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Cerdán-Santacruz C, Cano-Valderrama Ó, Santos Rancaño R, Terés LB, Vigorita V, Pérez TP, Rosciano Paganelli JG, Paredes Cotoré JP, Carre MK, Flor-Lorente B, Antona FB, Martín EY, Tebar JC, Cao IA, Coltell ZB, Alonso MG, Paredes Cotoré JP, Prada López BL, Riesco AB, Cánovas NI, Sánchez CM, Serrat DR, Conde GA, Toscano MJ, Aira AC, Pérez MR, Petit NM, Espín Basany E, Carré MK, Pellino G, Retuerta JM, Saldaña AG, Laso CÁ, Allende IA, Álvarez DH, Cazador AC, Sánchez Bautista WM, Torres Sánchez MT, Bonito AC, Velázquez MC, Díaz OM, Fuentes NS, Olías MDCDLV, Pérez TP, Rosciano Paganelli JG, Lorente BF, Valderrama ÓC, Santos Rancaño R, Terés LB, Santacruz CC. "Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study". EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106962. [PMID: 37414628 DOI: 10.1016/j.ejso.2023.06.014] [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: 09/15/2022] [Revised: 04/09/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce. METHODS This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival. RESULTS Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%. CONCLUSIONS The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.
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Affiliation(s)
| | | | | | - Lara Blanco Terés
- Colorectal Surgery Department, Hospital de la Princesa, Madrid, Spain
| | - Vicenzo Vigorita
- Colorectal Surgery Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | - Jesús Pedro Paredes Cotoré
- Colorectal Surgery Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, La Coruña, Spain
| | | | - Blas Flor-Lorente
- Colorectal Surgery Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | | | | | | | - Inés Aldrey Cao
- Complejo Hospitalario Universitario de Ourense, Orense, Spain
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Watanabe J, Takemasa I, Kotake M, Noura S, Kimura K, Suwa H, Tei M, Takano Y, Munakata K, Matoba S, Yamagishi S, Yasui M, Kato T, Ishibe A, Shiozawa M, Ishii Y, Yabuno T, Nitta T, Saito S, Saigusa Y, Watanabe M. Blood Perfusion Assessment by Indocyanine Green Fluorescence Imaging for Minimally Invasive Rectal Cancer Surgery (EssentiAL trial): A Randomized Clinical Trial. Ann Surg 2023; 278:e688-e694. [PMID: 37218517 PMCID: PMC10481925 DOI: 10.1097/sla.0000000000005907] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The aim of the present randomized controlled trial was to evaluate the superiority of indocyanine green fluorescence imaging (ICG-FI) in reducing the rate of anastomotic leakage in minimally invasive rectal cancer surgery. BACKGROUND The role of ICG-FI in anastomotic leakage in minimally invasive rectal cancer surgery is controversial according to the published literature. METHODS This randomized, open-label, phase 3, trial was performed at 41 hospitals in Japan. Patients with clinically stage 0-III rectal carcinoma less than 12 cm from the anal verge, scheduled for minimally invasive sphincter-preserving surgery were preoperatively randomly assigned to receive a blood flow evaluation by ICG-FI (ICG+ group) or no blood flow evaluation by ICG-FI (ICG- group). The primary endpoint was the anastomotic leakage rate (grade A+B+C, expected reduction rate of 6%) analyzed in the modified intention-to-treat population. RESULTS Between December 2018 and February 2021, a total of 850 patients were enrolled and randomized. After the exclusion of 11 patients, 839 were subject to the modified intention-to-treat population (422 in the ICG+ group and 417 in the ICG- group). The rate of anastomotic leakage (grade A+B+C) was significantly lower in the ICG+ group (7.6%) than in the ICG- group (11.8%) (relative risk, 0.645; 95% confidence interval 0.422-0.987; P =0.041). The rate of anastomotic leakage (grade B+C) was 4.7% in the ICG+ group and 8.2% in the ICG- group ( P =0.044), and the respective reoperation rates were 0.5% and 2.4% ( P =0.021). CONCLUSIONS Although the actual reduction rate of anastomotic leakage in the ICG+ group was lower than the expected reduction rate and ICG-FI was not superior to white light, ICG-FI significantly reduced the anastomotic leakage rate by 4.2%.
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Affiliation(s)
- Jun Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Minami-ku, Yokohama, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Chuo-ku, Sapporo, Japan
| | - Masanori Kotake
- Department of Surgery, Kouseiren Takaoka Hospital, Takaoka, Toyama, Japan
| | - Shingo Noura
- Department of Gastroenterological Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kei Kimura
- Department of Lower Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirokazu Suwa
- Department of Surgery, Yokosuka Kyosai Hospital, Nakahara-ku, Kawasaki, Kanagawa, Japan
| | - Mitsuyoshi Tei
- Department of Surgery, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yoshinao Takano
- Department of Surgery, Southern TOHOKU Research Institute for Neuroscience, Southern TOHOKU General Hospital, Yatsuyamada, Koriyama, Japan
| | - Koji Munakata
- Department of Gastroenterological Surgery, Ikeda City Hospital, Ikeda, Osaka, Japan
| | - Shuichiro Matoba
- Department of Gastroenterological Surgery, Toranomon Hospital, Minato City, Tokyo, Japan
| | - Sigeru Yamagishi
- Department of Surgery, Fujisawa City Hospital, Fujisawa, Kanagawa, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takeshi Kato
- Department of Surgery, National Hospital Organization Osaka National Hospital, Chuo Ward, Osaka, Japan
| | - Atsushi Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Manabu Shiozawa
- Department of Surgery, Kanagawa Cancer Center, Yokohama, Kanagawa, Japan
| | - Yoshiyuki Ishii
- Department of Surgery, Kitasato University Kitasato Institute Hospital, Minato City, Tokyo, Japan
| | - Taichi Yabuno
- Department of Surgery, Yokohama Municipal Citizen’s Hospital, Yokohama, Kanagawa, Japan
| | - Toshikatsu Nitta
- Division of Surgery Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan
| | - Shuji Saito
- Division of Surgery, Gastrointestinal Center, Yokohama Shin-Midori General Hospital, Yokohama, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University Kitasato Institute Hospital, Minato City, Tokyo, Japan
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Bananzade A, Dehghankhalili M, Bahrami F, Tadayon SMK, Ghaffarpasand F. Outcome of early versus late ileostomy closure in patients with rectal cancers undergoing low anterior resection: A prospective cohort study. Asian J Surg 2023; 46:4277-4282. [PMID: 36797086 DOI: 10.1016/j.asjsur.2023.01.099] [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: 09/19/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates. METHODS This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure. RESULTS Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications. CONCLUSION Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome.
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Affiliation(s)
- Alimohammad Bananzade
- Colorectal Research Center, Department of Colorectal Surgery, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | | | - Faranak Bahrami
- Colorectal Research Center, Department of Colorectal Surgery, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Seyed Mohammad Kazem Tadayon
- Colorectal Research Center, Department of Colorectal Surgery, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.
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Zhang T, Wang G, Fang G, Qiu L, Lu F, Yin K, Miao Y. Clinical efficacy of anastomotic reinforcement suture in preventing anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:322. [PMID: 37594605 DOI: 10.1007/s00423-023-03058-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, with an incidence of about 10%, and the efficacy of reinforced sutures for preventing AL remains contentious. This study investigated the safety and effectiveness of reinforcement sutures for preventing AL after rectal cancer surgery. METHODS The present authors conducted a systematic search in the PubMed, Embase, Cochrane Library, Sinomed, Web of Science, Wanfang, VIP, and CNKI databases for randomized controlled trials (RCTs) and nonrandomized studies up to June 2023. We performed a meta-analysis to evaluate the efficacy of anastomotic reinforcement sutures after rectal cancer surgery. The primary outcome measures were AL, anastomotic bleeding, and infection rates. RESULTS Eleven articles (1921 subjects) were analyzed, with 912 and 1009 cases in the reinforced and unreinforced suture groups, respectively. The reinforced suture group showed a lower AL incidence (odds ratio [OR]=0.25, 95% CI 0.17-0.37, P< 0.00001), lower infection rate (OR=0.41, 95%CI 0.19-0.89, P<0.05), shorter hospital stay (mean difference [MD]=-0.57, 95%CI -1.15-0.00, P≤0.05), and earlier anal exhaust (MD=-0.12, 95%CI -0.23-0.00, P<0.05). However, the operative time (MD=18.25, 95% CI 12.20-24.30, P<0.00001) was longer for reinforced sutures than for unreinforced sutures. There were no significant differences between the suture techniques in intraoperative blood loss MD=2.74, 95% CI -4.50-9.97, P>0.05), incidence of anastomotic bleeding (OR=0.49, 95%CI 0.12-1.97, P>0.05), and incidence of intestinal obstruction (OR=0.65, 95%CI 0.27-1.61, P>0.05). CONCLUSION Existing articles indicate that anastomotic reinforcement sutures can significantly reduce AL incidence. However, this conclusion still requires confirmation based on multicentre, high-quality RCTs with large sample sizes.
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Affiliation(s)
- Tao Zhang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Gang Wang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Guida Fang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Lei Qiu
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Feng Lu
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Kaihong Yin
- Department of Digestive Medicine, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Yongchang Miao
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China.
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Rutegård M, Tang A, Gregoire DJ, Stewart C, Hurt L, Chandler S, Hitchings MD, Healy B, Harris D. Oral antibiotics and mechanical bowel preparation for colorectal surgery: A prospective observational study of surgical site infection and microbial analysis. Int J Colorectal Dis 2023; 38:210. [PMID: 37555867 PMCID: PMC10412473 DOI: 10.1007/s00384-023-04497-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Surgical site infections (SSIs) are common in colorectal surgery. Mechanical bowel preparation (MBP) in conjunction with oral antibiotics (OABs) have been shown to reduce SSI rates. It however is still unclear which OABs to use, and how this can be implemented in practice. METHODS This is a prospective observational study carried out in Swansea Bay University Health Board during 2019-2021, evaluating the introduction of OABs in a stepwise manner on the incidence of SSI in major colorectal surgery. A control group having MBP only was compared to two OAB groups: one group had MBP plus metronidazole only and the second MBP plus metronidazole and neomycin. A 30-day follow-up after surgery was ascertained via chart review and telephone contact. Logistic regression was performed to estimate the relation between OAB use and SSI, with adjustment for confounding. In a subset of patients, faecal samples were analysed through 16S rRNA amplicon sequencing before and after OAB treatment, depicting the impact of the gut microbiome. RESULTS In total 160 patients were analysed: 46 patients had MBP only, whilst 76 patients had MBP plus metronidazole only and 38 patients had MBP with metronidazole/neomycin. The SSI rate in the entire cohort was 33.8%, whilst the adjusted ORs for the single- and dual-OAB groups were 0.76 (95% CI: 0.17-1.81) and 0.50 (95% CI: 0.17-1.52). The microbial analysis demonstrated that the relative abundance for many bacterial genera was changed before and after OAB treatment, but no link with SSI development could be shown. CONCLUSIONS Introduction of OABs in conjunction with MBP in colorectal surgery is feasible, and may potentially lead to lower rates of SSI, as well as altering the community structure of the faecal microbiome. More research is needed, especially considering different OABs and mechanistic studies of the gut microbiome in the context of colorectal surgery.
