experience led us to raise questions about the validity of the reported risk factors and patient characteristics associated with permanent stomas after sphincter-preserving resection for rectal cancer.

OBJECTIVE

The present retrospective study aimed to identify and compare our center's incidence and risk factors for a permanent ostomy after low anterior resection (LAR) with a diverting stoma for locally advanced mid and low rectal cancer with those in published reports.

PATIENTS

A total of 239 patients underwent a sphincter-preserving procedure (LAR) for rectal cancer between 2000 and 2018, and 236 of them (age range 33-83 years, 100 males (42%)) were included in the analysis. The study cohort was divided into 2 groups comprised of patients with and without permanent stomas after rectal cancer surgery.

RESULTS

Only 25 of the 236 operated patients (10.6%) remained with permanent stomas after rectal cancer surgery. Factors associated with stoma non-closure in the multivariate analysis were pathological stage 3 (13 (52%) vs 51 (24.2%) for patients with closed stomas, p = 0.032), disease recurrence (14 (56%) vs 40 (18.9%), respectively, p = 0.048), length of stay > 10 days, p = 0.032), and anastomotic leaks with a Clavien-Dindo score > 2 or reoperations (6 (24%) vs 13 (6.1%), p = 0.019).

CONCLUSIONS

Sphincter-preserving surgery for rectal cancer was associated with a lower incidence of stoma non-closure than published values. The major risk factors for non-closure were aggressive disease and severe complications of surgery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Redo-surgery after failed colorectal or coloanal anastomosis: Morbidity, mortality and factors predictive of success. A retrospective study of 200 patients

AIM

In cases of anastomotic failure after colorectal (CRA) or coloanal anastomosis (CAA), revision of the anastomosis is an ambitious surgical option that can be proposed in order to maintain bowel continuity. Our aim was to assess postoperative morbidity, risk of failure and risk factor for failure in patients after CRA or CAA.

METHODS

All consecutive patients who underwent redo-CRA/CAA in our institution between 2007-2018 were retrospectively included. The success of redo-CRA/CAA was defined by the restoration of bowel continuity 12 months after the surgery.

RESULTS

Two hundred patients (114 male: 57%) were analyzed. The indication for redo-CRA/CAA was chronic pelvic infection in 74 patients (37%), recto-vaginal or urinary fistula in 59 patients (30%), anastomotic stenosis in 36 patients (18%) and redo anastomosis after previous anastomosis takedown in 31 patients (15%). Twenty-three percent of the patients developed a severe postoperative complication. Anastomotic leakage was diagnosed in 39 patients (20%). One-year-success of the redo-CRA/CAA was obtained in 80% of patients. In multivariate analysis, only obesity was associated with redo-CRA/CAA failure (p = 0.042). We elaborated a pre-operative predictive score of success using the four variables: male sex, age > 60 years, obesity and history of pelvic radiotherapy. The success of redo-CRA/CAA was 92%, 86%, 80% and 62% for a preoperative predictive score value of 0, 1, 2 and ≥3, respectively (p = 0.010).

CONCLUSIONS

In case of failure of primary CRA/CAA, bowel continuity can be saved in 4 out of 5 patients by redo-CRA/CAA despite 23% suffering severe postoperative morbidity.

Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review

Introduction

Case presentation

Discussion

Conclusion

•

Complications after colorectal anastomosis, such as septic leakage or anastomotic disruption, remain a problem to deal with for colorectal surgeons.

•

Conversion to terminal colostomy is the most frequent option chosen, but the most of time restoration of bowel continuity is not performed.

•

Delayed coloanal anastomosis with pull-through procedure described by Turnbull-Cutait might be an option to consider in difficult situations, to maintain or to restore intestinal continuity and could be also chosen as a first option for coloanal anastomosis.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Evaluation of the SafeHeal Colovac+ Anastomosis Protection Device: A Preclinical Study

BackgroundThe protective ostomy is the current standard of care to protect a low colorectal anastomosis from leakage, but exposes patients to complications requiring an alternative strategy. The Colovac+ is a vacuum-based intraluminal bypass device designed to shield the anastomosis from fecal content, preventing the clinical outcomes of anastomotic leakage. The objective of this study was to evaluate the preliminary efficacy, safety, and technical feasibility of the Colovac+ in a porcine model. Methods: Twelve pigs received a colorectal anastomosis with Colovac+ implantation. The device was left in situ for 10 days and then retrieved endoscopically. Six pigs were to be sacrificed immediately after device retrieval and the other 6 were to be sacrificed on day 38. Clinical, endoscopic, and histopathological examinations were performed to evaluate the following endpoints: prevention of contact between the anastomosis and fecal content, device migration, feasibility of the implantation and retrieval procedure, collateral damage to the colonic wall, colon healing after device retrieval, and systemic toxicity related to the device. Results: Eleven pigs completed the study. One pig died prematurely due to a surgical complication unrelated to the device (bladder damage with uroperitoneum). There was no evidence of contact between the anastomosis and fecal content, none of the pigs developed symptomatic anastomotic leakage, there were no significant device migrations, and there was no evidence of systemic toxicity. Colovac+ implantation was easily performed in all cases except 1 (due to an inappropriate lubricant). Colovac+ retrieval was achieved successfully in all cases. Postretrieval examinations on day 10 revealed ulcerations at the anchoring site in 4 cases indicating mechanical damage caused by the stent. However, in the recovery group, no ulcerations were observed on day 38, and the colonic wall had properly healed in all animals. Conclusions: The Colovac+ is a technically feasible, safe, and efficient device for the protection of a colorectal anastomosis in a porcine model. The device holds promise for clinical use and warrants further research.

Improving the time to ileostomy closure following an anterior resection for rectal cancer in the UK

AIM

Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure.

METHOD

This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines.

RESULTS

Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy.

CONCLUSION

There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

Long-term stoma-related reinterventions after anterior resection for rectal cancer with or without anastomosis: population data from the Dutch snapshot study

BACKGROUND

The aim of this study was to analyze the stoma-related reinterventions, complications and readmissions after an anterior resection for rectal cancer, based on a cross-sectional nationwide cohort study with 3-year follow-up.

METHODS

Rectal cancer patients who underwent a resection with either a functional anastomosis, a defunctioned anastomosis, or Hartmann's procedure (HP) with an end colostomy in 2011 in 71 Dutch hospitals were included. The primary outcome was number of stoma-related reinterventions.

RESULTS

Of the 2095 patients with rectal cancer, 1400 patients received an anterior resection and were included in this study; 257 received an initially functional anastomosis, 741 a defunctioned anastomosis, and 402 patients a HP. Of the 1400 included patients, 62% were males, 38% were females and the mean age was 67 years (SD 11.1). Following a primary functional anastomosis, 48 (19%) patients received a secondary stoma. Stoma-related complications occurred in six (2%) patients, requiring reintervention in one (0.4%) case. In the defunctioned anastomosis group, stoma-related complications were present in 92 (12%) patients, and required reintervention in 23 (3%) patients, in 10 (1%) of these more than 1 year after initial resection. Stoma-related complications occurred in 92 (23%) patients after a HP, and required reintervention in 39 (10%) patients in 17 (4%) of cases more than 1 year after initial resection. The permanent stoma rate was 11% and 20%, in the functional anastomosis and the defuctioned anastomosis group, respectively. The end colostomy in the HP group was reversed in 4% of cases.

CONCLUSIONS

Construction of a stoma after resection for rectal cancer with preservation of the sphincter is accompanied with long-term stoma-related morbidity. Stoma complications are more frequent after a HP. Even after 1 year, a significant number of reinterventions are required.