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Affiliation(s)
- Martin Rutegård
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - Alethea Tang
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
- Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, UK
| | - Darren James Gregoire
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Christopher Stewart
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Libor Hurt
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Susan Chandler
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | | | - Brendan Healy
- Public Health Wales, Swansea Bay University Health Board, Swansea, UK
| | - Dean Harris
- Department of Colorectal Surgery, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
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Zhang HQ, Xu L, Wang ZL, Shao Y, Chen Y, Lu YF, Fu Z. The effect of reinforcing sutures and trans-anal drainage tube on the outcome of laparoscopic resection for rectal cancer: propensity score‑matched analysis. Langenbecks Arch Surg 2023; 408:289. [PMID: 37515648 DOI: 10.1007/s00423-023-03027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES Laparoscopic resection for rectal cancer is currently the predominant treatment modality for rectal tumors, with an ongoing focus on reducing the incidence of postoperative complications. In an effort to decrease the occurrence of anastomotic leakage, two additional steps worth considering are reinforcing the anastomosis with a barbed suture and retaining an anal drain as part of the procedure. The results of the operation were analyzed by comparing them to cases where the anastomosis was performed with a stapler alone. METHODS This study retrospectively analyzed patients who underwent laparoscopic radical rectal cancer surgery between July 2020 and March 2023. The patients were categorized into three cohorts based on the postoperative management following instrumented anastomosis: cohort A, the instrumented anastomosis alone group; cohort B, the reinforced suture group; and cohort C, the reinforced suture and indwelling transanal drainage tube group. Propensity score matching was performed twice in a 1:1 ratio, comparing cohort B to cohort A and cohort C to cohort B. The objective was to compare the benefits and drawbacks among the different groups in terms of operative time, postoperative outcomes and operative costs. RESULTS 529 patients with laparoscopic resection for rectal cancer were eligible for inclusion. the instrumented anastomosis alone group, reinforced suture group and the reinforced suture and indwelling transanal drainage tube group were performed in 205 patients, 198 patients and 126 patients, respectively. Cohort A and Cohort B differed in three variables after PSM: total operative time (p = 0.018), postoperative hospital stay (p < 0.001) and incidence of anastomotic leakage (p = 0.038). Cohort B had a longer total operative time, shorter postoperative hospital stay and a lower incidence of anastomotic leakage. Similarly, cohort C had less postoperative drainage (P = 0.01) and a longer postoperative hospital stay (P = 0.003) when cohort B and cohort C were matched for propensity scores. There was no significant difference in the cost of surgery between the three cohorts. CONCLUSIONS The incorporation of barbed suture reinforcement significantly reduces the occurrence of postoperative anastomotic leakage in rectal cancer surgeries. On the other hand, although trans-anal drainage was used as an additional measure to the reinforcement suture of the anastomosis, the utilization of trans-anal drainage tubes does not demonstrate a significant improvement in surgical outcomes.
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Affiliation(s)
- Hong-Qiang Zhang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Xu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen-Ling Wang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Shao
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Chen
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yun-Fei Lu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zan Fu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Ozata IH, Bozkurt E, Sucu S, Karahan SN, Camci F, Cetin F, Ozoran E, Agcaoglu O, Balik E, Bugra D. A novel scoring system for the early detection of anastomotic leakage: bedside leak score-a pilot study. Front Surg 2023; 10:1204785. [PMID: 37601530 PMCID: PMC10434221 DOI: 10.3389/fsurg.2023.1204785] [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: 04/12/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background Anastomotic leakage is a major complication in colorectal surgery, resulting in significant morbidity and mortality rates. Despite substantial progress in surgical technique, anastomotic leakage rates remain stable. An early diagnosis of anastomotic leaks was proven to reduce adverse outcomes and improve survival. Objective This study aims to find a novel scoring system for detecting anastomotic leaks using inflammatory and nutritional indicators after colorectal surgery. Our purpose was to analyze the diagnostic accuracy of leak scores ( ( CRP POD 3 ) ( CRP POD 1 ) ∗ preoperative albumin level ) in predicting postoperative complications. Design The study included colorectal cancer patients who underwent curative surgery at Koc University Hospital between 2014 and 2018. Patients were categorized into two groups depending on the presence of anastomotic leaks and compared in terms of preoperative albumin levels, CRP levels in postoperative days 1 and 3, anastomotic leakage rates, length of hospital stay, and CRP quotient, which was calculated by dividing POD 3 CRP level to POD 1 CRP level. The bedside leak score is calculated by dividing the CRP quotient by the preoperative albumin level. The predictive value of bedside leak score, CRP quotient, and preoperative albumin levels in estimating anastomotic leakage was analyzed, and a cutoff value for the leak score was calculated. Results A total of 184 patients were included in the study. The leak score, CRP POD 3-1 ratio, and preoperative albumin levels were found to successfully detect anastomotic leakage. The area under the curve for the leak score was calculated as 0.78. The optimal cutoff value was found to be 50.3 for the bedside leak score, which shows 90.9% sensitivity and 59.3% specificity. Conclusion The leak score may represent a valuable diagnostic tool for detecting patients at risk for anastomotic leakage after colorectal surgery and planning a better strategy to reduce morbidity and mortality rates and associated costs. However, further multicenter studies with large cohorts are necessary to confirm these results.
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Affiliation(s)
- Ibrahim H. Ozata
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Bozkurt
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Serkan Sucu
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Salih N. Karahan
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Furkan Camci
- Koc University School of Medicine, Istanbul, Turkey
| | - Feyza Cetin
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Ozoran
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Orhan Agcaoglu
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, Koç University School of Medicine, Istanbul, Turkey
- Department of General Surgery, VKV American Hospital, Istanbul, Turkey
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8
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Chierici A, Granieri S, Frontali A. Diagnostic accuracy of water-soluble contrast enema, contrast-enema computed tomography and endoscopy in detecting anastomotic leakage after (Colo) proctectomy: A meta-analysis. Colorectal Dis 2023; 25:1371-1380. [PMID: 37264714 DOI: 10.1111/codi.16591] [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: 11/23/2022] [Revised: 02/19/2023] [Accepted: 04/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) as a result of creation of a colorectal/anal anastomosis still represents a frequent complication of colorectal surgery, with short- and long-term consequences on postoperative morbidity, quality of life and oncological outcomes. However, early diagnosis of AL may result in improved outcomes. The aims of this study were to evaluate the diagnostic accuracy of water-soluble contrast enema (WSCE), contrast enema computed tomography (CECT) and endoscopy in identifying AL and to identify the diagnostic procedure that is most accurate. METHODS A systematic review and meta-analysis of 19 studies accounting for a total of 25 tests reporting diagnostic accuracy estimates was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines up to June 2021. For the diagnostic tests we evaluated the pooled estimates and conducted pairwise comparisons. RESULTS For WSCE, the pooled sensitivity was 0.50, the pooled specificity was 0.99 and the area under the curve (AUC) was 0.91. For endoscopy, the pooled sensitivity was 0.69, specificity was 1.00 and AUC was 0.99. The pooled sensitivity and specificity for CECT were 0.89 and 1.00, respectively; the AUC was 0.99. The comparison between CECT and WSCE highlighted a significantly greater sensitivity (p = 0.04) for CECT, whereas no difference was found for specificity. Compared with CECT, endoscopy was not significantly more accurate in terms of either sensitivity or specificity. Endoscopy was found to be significantly more specific than WSCE (p = 0.031) but no difference was found for sensitivity. CONCLUSION Water-soluble contrast enema, endoscopy and CECT have an elevated diagnostic accuracy. However, WSCE is less accurate than either endoscopy or CECT. Although greater sensitivity was demonstrated for CECT compared with endoscopy, this was not significant.
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Affiliation(s)
- Andrea Chierici
- Service de Chirurgie Digestive et Transplantation Hépatique - Hôpital l'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, Vimercate, Italy
| | - Alice Frontali
- Coloproctology and IBD Surgery Unit, IRCCS San Raffaele, Milan, Italy
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9
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Engel RM, Oliva K, Centauri S, Wang W, McMurrick PJ, Yap R. Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study. Dis Colon Rectum 2023; 66:923-933. [PMID: 36538716 DOI: 10.1097/dcr.0000000000002454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Anastomotic leak after restorative surgery for rectal cancer is a major complication and may lead to worse long-term oncological and survival outcomes. OBJECTIVE The purpose of this study was to identify risk factors associated with anastomotic leak and to assess the perioperative and long-term oncological impact of anastomotic leak in our cohort of patients with rectal cancer. DESIGN A retrospective analysis was performed on data from the prospectively maintained Cabrini Monash colorectal neoplasia database. Patients who had undergone rectal cancer resection and subsequently received anastomosis between November 2009 and May 2020 were included in this study. Patient and tumor characteristics, technical risk factors, and short-term and perioperative as well as long-term oncological and survival outcomes were assessed. SETTINGS The study was conducted in 3 tertiary hospitals. PATIENTS A total of 693 patients met the inclusion criteria for this study. MAIN OUTCOME MEASURES Univariate analyses were performed to assess the relationship between anastomotic leak and patient and technical risk factors, as well as perioperative and long-term outcomes. Univariate and multivariate proportional HR models of overall and disease-free survival were calculated. Kaplan-Meier survival analyses assessed disease-free and overall survival. RESULTS Anastomotic leak rate was 3.75%. Males had an increased risk of anastomotic leak, as did patients with hypertension and ischemic heart disease. Patients who experience an anastomotic leak were more likely to require reoperation and hospital readmission and were more likely to experience an inpatient death. Disease-free and overall survival were also negatively impacted by anastomotic leaks. LIMITATIONS This is a retrospective analysis of data from only 3 centers with the usual limitations. However, these effects have been minimized because of the high quality and completeness of the prospective data collection. CONCLUSIONS Anastomotic leaks after restorative surgery negatively affect long-term oncological and survival outcomes for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/C81 . IMPACTO DE LA FUGA ANASTOMTICA EN LOS RESULTADOS ONCOLGICOS A LARGO PLAZO TRAS CIRUGA RESTAURADORA PARA EL CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO ANTECEDENTES:La fuga anastomótica tras una cirugía restauradora para el cáncer de recto es una complicación mayor y puede conducir a peores resultados oncológicos y de supervivencia a largo plazo.OBJETIVO:El propósito de este estudio fue identificar los factores de riesgo asociados con la fuga anastomótica y evaluar el impacto oncológico perioperatorio y a largo plazo de la fuga anastomótica en nuestra cohorte de pacientes con cáncer de recto.DISEÑO:Se realizó un análisis retrospectivo de datos obtenidos de la base de datos Cabrini Monash sobre neoplasia colorrectal la cual es mantenida prospectivamente. Se incluyeron en este estudio pacientes que fueron sometidos a una resección del cáncer de recto y que posteriormente recibieron una anastomosis entre noviembre de 2009 y mayo de 2020. Se evaluaron las características del paciente y del tumor, los factores de riesgo relacionados a la técnica, los resultados oncológicos y de supervivencia perioperatorio, así como los resultados a corto y largo plazo.AJUSTES:El estudio se realizó en tres hospitales terciarios.PACIENTES:Un total de 693 pacientes cumplieron con los criterios de inclusión para este estudio.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis univariados para evaluar la relación entre la fuga anastomótica y aquellos factores relacionados al paciente, a la técnica, así como los resultados perioperatorios y a largo plazo. Se calcularon modelos de razón de riesgo proporcional univariante y multivariante de supervivencia global y libre de enfermedad. Los análisis de supervivencia de Kaplan-Meier evaluaron la supervivencia libre de enfermedad y la supervivencia global.RESULTADOS:La tasa de fuga anastomótica fue del 3,75%. Los hombres tenían un mayor riesgo de fuga anastomótica al igual que aquellos pacientes con hipertensión y cardiopatía isquémica. Los pacientes que sufrieron una fuga anastomótica tuvieron mayores probabilidades de requerir una reintervención y reingreso hospitalario, así como también tuvieron mayores probabilidades de sufrir una muerte hospitalaria. La supervivencia libre de enfermedad y general también se vio afectada negativamente por las fugas anastomóticas.LIMITACIONES:Este es un análisis retrospectivo de datos de solo tres centros con las limitaciones habituales. Sin embargo, estos efectos han sido minimizados debido a la alta calidad y la exhaustividad de la recopilación prospectiva de datos.CONCLUSIONES:Las fugas anastomóticas después de una cirugía restauradora afectan negativamente los resultados oncológicos y de supervivencia a largo plazo para los pacientes con cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C81 . (Traducción-Dr. Osvaldo Gauto ).
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Affiliation(s)
- Rebekah M Engel
- Department of Surgery, Cabrini Health, Cabrini Monash University, Malvern, Victoria, Australia
- Department of Anatomy and Developmental Biology, Monash University, Clayton, Victoria, Australia
- Stem Cells and Development Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Karen Oliva
- Department of Surgery, Cabrini Health, Cabrini Monash University, Malvern, Victoria, Australia
| | - Suellyn Centauri
- Department of Surgery, Cabrini Health, Cabrini Monash University, Malvern, Victoria, Australia
| | - Wei Wang
- Cabrini Institute, Malvern, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Paul J McMurrick
- Department of Surgery, Cabrini Health, Cabrini Monash University, Malvern, Victoria, Australia
| | - Raymond Yap
- Department of Surgery, Cabrini Health, Cabrini Monash University, Malvern, Victoria, Australia
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Li R, Zhou J, Zhao S, Sun Q, Wang D. Prediction model of anastomotic leakage after anterior resection for rectal cancer-based on nomogram and multivariate analysis with 1995 patients. Int J Colorectal Dis 2023; 38:139. [PMID: 37212917 DOI: 10.1007/s00384-023-04438-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Postoperative anastomotic leakage for rectal cancer shows higher morbidity with grievous concomitant symptoms. Accurate assessment of the incidence of anastomotic leakage, multivariate analysis, and establishment of a scientific prediction model can be useful to dispose of its possible severe clinical consequences. METHODS This retrospective study collected 1995 consecutive patients who underwent anterior resection of rectal cancer with primary anastomosis at Northern Jiangsu People's Hospital between January 2016 and June 2022. Independent risk factors associated with anastomotic leakage were analyzed by univariate and multivariate logistic regression. The chosen independent risk factors were used to construct a nomogram risk prediction model whose availability was evaluated by using a bootstrapped-concordance index and calibration plots with R software. RESULTS A total of 1995 patients who underwent anterior resection for rectal cancer were included while 120 patients were diagnosed with anastomotic leakage, an incidence of 6.0%. Univariate analysis and its concomitant multivariate cox regression analysis indicated that independent risk factors associated with anastomotic leakage included male gender (odds ratio (OR) = 2.873), diabetes (OR = 2.480), neoadjuvant therapy (OR = 5.283), tumor's distance from the anus verge < 5 cm (OR = 5.824), tumor size ≥ 5 cm (OR = 4.888), and the blood lose > 50 mL (OR = 9.606).We established a nomogram prediction model with proper applicability (concordance index, 0.83) and the calibration curve to justify its predictive ability that the predicted occurrence probability keeps a high degree of consistency with the actual occurrence probability. Meanwhile, the area under the receiver operating characteristic (ROC) curve was 0.83. CONCLUSIONS The characteristics of patients and tumor surgery-related conditions can affect the incidence of anastomotic leakage. However, whether the surgical method will affect morbidity is still controversial. Our nomogram can be seen as an effective instrument to predict anastomotic leakage after anterior resection for rectal cancer precisely.
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Affiliation(s)
- Ruiqi Li
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China
| | - Qiannan Sun
- Northern Jiangsu People's Hospital, Yangzhou, China
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
| | - Daorong Wang
- Northern Jiangsu People's Hospital Affiliated to Medical School of Nanjing University, Yangzhou, 225001, China.
- Northern Jiangsu People's Hospital, Yangzhou, China.
- Yangzhou Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China.
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Shibutani M, Fukuoka T, Iseki Y, Kasashima H, Maeda K. Efficacy of the polyglycolic acid sheet for preventing anastomotic leakage in double-stapling technique anastomosis for left-sided colon or rectal cancer surgery: a propensity score-matched study. BMC Surg 2023; 23:135. [PMID: 37198625 DOI: 10.1186/s12893-023-02044-0] [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: 12/11/2022] [Accepted: 05/11/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND To prevent anastomotic leakage in patients with left-sided colorectal cancer who underwent double-stapling technique (DST) anastomosis, we investigated a new method: DST anastomosis with a polyglycolic acid (PGA) sheet. This procedure has been shown to have the potential to decrease the rate of anastomotic leakage. However, due to the small number of cases enrolled in our previous study, it was not possible to compare the outcomes of the new and conventional procedures. The aim of this study was to evaluate the effect of the PGA sheet on preventing anastomotic leakage in patients with left-sided colorectal cancer who underwent DST anastomosis by retrospectively comparing the anastomotic leakage rate between the PGA sheet and conventional groups. METHODS A total of 356 patients with left-sided colorectal cancer who underwent DST anastomosis during surgery at Osaka City University Hospital between January 2016 and April 2022 were enrolled in this study. Propensity score matching was performed to reduce the confounding effects secondary to imbalances in the use of PGA sheets. RESULTS The PGA sheet was used in 43 cases (PGA sheet group) and it was not used in 313 cases (conventional group). After propensity score matching, the incidence of anastomotic leakage in the PGA sheet group was significantly lower than that in the conventional group. CONCLUSION DST anastomosis with PGA sheet, which is easy to perform, contributes to the reduction of anastomotic leakage rate by increasing the strength of the anastomotic site.
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Affiliation(s)
- Masatsune Shibutani
- Department of Gastroenterological Surgery, Osaka metropolitan university graduate school of medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka City, 545-8585, Osaka Prefecture, Japan.
| | - Tatsunari Fukuoka
- Department of Gastroenterological Surgery, Osaka metropolitan university graduate school of medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka City, 545-8585, Osaka Prefecture, Japan
| | - Yasuhito Iseki
- Department of Gastroenterological Surgery, Osaka metropolitan university graduate school of medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka City, 545-8585, Osaka Prefecture, Japan
| | - Hiroaki Kasashima
- Department of Gastroenterological Surgery, Osaka metropolitan university graduate school of medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka City, 545-8585, Osaka Prefecture, Japan
| | - Kiyoshi Maeda
- Department of Gastroenterological Surgery, Osaka metropolitan university graduate school of medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka City, 545-8585, Osaka Prefecture, Japan
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12
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Hansen RB, Balachandran R, Valsamidis TN, Iversen LH. The role of preoperative mechanical bowel preparation and oral antibiotics in prevention of anastomotic leakage following restorative resection for primary rectal cancer - a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:129. [PMID: 37184767 DOI: 10.1007/s00384-023-04416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Anastomotic leakage after colorectal cancer resection is a feared postoperative complication seen among up till 10-20% of patients, with a higher risk following rectal resection than colon resection. Recent studies suggest that the combined use of preoperative mechanical bowel preparation and oral antibiotics may have a preventive effect on anastomotic leakage. This systematic review aims to explore the association between preoperative mechanical bowel preparation combined with oral antibiotics and the risk of anastomotic leakage following restorative resection for primary rectal cancer. METHODS Three databases were systematically searched in February 2022. Studies reporting anastomotic leakage rate in patients, who received mechanical bowel preparation and oral antibiotics before elective restorative resection for primary rectal cancer, were included. A meta-analysis was conducted based on the risk ratios of anastomotic leakage. RESULTS Among 839 studies, 5 studies met the eligibility criteria. The median number of patients were 6111 (80-29,739). The combination of preoperative mechanical bowel preparation and oral antibiotics was associated with a decreased risk of anastomotic leakage (risk ratio = 0.52 (95% confidence interval 0.39-0.69), p-value < 0.001). Limitations included a low number of studies, small sample sizes and the studies being rather heterogenous. CONCLUSION This systematic review and meta-analysis found that the use of mechanical bowel preparation and oral antibiotics is associated with a decreased risk of anastomotic leakage among patients undergoing restorative resection for primary rectal cancer. The limitations of the review should be taken into consideration when interpreting the results.
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Affiliation(s)
| | - Rogini Balachandran
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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13
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Xia S, Wu W, Luo L, Ma L, Yu L, Li Y. Indocyanine green fluorescence angiography decreases the risk of anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1157389. [PMID: 37250631 PMCID: PMC10213353 DOI: 10.3389/fmed.2023.1157389] [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: 02/02/2023] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Background Anastomotic leakage is a serious complication after rectal cancer resection. Intraoperative use of indocyanine green fluorescence angiography (ICGFA) can help prevent anastomotic leakage, but its use is controversial. We conducted a systematic review and meta-analysis to determine the efficacy of ICGFA in reducing anastomotic leakage. Methods Relevant data and research published until September 30, 2022, was retrieved from the PubMed, Embase, and Cochrane Library databases, and the difference in the incidence of anastomotic leakage after rectal cancer resection between ICGFA and standard treatment was compared. Results This meta-analysis included 22 studies with a total of 4,738 patients. The results showed that ICGFA use during surgery decreased the incidence of anastomotic leakage after rectal cancer surgery [risk ratio (RR) = 0.46; 95% confidence interval (95% CI), 0.39-0.56; p < 0.001]. Simultaneously, in subgroup analyses for different regions, ICGFA was found to be used to reduce the incidence of anastomotic leakage after rectal cancer surgery in Asia (RR = 0.33; 95% CI, 0.23-0.48; p < 0.00001) and Europe (RR = 0.38; 95% CI, 0.27-0.53; p < 0.00001) but not in North America (RR = 0.72; 95% CI, 0.40-1.29; p = 0.27). Regarding different levels of anastomotic leakage, ICGFA reduced the incidence of postoperative type A anastomotic leakage (RR = 0.25; 95% CI, 0.14-0.44; p < 0.00001) but did not reduce the incidence of type B (RR = 0.70; 95% CI, 0.38-1.31; p = 0.27) and type C (RR = 0.97; 95% CI, 0.51-1.97; p = 0.93) anastomotic leakages. Conclusion ICGFA has been linked to a reduction in anastomotic leakage after rectal cancer resection. However, multicenter randomized controlled trials with larger sample sizes are required for further validation.
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Affiliation(s)
- Shijun Xia
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Wenjiang Wu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Lidan Luo
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Lijuan Ma
- Shenzhen Traditional Chinese Medicine Anorectal Hospital, Shenzhen, China
| | - Linchong Yu
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Yue Li
- Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, China
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Influence of Perioperative Anesthesia on Cancer Recurrence: from Basic Science to Clinical Practice. Curr Oncol Rep 2023; 25:63-81. [PMID: 36512273 PMCID: PMC9745294 DOI: 10.1007/s11912-022-01342-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSEOF REVIEW In this review, we will summarize the effects of these perioperative anesthetics and anesthetic interventions on the immune system and tumorigenesis as well as address the related clinical evidence on cancer-related mortality and recurrence. RECENT FINDINGS Cancer remains a leading cause of morbidity and mortality worldwide. For many solid tumors, surgery is one of the major therapies. Unfortunately, surgery promotes angiogenesis, shedding of circulating cancer cells, and suppresses immunity. Hence, the perioperative period has a close relationship with cancer metastases or recurrence. In the perioperative period, patients require multiple anesthetic management including anesthetics, anesthetic techniques, and body temperature control. Preclinical and retrospective studies have found that these anesthetic agents and interventions have complex effects on cancer outcomes. Therefore, well-planned, prospective, randomized controlled trials are required to explore the effects of different anesthetics and techniques on long-term outcomes after cancer surgery. Due to the conflicting effects of anesthetic management on cancer recurrence, further preclinical and clinical trials are required and beneficial to the development of systemic cancer therapies.
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Abstract
Many surgeons tend to overuse proximal fecal diversion in the setting of colonic surgery. The decision to proximally divert an anastomosis should be made with careful consideration of the risks and benefits of proximal diversion. Proximal diversion does not decrease the rate of anastomotic leak, but it does decrease the severity of leaks. Anastomotic height for low pelvic anastomoses, hemodynamic instability, steroid use, male sex, obesity, malnutrition, smoking, and alcohol abuse increase the rate of anastomotic leak. Biologics, most immunosuppressive agents, unprepped colons, and radiation for rectal cancer do not contribute to increased rates of anastomotic leak. Proximal fecal diversion creates additional potential morbidity, higher rates of readmission, and need for a subsequent hospitalization and operation for reversal. Additionally, diverted patients have higher rates of anastomotic stricture and delayed recognition of chronic leaks. These downsides to diversion must be weighed with a patient's perceived ability to handle the physiologic stress and consequences of a severe leak if reoperation is required. When trying to determine which patients can handle a leak, the modified frailty index can help to objectively determine a patient's risk for increased rate of morbidity and failure to rescue in the event of a leak. While proximal diversion is still warranted in many cases, we find that certain clinical scenarios often lead to overuse of proximal diversion. The old surgical adage "If you are considering diverting, you should probably do it" should be tempered by an understanding of the risk and benefits of diversion.
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Affiliation(s)
- William Buckley Lyman
- Department of Surgery, University of Tennessee at Chattanooga, Chattanooga, Tennessee
| | - Charles B. Whitlow
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Closure timing of a temporary ileostomy in patients with rectal cancer undergoing anus-preserving operation: a retrospective cohort study. Surg Today 2023; 53:116-129. [PMID: 35861894 DOI: 10.1007/s00595-022-02543-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the optimal closure time of a temporary ileostomy in patients with rectal cancer receiving anus-preserving operation. METHODS Patients with rectal cancer were enrolled from the Affiliated Hospital of Jiangsu University from May 2010 to June 2019. The eligible patients were grouped according to their actual ileostomy closure time after stoma creation. Outcomes were complications during stoma closure and complications within one year after stoma closure. RESULTS This study included 361 qualified subjects, with 108 patients in the 3-5 months group, 133 in the 5-7 months group and 120 in the ≥ 7 months group. Compared with the risk of complications during stoma closure in the 3-5 months group, that in the 5-7 months group was significantly reduced (odds ratio [OR]: 0.36, 95% confidence interval [CI] 0.13-0.99), and that in the ≥ 7 months group was significantly increased (OR: 5.88, 95% CI 2.38-14.56). In contrast to the 3-5 months group, the 5-7 months group showed a significantly decreased risk (OR: 0.21, 95% CI 0.07-0.67), and the ≥ 7 months group showed a significantly increased risk (OR: 4.21, 95% CI 1.61-11.01) of complications within 1 year after stoma closure. CONCLUSION 5-7 months after the ileostomy is created may be the optimal time for its closure.
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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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Oh BY, Park YA, Huh JW, Cho YB, Yun SH, Kim HC, Lee WY. Neoadjuvant chemoradiotherapy determines the prognostic impact of anastomotic leakage in advanced rectal cancer. Ann Surg Treat Res 2022; 103:235-243. [PMID: 36304190 PMCID: PMC9582617 DOI: 10.4174/astr.2022.103.4.235] [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: 07/26/2022] [Revised: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The prognostic impact of anastomotic leakage (AL) in rectal cancer remains uncertain. We investigated the prognostic significance of AL in rectal cancer patients who underwent curative surgery, especially in terms of chemoradiotherapy. Methods A total of 1,818 rectal cancer patients who underwent radical surgery from 2011 to 2015 were retrospectively evaluated. We categorized patients according to AL and compared survival outcomes between the groups before and after matching. In locally advanced rectal cancer patients, we classified patients according to neoadjuvant chemoradiotherapy (nCRT) or adjuvant chemotherapy (aCTx) and analyzed survival outcomes according to AL in each group. Results Before matching, overall survival (OS) was significantly worse in the AL (+) group compared to the AL (–) group (P = 0.004). In matched patients, there were no differences in disease-free survival (DFS) and OS between groups (P = 0.423 and P = 0.083, respectively). In subgroup analysis for locally advanced rectal cancer, patients were classified as follows: nCRT (+) and aCTx (+) group; nCRT (+) and aCTx (–) group; nCRT (–) and aCTx (+) group; and nCRT (–) and aCTx (–) group. In the nCRT (–) and aCTx (+) group, patients with AL exhibited significantly worse DFS than patients without AL (P = 0.040). In the other 3 groups, there were no differences in DFS according to AL. Conclusion In locally advanced rectal cancer, AL had an adverse effect on oncologic outcome in patients receiving aCTx without nCRT but not in patients receiving nCRT.
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Affiliation(s)
- Bo Young Oh
- Department of Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lin H, Yu M, Ye G, Qin S, Fang H, Jing R, Gong T, Luo Y, Zhong M. Intracorporeal reinforcement with barbed suture is associated with low anastomotic leakage rates after laparoscopic low anterior resection for rectal cancer: a retrospective study. BMC Surg 2022; 22:335. [PMID: 36085058 PMCID: PMC9461121 DOI: 10.1186/s12893-022-01782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background Anastomotic leakage (AL) is one of most severe postoperative complications following low anterior resection (LAR) for rectal cancer, and has an adverse impact on postoperative recovery. The occurence of AL is associated with several factors, while few studies explored the role of intracorporeal barbed suture reinforcement in it. Methods Consecutive cases underwent laparoscopic LAR for rectal cancer from Mar. 2018 to Feb. 2021 in our center were retrospectively collected. Cases were classified into the intracorporeal barbed suture reinforcement group and the control group according to whether performing intracorporeal reinforcement with barbed suture, and AL incidences were compared between two groups. Propensity score matching (PSM) was then performed based on identified risk factors to reduce biases from covariates between two groups. AL incidences in the matched cohort were compared. Results A total of 292 cases entered into the study, and AL incidences were significantly lower in the intracorporeal barbed suture reinforcement group compared with the control group (10.00% vs 2.82%, P = 0.024). Sex, BMI, preoperative adjuvant chemoradiotherapy and anastomotic level were chose for PSM analyses based on previous studies. In the matched cohort, the AL incidences were still significantly lower in the intracorporeal barbed suture reinforcement group (10.57% vs 2.44%, SD = 0.334). Conclusions Intracorporeal barbed suture reinforcement is associated with low AL incidences after laparoscopic LAR for rectal cancer, which is a potential procedure for reducing AL and worthy of application clinically.
Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01782-x.
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Magnin J, Fournel I, Doussot A, Régimbeau JM, Zerbib P, Piessen G, Beyer-Berjot L, Deguelte S, Lakkis Z, Schwarz L, Orry D, Ayav A, Muscari F, Mauvais F, Passot G, Trelles N, Venara A, Benoist S, Messager M, Fuks D, Borraccino B, Trésallet C, Valverde A, Souche FR, Herrero A, Gaujoux S, Lefevre J, Bourredjem A, Cransac A, Ortega-Deballon P. Benefit of a flash dose of corticosteroids in digestive surgical oncology: a multicenter, randomized, double blind, placebo-controlled trial (CORTIFRENCH). BMC Cancer 2022; 22:913. [PMID: 35999521 PMCID: PMC9400297 DOI: 10.1186/s12885-022-09998-z] [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: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 11/12/2022] Open
Abstract
Background The modulation of perioperative inflammation seems crucial to improve postoperative morbidity and cancer-related outcomes in patients undergoing oncological surgery. Data from the literature suggest that perioperative corticosteroids decrease inflammatory markers and might be associated with fewer complications in esophageal, liver, pancreatic and colorectal surgery. Their benefit on cancer-related outcomes has not been assessed. Methods The CORTIFRENCH trial is a phase III multicenter randomized double-blind placebo-controlled trial to assess the impact of a flash dose of preoperative corticosteroids versus placebo on postoperative morbidity and cancer-related outcomes after elective curative-intent surgery for digestive cancer. The primary endpoint is the frequency of patients with postoperative major complications occurring within 30 days after surgery (defined as all complications with Clavien-Dindo grade > 2). The secondary endpoints are the overall survival at 3 years, the disease-free survival at 3 years, the frequency of patients with intraabdominal infections and postoperative infections within 30 days after surgery and the hospital length of stay. We hypothesize a reduced risk of major complications and a better disease-survival at 3 years in the experimental group. Allowing for 5% of drop-out, 1 200 patients (600 per arm) should be included. Discussion This will be the first trial focusing on the impact of perioperative corticosteroids on cancer related outcomes. If significant, it might be a strong improvement on oncological outcomes for patients undergoing surgery for digestive cancers. Trial registration ClinicalTrials.gov, NCT03875690, Registered on March 15, 2019, URL: https://clinicaltrials.gov/ct2/show/NCT03875690. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09998-z.
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Affiliation(s)
- Joséphine Magnin
- Service de Chirurgie Digestive et Cancérologique, CHU François Mitterrand, 14 rue Paul Gaffarel, 21000 , Dijon, France. .,Department of Digestive Surgical Oncology, University Hospital of Dijon, INSERM 1432, University of Bourgogne, Dijon, France.
| | - Isabelle Fournel
- Department of Clinical Epidemiology, University Hospital of Dijon, INSERM CIC 1432, University of Bourgogne, Dijon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Jean-Marc Régimbeau
- Department of Digestive Surgical Oncology, University Hospital of Amiens, Amiens, France
| | - Philippe Zerbib
- Department of Digestive Surgical Oncology and Liver Transplantation, Claude Huriez University Hospital, Chu Lille, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Chu Lille, France
| | - Laura Beyer-Berjot
- Department of Digestive Surgical Oncology, North University Hospital, Marseille, France
| | - Sophie Deguelte
- Department of Digestive Surgical Oncology, University Hospital of Reims, Reims, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Lilian Schwarz
- Department of Digestive Surgical Oncology, University Hospital of Rouen, Rouen, France
| | - David Orry
- Department of Surgical Oncology, Georges François Leclerc Cancer Center, Dijon, France
| | - Ahmet Ayav
- Department of Digestive Surgical Oncology, University Hospital of Nancy, Nancy, France
| | - Fabrice Muscari
- Department of Digestive Surgical Oncology, Rangueil University Hospital, Toulouse, France
| | - François Mauvais
- Department of Digestive Surgery, Simone Veil Hospital, Beauvais, France
| | - Guillaume Passot
- Department of Digestive Surgical Oncology, Pierre Bénite University Hospital, Lyon, France
| | - Nelson Trelles
- Department of Digestive Surgery, René-Dubos Hospital, Cergy-Pontoise, France
| | - Aurélien Venara
- Department of Digestive Surgical Oncology, University Hospital of Angers, Angers, France
| | - Stéphane Benoist
- Department of Digestive Surgical Oncology, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
| | - Mathieu Messager
- Department of Digestive Surgery, Gustave Dron Hospital, Tourcoing, France
| | - David Fuks
- Department of Digestive Surgical Oncology, Cochin University Hospital, Paris, France
| | | | - Christophe Trésallet
- Department of Digestive Surgical Oncology, Avicenne University Hospital, Paris, France
| | - Alain Valverde
- Department of Digestive Surgery, La Croix Saint Simon Hospital, Paris, France
| | - François-Régis Souche
- Department of Digestive Surgical Oncology, University Hospital of Montpellier, Montpellier, France
| | - Astrid Herrero
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Montpellier, Montpellier, France
| | - Sébastien Gaujoux
- Department of Digestive Surgical Oncology, Pitié Salpêtrière University Hospital, Paris, France
| | - Jérémie Lefevre
- Department of Digestive Surgical Oncology, Saint-Antoine University Hospital, Paris, France
| | - Abderrahmane Bourredjem
- Department of Clinical Epidemiology, University Hospital of Dijon, INSERM CIC 1432, University of Bourgogne, Dijon, France
| | - Amélie Cransac
- Department of Pharmacy, University Hospital of Dijon, Dijon, France
| | - Pablo Ortega-Deballon
- Service de Chirurgie Digestive et Cancérologique, CHU François Mitterrand, 14 rue Paul Gaffarel, 21000 , Dijon, France.,Department of Digestive Surgical Oncology, University Hospital of Dijon, INSERM 1432, University of Bourgogne, Dijon, France
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Grahn O, Lundin M, Chapman SJ, Rutegård J, Matthiessen P, Rutegård M. Postoperative nonsteroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer. Colorectal Dis 2022; 24:933-942. [PMID: 35108455 PMCID: PMC9541253 DOI: 10.1111/codi.16074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/07/2021] [Accepted: 01/21/2022] [Indexed: 12/23/2022]
Abstract
AIM The aim of this work was to investigate whether nonsteroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing. METHOD This is a protocol-based retrospective cohort study on colorectal cancer patients operated on between 2007 and 2012 at 21 hospitals in Sweden. NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or nonradically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term outcomes and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs). RESULTS Some 6945 patients remained after exclusion, of whom 3996 were treated at hospitals where a NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97, 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83, 95% CI 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68, 95% CI 0.48-0.97) and distant recurrences (HR 0.85, 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%, 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo-rectal and ileo-rectal anastomoses (HR 0.47, 95% CI 0.33-0.68). CONCLUSION There was no association between NSAID exposure and recurrence-free survival, but an association with reduced cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.
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Affiliation(s)
- Oskar Grahn
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
| | - Mathias Lundin
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
- Department of StatisticsUmeå School of Business and EconomicsUmeå UniversityUmeåSweden
| | - Stephen J. Chapman
- Leeds Institute of Medical Research at St James'sUniversity of LeedsLeedsUK
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
| | - Peter Matthiessen
- Department of SurgeryFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, SurgeryUmeå UniversityUmeåSweden
- Wallenberg Centre for Molecular MedicineUmeå UniversityUmeåSweden
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22
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Plastiras A, Korkolis D, Frountzas M, Theodoropoulos G. The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients. Discov Oncol 2022; 13:52. [PMID: 35751713 PMCID: PMC9233722 DOI: 10.1007/s12672-022-00518-w] [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: 04/12/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this review was to collect all available literature data analysing the effects of the anastomotic leak (AL) on post-sphincter preserving rectal cancer surgery bowel and urogenital function as well as to quality of life (QoL) dimensions. METHODS A literature search of the PubMed and Embase electronic databases was conducted by two independent investigators and all studies using either functional parameters or QoL as a primary or secondary endpoint after a rectal cancer surgery AL were included. RESULTS Amongst the 13 identified studies focusing on the post-AL neorecto-anal function, 3 case-matched studies,3 comparative studies and 1 population-based study supported the deleterious effects of the AL on bowel function, with disturbances of the types of high bowel movement frequency, urgency and increased incontinent episodes to predominate. At one case-matched study the Low Anterior Resection Syndrome (LARS) score was inferior in the AL patients. At limited under-powered studies, urinary frequency, reduced male sexual activity and female dyspareunia may be linked to a prior AL. According to two QoL-targeted detailed studies, QoL disturbances, such as physical and emotional function difficulties may persist up to 3 years after the AL occurrence. CONCLUSIONS AL may have adverse effects on postoperative pelvic function and QoL in rectal cancer patients. As evidenced by this literature review, the limited reports on this intriguing topic may trigger the initiative for planning and undertaking larger, multicentre studies on rectal cancer patients with varying degrees of AL severity.
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Affiliation(s)
- Aris Plastiras
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Dimitrios Korkolis
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Maximos Frountzas
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece
| | - George Theodoropoulos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece.
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Schardey J, von Ahnen T, Schardey E, Kappenberger A, Zimmermann P, Kühn F, Andrassy J, Werner J, Arbogast H, Wirth U. Antibiotic Bowel Decontamination in Gastrointestinal Surgery—A Single-Center 20 Years’ Experience. Front Surg 2022; 9:874223. [PMID: 35651691 PMCID: PMC9150795 DOI: 10.3389/fsurg.2022.874223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery. Methods Based on 20 years’ experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications. Results A total of n = 477 cases of gastrointestinal surgery in gastric cancer (n = 80), sigmoid cancer (n = 168), and rectal cancer (n = 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed. Conclusion Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.
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Affiliation(s)
- Josefine Schardey
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Thomas von Ahnen
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
| | - Emily Schardey
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Alina Kappenberger
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Petra Zimmermann
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Kühn
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Helmut Arbogast
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Correspondence: Ulrich Wirth
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Sugamata N, Okuyama T, Takeshita E, Oi H, Hakozaki Y, Miyazaki S, Takada M, Mitsui T, Noro T, Yoshitomi H, Oya M. Surgical site infection after laparoscopic resection of colorectal cancer is associated with compromised long-term oncological outcome. World J Surg Oncol 2022; 20:111. [PMID: 35387666 PMCID: PMC8988355 DOI: 10.1186/s12957-022-02578-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background We evaluated the influence of infectious complications, particularly surgical site infection (SSI), on long-term oncological results after elective laparoscopic resection of colorectal cancer. Methods A total of 199 patients who underwent laparoscopic elective resection with negative resection margins for stage I–III colorectal cancer were retrospectively examined. The postoperative course was recorded based on hospital records, and cancer relapse was diagnosed based on radiological or pathological findings under a standardized follow-up program. The severity of complications was graded using Clavien-Dindo (CD) classification. Results SSI was found in 25 patients (12.6%), with 12 (6.0%) showing anastomotic leak. The postoperative relapse-free survival (RFS) rate was significantly lower in patients with SSI (49.2%) than in patients without SSI (87.2%, P<0.001). Differences in RFS were found after both colectomy and rectal resection (P<0.001 and P<0.001, respectively). RFS did not differ between patients who had major SSI CD (grade III) and those who had minor SSI CD (grades I or II). Multivariate Cox regression analysis identified the occurrence of SSI and pathological stage as independent co-factors for RFS (P<0.001 and P=0.003). Conclusion These results suggest that postoperative SSI compromises long-term oncological results after laparoscopic colorectal resection. Further improvements in surgical technique and refinements in perioperative care may improve long-term oncological results.
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Affiliation(s)
- Nana Sugamata
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Takashi Okuyama
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan.
| | - Emiko Takeshita
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Haruka Oi
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Yuhei Hakozaki
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Shunya Miyazaki
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Musashi Takada
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Takashi Mitsui
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Takuji Noro
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Hideyuki Yoshitomi
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Masatoshi Oya
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama, 343-8555, Japan
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Koedam TWA, Bootsma BT, Deijen CL, van de Brug T, Kazemier G, Cuesta MA, Fürst A, Lacy AM, Haglind E, Tuynman JB, Daams F, Bonjer HJ. Oncological Outcomes After Anastomotic Leakage After Surgery for Colon or Rectal Cancer: Increased Risk of Local Recurrence. Ann Surg 2022; 275:e420-e427. [PMID: 32224742 DOI: 10.1097/sla.0000000000003889] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate oncological outcome for patients with and without anastomotic leakage after colon or rectal cancer surgery. SUMMARY OF BACKGROUND DATA The role of anastomotic leakage in oncological outcome after colorectal cancer surgery is still topic of debate and impact on follow-up and consideration for further treatment remains unclear. METHODS Patients included in the international, multicenter, non-inferior, open label, randomized, controlled trials COLOR and COLOR II, comparing laparoscopic surgery for curable colon (COLOR) and rectal (COLOR II) cancer with open surgery, were analyzed. Patients operated by abdominoperineal excision were excluded. Both univariate and multivariate analyses were performed to investigate the impact of leakage on overall survival, disease-free survival, local and distant recurrences, adjusted for possible confounders. Primary endpoints in the COLOR and COLOR II trial were disease-free survival and local recurrence at 3-year follow-up, respectively, and secondary endpoints included anastomotic leakage rate. RESULTS For colon cancer, anastomotic leakage was not associated with increased percentage of local recurrence or decreased disease-free-survival. For rectal cancer, an increase of local recurrences (13.3% vs 4.6%; hazard ratio 2.96; 95% confidence interval 1.38-6.34; P = 0.005) and a decrease of disease-free survival (53.6% vs 70.9%; hazard ratio 1.67; 95% confidence interval 1.16-2.41; P = 0.006) at 5-year follow-up were found in patients with anastomotic leakage. CONCLUSION Short-term morbidity, mortality, and long-term oncological outcomes are negatively influenced by the occurrence of anastomotic leakage after rectal cancer surgery. For colon cancer, no significant effect was observed; however, due to low power, no conclusions on the influence of anastomotic leakage on outcomes after colon surgery could be reached. Clinical awareness of increased risk of local recurrence after anastomotic leakage throughout the follow-up is mandatory.Trial Registration: Registered with ClinicalTrials.gov, number NCT00387842 and NCT00297791.
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Affiliation(s)
- Thomas W A Koedam
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Charlotte L Deijen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Tim van de Brug
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Miguel A Cuesta
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Alois Fürst
- Department of Surgery, Caritas Krankenhaus St Josef Regensburg, Regensburg, Germany
| | - Antonio M Lacy
- Department of Surgery, Hospital Clínic Universitari, Barcelona, Spain
| | - Eva Haglind
- Department of Surgery, Sahlgrenska University Hospital-Östra, Gothenburg, Sweden
| | - Jurriaan B Tuynman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Hendrik J Bonjer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
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Ocaña J, Pastor-Peinado P, Abadía P, Ballestero A, Ramos D, García-Pérez JC, Fernández-Cebrián JM, Die J. Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0041-1740207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. The main aim of the present study was to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity.
Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity.
Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of AL was 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p = 0.038), in the elective-laparoscopic approach subgroup (p = 0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p = 0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA.
Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgery may improve short-term outcomes.
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Affiliation(s)
- J. Ocaña
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - P. Pastor-Peinado
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - P. Abadía
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - A. Ballestero
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - D. Ramos
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - JC. García-Pérez
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - JM. Fernández-Cebrián
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
| | - J. Die
- Department of General and Digestive Surgery, Division of Coloproctology, Ramón y Cajal University Hospital, Madrid, Spain
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Bao QR, Pellino G, Spolverato G, Restivo A, Deidda S, Capelli G, Ruffolo C, Bianco F, Cuicchi D, Jovine E, Lombardi R, Belluco C, Amato A, La Torre F, Asteria C, Infantino A, Contardo T, Del Bianco P, Delrio P, Pucciarelli S. The impact of anastomotic leak on long-term oncological outcomes after low anterior resection for mid-low rectal cancer: extended follow-up of a randomised controlled trial. Int J Colorectal Dis 2022; 37:1689-1698. [PMID: 35773492 PMCID: PMC9262787 DOI: 10.1007/s00384-022-04204-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The impact of anastomotic leaks (AL) on oncological outcomes after low anterior resection for mid-low rectal cancer is still debated. The aim of this study was to evaluate overall survival (OS), disease-free survival (DFS), and local and distant recurrence in patients with AL following low anterior resection. METHODS This is an extension of a multicentre RCT (NCT01110798). Kaplan-Meier method and the log-rank test were used to estimate and compare the 3-, 5-, and 10-year OS and DFS, and local and distant recurrence in patients with and without AL. Predictors of OS and DFS were evaluated using the Cox regression analysis as secondary aim. RESULTS Follow-up was available for 311 patients. Of them, 252 (81.0%) underwent neoadjuvant chemoradiotherapy and 138 (44.3%) adjuvant therapy. AL occurred in 63 (20.3%) patients. At a mean follow-up of 69.5 ± 31.9 months, 23 (7.4%) patients experienced local recurrence and 49 (15.8%) distant recurrence. The 3-, 5-, and 10-year OS and DFS were 89.2%, 85.3%, and 70.2%; and 80.7%, 75.1%, and 63.5% in patients with AL, and 88.9%, 79.8% and 72.3%; and 83.7, 74.2 and 62.8%, respectively in patients without (p = 0.89 and p = 0.84, respectively). At multivariable analysis, AL was not an independent predictor of OS (HR 0.65, 95%CI 0.34-1.28) and DFS (HR 0.70, 95%CI 0.39-1.25), whereas positive circumferential resection margins and pathological stage impaired both. CONCLUSIONS In the context of modern multimodal rectal cancer treatment, AL does not affect long-term OS, DFS, and local and distant recurrence in patients with mid-low rectal cancer.
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Affiliation(s)
- Quoc Riccardo Bao
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy
| | - Gaya Spolverato
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Angelo Restivo
- Colorectal Surgery Unit, A.O.U. Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Simona Deidda
- Colorectal Surgery Unit, A.O.U. Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Giulia Capelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Cesare Ruffolo
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Francesco Bianco
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Dajana Cuicchi
- General Surgery Unit, Department of Alimentary Tract, IRCCS Azienda Ospedaliera Universitaria Di Bologna, Bologna, Italy
| | - Elio Jovine
- General Surgery and Emergency, IRCCS Azienda Ospedaliera Universitaria Di Bologna, Bologna, Italy
| | - Raffaele Lombardi
- General Surgery and Emergency, IRCCS Azienda Ospedaliera Universitaria Di Bologna, Bologna, Italy
| | - Claudio Belluco
- Department of Surgical Oncology, National Cancer Institute, Aviano, PN, Italy
| | - Antonio Amato
- Department of Coloproctology, Sanremo Hospital, Sanremo, IM, Italy
| | - Filippo La Torre
- Division of Emergency and Trauma Surgery, Emergency Department, Policlinico Umberto I, College of Medicine and Dentistry, Sapienza University, Rome, Italy
| | - Corrado Asteria
- Department of General Surgery, Ospedale Carlo Poma, Mantua, Italy
| | - Aldo Infantino
- Surgical Unit, Department of General Surgery, Santa Maria Dei Battuti Hospital, San Vito al Tagliamento (PN), Italy
| | - Tania Contardo
- Department of Surgery, Regional Centre for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - Paola Del Bianco
- Clinical Research Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Paolo Delrio
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Salvatore Pucciarelli
- General Surgery 3, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
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Podda M, Coccolini F, Gerardi C, Castellini G, Wilson MSJ, Sartelli M, Pacella D, Catena F, Peltrini R, Bracale U, Pisanu A. Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes. Int J Colorectal Dis 2022; 37:737-756. [PMID: 35190885 PMCID: PMC8860143 DOI: 10.1007/s00384-022-04106-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE We performed a systematic review and meta-analysis with trial sequential analysis (TSA) to answer whether early closure of defunctioning ileostomy may be suitable after low anterior resection. METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, up to October 2021, for RCTs comparing early closure (EC ≤ 30 days) and delayed closure (DC ≥ 60 days) of defunctioning ileostomy. The risk ratio (RR) with 95% CI was calculated for dichotomous variables and the mean difference (MD) with 95% CI for continuous variables. The GRADE methodology was implemented for assessing Quality of Evidence (QoE). TSA was implemented to address the risk of random error associated with sparse data and/or multiple testing. RESULTS Seven RCTs were included for quantitative synthesis. 599 patients were allocated to either EC (n = 306) or DC (n = 293). EC was associated with a higher rate of wound complications compared to DC (RR 2.56; 95% CI 1.33 to 4.93; P = 0.005; I2 = 0%, QoE High), a lower incidence of postoperative small bowel obstruction (RR 0.46; 95% CI 0.24 to 0.89; P = 0.02; I2 = 0%, QoE moderate), and a lower rate of stoma-related complications (RR 0.26; 95% CI 0.16 to 0.42; P < 0.00001; I2 = 0%, QoE moderate). The rate of minor low anterior resection syndrome (LARS) (RR 1.13; 95% CI 0.55 to 2.33; P = 0.74; I2 = 0%, QoE low) and major LARS (RR 0.80; 95% CI 0.59 to 1.09; P = 0.16; I2 = 0%, QoE low) did not differ between the two groups. TSA demonstrated inconclusive evidence with insufficient sample sizes to detect the observed effects. CONCLUSION EC may confer some advantages compared with a DC. However, TSA advocated a cautious interpretation of the results. PROSPERO REGISTER ID CRD42021276557.
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy.
- Emergency Surgery Unit, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria Di Cagliari, Cagliari, Italy.
- Department of Surgical Science, University of Cagliari, Policlinico Universitario "D. Casula", Azienda Ospedaliero-Universitaria Di Cagliari, SS 554, Km 4,500, 09042, Monserrato, Italy.
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Chiara Gerardi
- Centro di Politiche Regolatorie in Sanità, Istituto di Ricerche Farmacologiche "Mario Negri" - IRCSS -, Milano, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | - Massimo Sartelli
- Department of General and Emergency Surgery, Macerata General Hospital, Macerata, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Fausto Catena
- Department of General, Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Roberto Peltrini
- Department of Public Health, Minimally Invasive General and Oncological Surgery Unit, University of Naples Federico II, Naples, Italy
| | - Umberto Bracale
- Department of Public Health, Minimally Invasive General and Oncological Surgery Unit, University of Naples Federico II, Naples, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
- Emergency Surgery Unit, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria Di Cagliari, Cagliari, Italy
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Holmgren K, Jonsson P, Lundin C, Matthiessen P, Rutegård J, Sund M, Rutegård M. OUP accepted manuscript. BJS Open 2022; 6:6598239. [PMID: 35652588 PMCID: PMC9161645 DOI: 10.1093/bjsopen/zrac072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/09/2022] [Accepted: 04/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Methods Results Conclusion
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Affiliation(s)
- Klas Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Correspondence to: Klas Holmgren, Department of Surgical and Perioperative Sciences, Umeå University, Umeå University Hospital, SE-901 85 Umeå, Sweden (e-mail: )
| | - Pär Jonsson
- Department of Chemistry, Umeå University, Umeå, Sweden
| | - Christina Lundin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Malin Sund
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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Ponholzer F, Klingler CP, Gasser E, Gehwolf P, Ninkovic M, Bellotti R, Kafka-Ritsch R, Öfner D. Long-term outcome after chronic anastomotic leakage following surgery for low rectal cancer. Int J Colorectal Dis 2022; 37:1807-1816. [PMID: 35819487 PMCID: PMC9388432 DOI: 10.1007/s00384-022-04213-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE This study analyzed the prevalence and factors influencing the history of chronic anastomotic leakage following low anterior resection for rectal cancer. Furthermore, the treatment of a persisting presacral sinus and the impact of stoma reversal on outcome were evaluated. METHODS The institutional database was scanned for all patients with anastomotic leakage, who were primarily treated for low rectal cancer between January 1995 and December 2019. Patients with rectovaginal and rectovesical fistula or an inadequate follow-up were excluded (n = 5). After applying the exclusion criteria, 71 patients remained for analysis. RESULTS A total of 39 patients out of 71 patients with anastomotic leakage (54.9%) developed a persisting presacral sinus. Neoadjuvant radiochemotherapy or chemotherapy showed a significant impact on the formation of a chronic anastomotic leakage (radiochemotherapy: p = 0.034; chemotherapy: p = 0.050), while initial surgical treatment showed no difference for anastomotic healing (p = 0.502), but a significantly better overall survival (p = 0.042). Multiple therapies and surgical revision had a negative impact on patients' rate of natural bowel continuity (p = 0.006/ < 0.001). In addition, the stoma reversal cohort showed improved overall 10-year survival (p = 0.004) and functional results (bowel continuity: p = 0.026; pain: p = 0.031). CONCLUSION Primary surgical therapy for chronic anastomotic leakage should consist of surgical treatment. Furthermore, the reversal of a protective stoma should be considered a viable option in treating chronic presacral sinus to improve pain symptoms and bowel continuity.
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Affiliation(s)
- Florian Ponholzer
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Clemens Paul Klingler
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Elisabeth Gasser
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Philipp Gehwolf
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Marijana Ninkovic
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ruben Bellotti
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Reinhold Kafka-Ritsch
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Dietmar Öfner
- grid.5361.10000 0000 8853 2677Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Tan X, Zhang M, Li L, Wang H, Liu X, Jiang H. Retrospective study of active drainage in the management of anastomotic leakage after anterior resection for rectal cancer. J Int Med Res 2021; 49:3000605211065942. [PMID: 34918983 PMCID: PMC8721718 DOI: 10.1177/03000605211065942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Anastomotic leakage (AL) is the most serious postoperative complication following anterior resection for rectal cancer. We aimed to investigate the efficacy of active drainage for the management of AL. Methods This was a retrospective study using information from a database of patients who underwent colorectal resection without a defunctioning ileostomy at our center between September 2013 and January 2021. We identified 122 cases with definitive AL who did not require revision emergent laparotomy. Among these patients, we evaluated those who received active drainage to replace the original passive drainage. Results There were 62 cases in the active drainage group and 60 cases in the passive drainage group. The active drainage group had a shorter mean AL spontaneous resolution time (26.9 ± 3.3 vs. 32.2 ± 4.8 days) and lower average hospitalization costs (82,680.6 vs. 92,299.3 renminbi (RMB)) compared with the passive drainage group, respectively. Moreover, seven patients in the passive drainage group subsequently underwent diverting stoma to resolve the Al, while all ALs resolved spontaneously after replacing the passive drainage with active drainage. Conclusions Our study suggests that active drainage may accelerate the spontaneous resolution of AL.
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Affiliation(s)
- Xiaojie Tan
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Mei Zhang
- Department of Gastrointestinal Surgery, the People's Hospital of Jimo District of Qingdao, Shandong Province, 266200, China
| | - Lai Li
- Department of General Surgery, the Second Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266042, China
| | - He Wang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Xiaodong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Haitao Jiang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
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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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Bacteriological concentration of peritoneal drainage fluid could make an early diagnosis of anastomotic leakage following rectal resection. Sci Rep 2021; 11:23156. [PMID: 34848817 PMCID: PMC8632937 DOI: 10.1038/s41598-021-02649-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/09/2021] [Indexed: 11/08/2022] Open
Abstract
To investigate that the bacteriological concentration and pH value in peritoneal drainage fluid might serve as indicators of early diagnosis of anastomotic leakage following rectal resection. We prospectively analyzed consecutive patients who were treated for rectal diseases with anastomosis at the department of general surgery, the affiliated hospital of Nanjing University Medical School between August 2018 and December 2020. The bacteriological concentration and the pH value in peritoneal drainage fluid were tested on the first, fourth, seventh days postoperatively. A total of 300 consecutive patients underwent rectal resection were tested. 21 patients present with AL and the overall AL rate was 7%. The bacteriological concentration in peritoneal drainage fluid of AL group was significantly higher than that in non-AL group. The AUC value was 0.98 (95% confidence intervals 0.969-1.000) according to the ROC curve. The best cut-off value was 1143/uL. The sensitivity and specificity were 100% and 93.19% respectively. There was no difference of pH value between the AL and non-AL groups. According the results of present study, a high bacteriological concentration in peritoneal drainage fluid is a good marker for predicting and diagnosing AL following rectal resection. However, owing to the limitation of the sample, there was no validation attempt in the study. A large sample study is needed to validate the conclusion.
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35
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Lau SYC, Choy KT, Yang TWW, Heriot A, Warrier SK, Guest GD, Kong JC. Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis. ANZ J Surg 2021; 92:355-364. [PMID: 34676655 DOI: 10.1111/ans.17262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/14/2021] [Accepted: 09/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups. METHODS An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed. RESULTS Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group. CONCLUSION This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.
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Affiliation(s)
- Steve Yee Chiang Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Kay Tai Choy
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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An Y, Roodbeen SX, Talboom K, Tanis PJ, Bemelman WA, Hompes R. A systematic review and meta-analysis on complications of transanal total mesorectal excision. Colorectal Dis 2021; 23:2527-2538. [PMID: 34174138 DOI: 10.1111/codi.15792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/13/2022]
Abstract
AIM Transanal total mesorectal excision (TaTME) is a surgical approach for treating mid to low rectal cancer as well as other colorectal diseases. Since the procedure is difficult to master, perioperative complications of TaTME should be examined precisely, especially during the early implementation phase of this procedure. The primary aim of this review was to determine a pooled morbidity and anastomotic leakage (AL) rate after TaTME surgery, and the secondary aim was to show the completeness of reporting of complications among the included studies, as well as the correlation between completeness and reported incidence of complications. METHOD A systematic review of literature was conducted using Medline, Embase and Cochrane databases, searching for observational studies reporting on complications after TaTME. Studies published between 1 January 2010 and 15 October 2019 were included. Meta-analysis on the proportion of morbidity, AL and intraoperative complications was performed. RESULTS Forty-one studies (2446 TaTME cases), consisting of 27 noncomparative studies and 14 comparative studies, were included, after screening 1711 possible studies. The pooled rates of overall morbidity and AL were 30.0% (95% CI 26.4%-34.0%) and 6.8% (95% CI 5.2%-8.9%), respectively. Subgroup analysis showed that the morbidity rate in studies that reported 30-day results (35.5%; 95% CI 31.8%-39.4%) was significantly higher than the rate in studies that did not define the follow-up length for complications (23.4%; 95% CI 17.8%-30.1%; p = 0.003). The rates of intraoperative urethral injury, rectal injury, vaginal injury and bladder injury were 0.3% (95% CI 0.1%-1.7%), 0.4% (95% CI 0.1%-2.2%), 0.3% (95% CI 0.1%-0.8%) and 0.3% (95% CI 0.1%-1.7%), respectively. CONCLUSION This meta-analysis shows that pooled perioperative complication rates were within acceptable ranges. However, the significant difference in overall morbidity rate between the studies with 30-day results and the studies without a specified follow-up time, indicates a large under-reporting of complications in many studies.
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Affiliation(s)
- Yongbo An
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Back E, Häggström J, Holmgren K, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables. Br J Surg 2021; 108:1388-1395. [PMID: 34508549 PMCID: PMC10364873 DOI: 10.1093/bjs/znab260] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/03/2021] [Accepted: 06/20/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling. METHODS Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk. RESULTS Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive. CONCLUSION Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.
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Affiliation(s)
- E Back
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - K Holmgren
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
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The Role of Heart Rate, Body Temperature, and Respiratory Rate in Predicting Anastomotic Leakage following Surgery for Rectal Cancer. Mediators Inflamm 2021; 2021:8698923. [PMID: 34456630 PMCID: PMC8390156 DOI: 10.1155/2021/8698923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To explore the value of the heart rate, body temperature, and respiratory rate in the early prediction of anastomotic leakage after rectal cancer surgery. Methods Clinical data from patients with rectal cancer who underwent anterior rectal resection in the Department of Gastroenterology, Renmin Hospital of Wuhan University, from January 2017 to December 2019 were collected and analyzed retrospectively. Based on the occurrence of anastomotic leakage after surgery, the patients were divided into two groups: those with and without anastomotic leakage. The quantitative values of the heart rate, body temperature, and respiration rate at day 7 postsurgery were compared between the two groups. The ROC curve was used to analyze their role in the early prediction of anastomotic leakage. Results Among 441 patients with rectal cancer, 30 (6.81%) had clinical anastomotic leakage and were diagnosed at 7 ± 3 days postsurgery. Within 7 days postsurgery, the heart rate, body temperature, and respiratory rate in the anastomotic leakage group were higher than those in the nonanastomotic leakage group. The differences in heart rate (1-5 d), body temperature (2-7 d), and respiratory rate (1-7 d) were statistically significant (P < 0.05). The three ROC curves were drawn, respectively. The predictive value of the heart rate is greatest at days 2-3 postsurgery. The predictive value of the body temperature is greatest at days 4-6 postsurgery. The predictive value of the respiratory rate is best at days 1-4 postsurgery. Conclusion The changes of vital signs (heart rate, body temperature, and respiratory rate) have a certain value in the early prediction of anastomotic leakage after rectal cancer surgery. Observation of postoperative vital signs at 7 days postsurgery is helpful for the early diagnosis of anastomotic leakage.
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Oxidative Stress Level as a Predictor of Anastomotic Leakage after Rectal Surgery. Mediators Inflamm 2021; 2021:9968642. [PMID: 34257521 PMCID: PMC8261183 DOI: 10.1155/2021/9968642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background Early diagnosis of anastomotic leakage (AL) after rectal surgery can reduce the adverse effects of AL, thereby reducing morbidity and mortality. Currently, there are no accepted indicators or effective scoring systems that can clearly identify patients at risk of anastomotic leakage. Methods A prospective study with assessment of the diagnostic accuracy of oxidative stress level (CAT, SOD, MDA) in serum and drain fluid compared to white blood cell count (WBC), C-reactive protein (CRP), and neutrophil percentage (NEUT) in prediction of AL in patients undergoing elective rectal surgery with anastomosis. Results Most of the oxidative stress indicators we detected are of considerable significance in the diagnosis of anastomotic leakage. The level of MDA on postoperative day (POD)3 (areas under the curve (AUC): 0.831) and POD5 (AUC: 0.837) in the serum and on POD3 (AUC: 0.845) in the drain fluid showed the same excellent diagnostic accuracy as the level of CRP on the POD3 (AUC: 0.847) and POD5 (AUC: 0.896). Conclusions The overall level of oxidative stress in serum and drain fluid is a reliable indicator for the early diagnosis of anastomotic leakage after rectal surgery. More specifically, among the redox indicators analyzed, MDA has almost the same predictive value as CRP, which provides another useful biomarker for the early diagnosis of anastomotic leakage.
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Efficacy of a robotic stapler on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer. Surg Today 2021; 52:120-128. [PMID: 34110488 DOI: 10.1007/s00595-021-02313-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Clinical evidence demonstrating risk factors for anastomotic leakage including robotic staplers has remained limited, even though the use of robotic surgery has increased substantially. The purpose of this study was to evaluate the effects of robotic staplers on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer. METHODS A total of 427 consecutive patients with primary rectal cancer who underwent robotic low anterior resection without diverting stoma were investigated retrospectively. Symptomatic anastomotic leakage was defined as anastomotic leakage of Clavien-Dindo Grade ≥ II. We compared the symptomatic anastomotic leakage rates between manual and robotic staplers using propensity score matching and investigated the risk factors for symptomatic anastomotic leakage. RESULTS After propensity score matching, 168 pairs of manual and robotic stapler cases were selected. The symptomatic anastomotic leakage rate was significantly higher for manual staplers (6.5%) than for robotic staplers (1.2%, p = 0.02). In a multivariate analysis, the use of a manual stapler (p = 0.04, OR 4.86, 95% CI 1.08-21.8) and anastomosis < 4 cm from the anal verge (p < 0.01, OR 4.36, 95% CI 1.48-12.9) were identified as independent risk factors for symptomatic anastomotic leakage. CONCLUSIONS Robotic stapler use was associated with a significantly decreased rate of anastomotic leakage in robotic low anterior resection without diverting stoma for rectal cancer.
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Choy KT, Yang TWW, Heriot A, Warrier SK, Kong JC. Does rectal tube/transanal stent placement after an anterior resection for rectal cancer reduce anastomotic leak? A systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1123-1132. [PMID: 33515307 DOI: 10.1007/s00384-021-03851-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is increasing evidence that either a transanal stent (TAS) or rectal tube (RT) can decrease the risk of anastomotic leakage (AL) after anterior resection for rectal cancer, in which a diverting stoma may not be required. OBJECTIVES The aim of this review was to investigate the efficacy and safety of RT/TAS in preventing AL after anterior resections. DATA SOURCES An up-to-date systematic review was performed on the available literature between 2000 and 2020 on PubMed, EMBASE, Medline and Cochrane Library databases. STUDY SELECTION All studies reporting on anterior resections in adults, comparing transanal tube/stent versus non-tube/stent, were analysed. MAIN OUTCOME MEASURE The primary outcome was rates of AL, whereas secondary outcomes compared associated unplanned re-operation for AL and hospital length of stay (LOS). RESULTS Two randomized controlled trials and 13 observational studies were included, with 1714 patients receiving RT/TAS and 1741 patients without. There were 119 (7%) patients with AL in the RT/TAS group compared to 216 (12.3%) patients in the non-RT/TAS group (OR: 0.48, 95% CI: 0.38-0.62, p < 0.001). There were 47 (2.9%) patients with AL complications requiring surgery in the RT/TAS group compared to 132 (8%) patients in the non-RT/TAS group (OR: 0.29, 95% CI: 0.20-0.42, p < 0.001) and no significant difference identified with the standardized mean difference (SMD) favouring the RT/TAS group for hospital LOS (SMD: -0.23, 95% CI: -0.51 to 0.06, p = 0.115). CONCLUSION The use of RT/TAS post restorative anterior resection for rectal cancer should be considered, given the benefits shown from this meta-analysis.
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Affiliation(s)
- Kay T Choy
- Department of Surgery, Austin Hospital, 145 Studley Rd, Heidelberg, VIC, 3084, Australia.
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Lai IL, You JF, Chern YJ, Tsai WS, Chiang JM, Hsieh PS, Hung HY, Hsu YJ. The risk factors of local recurrence and distant metastasis on pT1/T2N0 mid-low rectal cancer after total mesorectal excision. World J Surg Oncol 2021; 19:116. [PMID: 33849564 PMCID: PMC8045195 DOI: 10.1186/s12957-021-02223-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/01/2021] [Indexed: 01/04/2023] Open
Abstract
Background Radical resection is associated with good prognosis among patients with cT1/T2Nx rectal cancer. However, still some of the patients experienced cancer recurrence following radical resection. This study tried to identify the postoperative risk factors of local recurrence and distant metastasis separately. Methods This retrospective, single-center study comprised of 279 consecutive patients from Linkou branch of Chang Gung Memorial Hospital in 2005–2016 with rectal adenocarcinoma, pT1/T2N0M0 at distance from anal verge ≤ 8cm, who received curative radical resection. Results The study included 279 patients with pT1/pT2N0 mid-low rectal cancer with median follow-up of 73.5 months. Nineteen (6.8%) patients had disease recurrence in total. Nine (3.2%) of them had local recurrence, and fourteen (5.0%) of them had distant metastasis. Distal resection margin < 0.9 (cm) (hazard ratio = 4.9, p = 0.050) was the risk factor of local recurrence. Preoperative carcinoembryonic antigen (CEA) ≥ 5 ng/mL (hazard ratio = 9.3, p = 0.0003), lymph node yield (LNY) < 14 (hazard ratio = 5.0, p = 0.006), and distal resection margin < 1.4cm (hazard ratio = 4.0, p = 0.035) were the risk factors of distant metastasis. Conclusion For patients with pT1/pT2N0 mid-low rectal cancer, current multidisciplinary treatment brings acceptable survival outcome. Insufficient distal resection margin attracted the awareness of risk factors for local recurrence and distant metastasis as a foundation for future research. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02223-4.
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Affiliation(s)
- I-Li Lai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jeng-Fu You
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yih-Jong Chern
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Wen-Sy Tsai
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Jy-Ming Chiang
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan
| | - Yu-Jen Hsu
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fu-Hsing Street, Guei-Shan, Tao-Yuan, Taiwan.
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Roodbeen SX, Blok RD, Borstlap WA, Bemelman WA, Hompes R, Tanis PJ. Does oncological outcome differ between restorative and nonrestorative low anterior resection in patients with primary rectal cancer? Colorectal Dis 2021; 23:843-852. [PMID: 33245846 PMCID: PMC8247354 DOI: 10.1111/codi.15464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/29/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
AIM Nonrestorative low anterior resection (n-rLAR) (also known as low Hartmann's) is performed for rectal cancer when a poor functional outcome is anticipated or there have been problems when constructing the anastomosis. Compared with restorative LAR (rLAR), little oncological outcome data are available for n-rLAR. The aim of this study was to compare oncological outcomes between rLAR and n-rLAR for primary rectal cancer. METHOD This was a nationwide cross-sectional comparative study including all elective sphincter-saving LAR procedures for nonmetastatic primary rectal cancer performed in 2011 in 71 Dutch hospitals. Oncological outcomes of patients undergoing rLAR and n-rLAR were collected in 2015; the data were evaluated using Kaplan-Meier survival analysis and the results compared using log-rank testing. Uni- and multivariable Cox regression analysis was used to evaluate the association between the type of LAR and oncological outcome measures. RESULTS A total of 1197 patients were analysed, of whom 892 (75%) underwent rLAR and 305 (25%) underwent n-rLAR. The 3-year local recurrence (LR) rate was 3% after rLAR and 8% after n-rLAR (P < 0.001). The 3-year disease-free survival and overall survival rates were 77% (rLAR) vs 62% (n-rLAR) (P < 0.001) and 90% (rLAR) vs 75% (n-rLAR) (P < 0.001), respectively. In multivariable Cox analysis, n-rLAR was independently associated with a higher risk of LR (OR = 2.95) and worse overall survival (OR = 1.72). CONCLUSION This nationwide study revealed that n-rLAR for rectal cancer was associated with poorer oncological outcome than r-LAR. This is probably a noncausal relationship, and might reflect technical difficulties during low pelvic dissection in a subset of those patients, with oncological implications.
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Affiliation(s)
- Sapho X. Roodbeen
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Robin D. Blok
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands,LEXORCenter for Experimental and Molecular MedicineOncode InstituteCancer Center AmsterdamAmsterdam UMC (AMC)University of AmsterdamAmsterdamthe Netherlands
| | - Wernard A. Borstlap
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Willem A. Bemelman
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam UMCCancer Center AmsterdamUniversity of AmsterdamAmsterdamthe Netherlands
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Anastomotic leak risk in complete responders to neoadjuvant therapy for rectal cancer: a systematic review. Int J Colorectal Dis 2021; 36:671-676. [PMID: 33427960 DOI: 10.1007/s00384-021-03833-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological benefits of achieving a complete pathological response following neoadjuvant chemoradiotherapy for rectal cancer are well defined. How a pathological response affects anastomotic healing or leak rates is not clear. The aim of this systematic review was to compare anastomotic leak rates among patients who did and did not achieve a complete pathological response. METHODS Three major databases (PubMed, Embase, and Scopus) were searched. Predetermined inclusion criteria included prospective and retrospective articles published in English reporting complete pathological response and anastomotic leak rates following total mesorectal excision in ≥ 30 patients with rectal cancer who underwent neoadjuvant chemoradiotherapy and total mesorectal excision. The primary outcomes measured included complete pathological response and 30-day postoperative morbidity. RESULTS From a total of 8919 patients with rectal cancer in 7 studies, 4165 fulfilled the criteria for inclusion. The majority (> 80%) of patients had clinical stage II or III disease. A defunctioning loop ileostomy was formed in 76.5%. A total of 589 (14.1%) patients achieved a pCR of whom 63 (10.7%) developed an anastomotic leak compared to 272/3576 (7.6%) patients without a pCR (p = 0.02). CONCLUSION Patients with complete pathological response following neoadjuvant chemoradiotherapy and total mesorectal excision may be at higher risk of anastomotic leak than incomplete responders. This may need to be taken into account when counseling patients about the relative risks of organ preservation versus anterior resection.
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Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database. World J Surg 2021; 45:1630-1641. [PMID: 33733700 PMCID: PMC8093169 DOI: 10.1007/s00268-021-06054-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 01/16/2023]
Abstract
Background Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR). Methods All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated. Results Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016–2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations. Conclusion Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.
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Ahmad NZ, Abbas MH, Khan SU, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. Int J Colorectal Dis 2021; 36:445-455. [PMID: 33064212 DOI: 10.1007/s00384-020-03771-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication. METHODS The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints. RESULTS A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively). CONCLUSION A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co, Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Saad Ullah Khan
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust, Poole, UK
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Han Z, Chen D, Li Y, Zhou G, Wang M, Zhang C. Development of a Risk Scoring System for Predicting Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery. Ther Clin Risk Manag 2021; 17:145-153. [PMID: 33628027 PMCID: PMC7898229 DOI: 10.2147/tcrm.s297278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/02/2021] [Indexed: 01/22/2023] Open
Abstract
Purpose To develop a risk scoring system that can predict the incidence of anastomotic leakage after laparoscopic rectal cancer surgery. Patients and Methods The clinical data of 387 patients with rectal cancer who underwent laparoscopic low anterior resection were retrospectively collected. Univariable and multivariable logistic regression analyses were used to evaluate independent risk factors for postoperative anastomotic leakage. A simplified points system was then developed based on the corresponding regression coefficient β of each risk factor. Receiver operating characteristic (ROC) analysis was used to evaluate the performance and the optimal cut-off value in predicting anastomotic leakage. The performance of the points system was then externally validated in an independent cohort of 192 patients based in another institution. Results Anastomotic leakage occurred in 36 of 387 patients with rectal cancer (9.30%). Logistic multivariable regression analysis showed that males, maximum tumor diameter (≥5cm), operation time (≥180min), preoperative chemoradiation, intraoperative blood transfusion and the anastomosis level from the anal verge (≤5cm) were independent risk factors for the incidence of anastomotic leakage. According to the scoring standard, the risk points of each patient were calculated. ROC analysis based on the risk points showed that the area under the curve (AUC) was 0.795 (95% CI:0.752-0.834) and the optimal cut-off value was 6, yielding a sensitivity of 88.89% and a specificity of 62.96%. Using this risk points system, the AUC of another cohort of 192 patients from another institution who underwent laparoscopic low anterior resection for rectal cancer was 0.853 (95% CI:0.794-0.900, p<0.001) and patients with risk points ≥6 had a 21.05% chance of developing anastomotic leakage. Conclusion This risk points system for predicting anastomotic leakage following laparoscopic rectal cancer surgery may be useful for surgeons in their decisions to perform intraoperative diversion stoma, which can reduce the incidence of postoperative anastomotic leakage.
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Affiliation(s)
- Zhongbo Han
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Dawei Chen
- Department of General Surgery, Jiangyin People's Hospital, School of Medicine, Southeast University, Jiangyin, Jiangsu, People's Republic of China
| | - Yan Li
- Department of Quality and Safety Management, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Guangshuai Zhou
- Department of Quality and Safety Management, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Meng Wang
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Chao Zhang
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
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Quality of Life and Bowel Function Following Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer: A Report from a Single-Center Randomized Controlled Trial. J Clin Med 2021; 10:jcm10040768. [PMID: 33671925 PMCID: PMC7919002 DOI: 10.3390/jcm10040768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess quality of life and bowel function in patients undergoing early vs. standard ileostomy closure. We retrospectively assessed patients from our previous randomized controlled trial. Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other. Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared. Thirty-six months (17–97) after stoma closure, we contacted patients by phone and filled in two questionnaires—The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and low anterior resection syndrome (LARS) score. This index trial was not powered to assess the difference in bowel function between the two groups. All the patients in the SC group had anastomosis <6 cm from the anal verge compared to 42 of 43 (97.7%) in the EC group. There were no statistically significant differences between EC (26 patients) and SC (25 patients) groups in the EORTC QLQ-C30 and LARS questionnaires. Global quality of life was 37.2 (0–91.7; ±24.9) in the EC group vs. 34.3 (0–100; ±16.2) in the SC (p = 0.630). Low anterior resection syndrome was present in 46% of patients in the EC and 56% in the SC group (p = 0.858). Major LARS was found more often in younger patients. However, no statistical significance was found (p = 0.364). The same was found with quality of life (p = 0.219). Age, gender, ileostomy closure timing, neoadjuvant treatment, complications had no effect of worse bowel function or quality of life. There was no difference in quality of life or bowel function in the late postoperative period after the early vs. late closure of ileostomy based on two questionnaires and small sample size. None of our assessed risk factors had a negative effect on bowel function o quality of life.
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Grewal S, Oosterling SJ, van Egmond M. Surgery for Colorectal Cancer: A Trigger for Liver Metastases Development? New Insights into the Underlying Mechanisms. Biomedicines 2021; 9:biomedicines9020177. [PMID: 33670204 PMCID: PMC7916916 DOI: 10.3390/biomedicines9020177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 12/24/2022] Open
Abstract
Surgery is a crucial intervention and provides the best chance of cure for patients with colorectal cancer. Experimental and clinical evidence, however, suggests that paradoxically surgery itself may precipitate or accelerate tumor recurrence and/or liver metastasis development. This review addresses the various aspects of surgery-induced metastasis formation and sheds light on the role of inflammation as potential trigger for metastasis development. Understanding these mechanisms may provide potential new perioperative interventions to improve treatment outcomes, and as such could transform the perioperative timeframe from a facilitator of metastatic progression to a window of opportunity to reduce the risk of liver metastasis development. Ultimately, this can potentially improve long-term survival rates and quality of life in patients with colorectal cancer.
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Affiliation(s)
- Simran Grewal
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, 1007 MB Amsterdam, The Netherlands;
- Department of Surgery, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-4448080
| | | | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, 1007 MB Amsterdam, The Netherlands;
- Department of Surgery, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
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Pang HY, Chen XL, Song XH, Galiullin D, Zhao LY, Liu K, Zhang WH, Yang K, Chen XZ, Hu JK. Indocyanine green fluorescence angiography prevents anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:261-271. [PMID: 33409585 DOI: 10.1007/s00423-020-02077-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The role of intraoperative use of indocyanine green (ICG) fluorescence angiography (ICGFA) to prevent anastomotic leakage (AL) in rectal cancer surgery remains controversial. METHODS The systematic review for studies evaluating ICGFA in patients undergoing rectal cancer surgery in PubMed, Embase, Web of Science, and the Cochrane Library was performed up to April 30, 2020. The primary outcome was the incidence of AL. The analysis was performed using RevMan v5.3 and Stata v12.0 software. RESULTS Eighteen studies comprising 4038 patients were included. In the present meta-analysis, intraoperative use of ICGFA markedly reduced AL rate (OR = 0.33; 95% CI: 0.24-0.45; P < 0.0001; I2 = 0%) in rectal cancer surgery, which was still significant in surgeries limited to symptomatic AL (OR = 0.44; 95% CI: 0.31-0.64; P < 0.0001; I2 = 22%). This intervention was also associated with shorter postoperative stays (MD = - 1.27; 95% CI: - 2.42 to - 0.13; P = 0.04; I2 = 60%). However, reoperation rate (OR = 0.61; 95% CI: 0.34-1.10; P = 0.10; I2 = 6%), ileus rate (OR = 1.30; 95% CI: 0.60-2.82; P = 0.51; I2 = 56%), and surgical site infection rate (OR = 1.40; 95% CI: 0.62-3.20; P = 0.42; I2 = 0%) were not significantly different between the two groups. CONCLUSION The use of ICGFA was associated with a lower AL rate after rectal cancer resection. However, more multi-center RCTs with large sample size are required to further verify the value of ICGFA in rectal cancer surgery.
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Affiliation(s)
- Hua-Yang Pang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xiao-Long Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xiao-Hai Song
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Danil Galiullin
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China.,Central Research Laboratory, Bashkir State Medical University, Ufa, Russia
| | - Lin-Yong Zhao
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kai Liu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Wei-Han Zhang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kun Yang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 Guo Xue Xiang Street, Chengdu, 610041, Sichuan Province, China.
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