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Sylla P, Sands D, Ricardo A, Bonaccorso A, Polydorides A, Berho M, Marks J, Maykel J, Alavi K, Zaghiyan K, Whiteford M, Mclemore E, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Moshier E, Wexner SD. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37:9483-9508. [PMID: 37700015 PMCID: PMC10709232 DOI: 10.1007/s00464-023-10266-9] [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: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, The Oregon Clinic, Providence Cancer Center, Portland, OR, USA
| | - Elisabeth Mclemore
- Division of Colorectal Surgery, Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sami Chadi
- Division of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre and University Health Network, Toronto, ON, Canada
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL, USA
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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2
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Collard MK, Rullier E, Tuech JJ, Sabbagh C, Souadka A, Loriau J, Faucheron JL, Benoist S, Dubois A, Dumont F, Germain A, Manceau G, Marchal F, Sourrouille I, Lakkis Z, Lelong B, Derieux S, Piessen G, Laforest A, Venara A, Prudhomme M, Brigand C, Duchalais E, Ouaissi M, Lebreton G, Rouanet P, Mège D, Pautrat K, Reynolds IS, Pocard M, Parc Y, Denost Q, Lefevre JH. Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR. Ann Surg 2023; 278:781-789. [PMID: 37522163 DOI: 10.1097/sla.0000000000006025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications. BACKGROUND DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA). METHODS All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included. RESULTS Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up. CONCLUSIONS DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.
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Affiliation(s)
- Maxime K Collard
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Eric Rullier
- Department of General and Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Jean-Jacques Tuech
- Department of General and Digestive Surgery, Hospital Charles Nicole, Rouen, France
| | - Charles Sabbagh
- Department of General and Digestive surgery, Amiens Hospital, France
| | - Amine Souadka
- Department of General and Digestive surgery, National Institute of Oncology, Rabat, Marocco
| | - Jérome Loriau
- Department of Digestive Surgery, Saint-Joseph Hospital, Paris, France
| | - Jean-Luc Faucheron
- Department of Colorectal Surgery, Hôpital Unversitaire de Grenoble, France
| | - Stéphane Benoist
- Department of General and Digestive surgery, Hôpital du Kremlin-Bicêtre, Kremlin-Bicêtre, France
| | - Anne Dubois
- Department of General and Digestive surgery, CHU Clermont-Ferrand Site Estaing, Clermont-Ferrand, France
| | - Frédéric Dumont
- Department of General and Digestive Surgery, Institut de cancérologie de l'ouest, Saint-Herblain, France
| | - Adeline Germain
- Department of General and Digestive Surgery, Hôpital Universitaire de Nancy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, Paris, France
| | - Frédéric Marchal
- Department of Surgical Oncology, Institut de Cancérologie de Lorraine, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | - Zaher Lakkis
- Department of Digestive Surgery, University Hospital of Besancon, Besancon, France
| | - Bernard Lelong
- Department of General and Digestive Surgery, Institute Paoli-Calmettes, Marseille, France
| | - Simon Derieux
- Department of General and Digestive Surgery, Groupe Hospitalier Diaconesses-Croix Saint Simon, Paris, France
| | - Guillaume Piessen
- Department of General and Digestive Surgery, Hôpital Huriez, Lille, France
| | - Anaïs Laforest
- Department of General and Digestive Surgery, Institute Monsouris, Paris, France
| | - Aurélien Venara
- Department of General and Digestive Surgery, Hôpital Universitaire d'Angers, France
| | - Michel Prudhomme
- Department of General and Digestive Surgery, Hôpital Universitaire de Nîmes, France
| | - Cécile Brigand
- Department of General and Digestive Surgery, Hôpital de Hautepierre-Hôpitaux Universitaires, Strasbourg, France
| | - Emilie Duchalais
- Department of General and Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
| | - Mehdi Ouaissi
- Department of General and Digestive Surgery, Hôpital Trousseau - CHRU Hôpitaux de Tours, Chambray-lès-Tours, France
| | - Gil Lebreton
- Department of General and Digestive Surgery, CHU côte de Nâcre, Caen, France
| | - Philippe Rouanet
- Department of General and Digestive Surgery, Institut du Cancer de Montpellier, Montpellier, France
| | - Diane Mège
- Department of General and Digestive Surgery, Hôpital de la Timone, Marseille, France
| | - Karine Pautrat
- Department of General and Digestive Surgery, Hôpital Lariboisière, Paris, France
| | - Ian S Reynolds
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marc Pocard
- Department of General and Digestive Surgery, Hôpital Pitié-Salpêtrère, Paris, France
| | - Yann Parc
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Quentin Denost
- Department of General and Digestive Surgery, Bordeaux Colorectal Institute, Bordeaux, France
| | - Jérémie H Lefevre
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
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Galletti RP, Agareno GA, Sesconetto LDA, da Silva RBR, Pandini RV, Gerbasi LS, Seid VE, Araujo SEA, Tustumi F. Outcomes of redo for failed colorectal or coloanal anastomoses: a systematic review and meta-analysis. Ann Coloproctol 2023; 39:375-384. [PMID: 36535708 PMCID: PMC10626334 DOI: 10.3393/ac.2022.00605.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE This study aimed to review the outcomes of redo procedures for failed colorectal or coloanal anastomoses. METHODS A systematic review was performed using the PubMed, Embase, Cochrane, and LILACS databases. The inclusion criteria were adult patients undergoing colectomy with primary colorectal or coloanal anastomosis and studies that assessed the postoperative results. The protocol is registered in PROSPERO (No. CRD42021267715). RESULTS Eleven articles met the eligibility criteria and were selected. The studied population size ranged from 7 to 78 patients. The overall mortality rate was 0% (95% confidence interval [CI], 0%-0.01%). The postoperative complication rate was 40% (95% CI, 40%-50%). The length of hospital stay was 13.68 days (95% CI, 11.3-16.06 days). After redo surgery, 82% of the patients were free of stoma (95% CI, 75%-90%), and 24% of patients (95% CI, 0%-39%) had fecal incontinence. Neoadjuvant chemoradiotherapy (P=0.002) was associated with a lower probability of being free of stoma in meta-regression. CONCLUSION Redo colorectal and coloanal anastomoses are strategies to restore colonic continuity. The decision to perform a redo operation should be based on a proper evaluation of the morbidity and mortality risks, the probability of remaining free of stoma, the quality of life, and a functional assessment.
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Affiliation(s)
| | | | | | | | - Rafael Vaz Pandini
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Victor Edmond Seid
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Francisco Tustumi
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
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4
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Classification of surgical causes of and approaches to the chronically failing ileoanal pouch. Tech Coloproctol 2023; 27:271-279. [PMID: 36040574 PMCID: PMC10008244 DOI: 10.1007/s10151-022-02688-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/14/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Although there are various surgical causes of and therapeutic approaches to the chronically failing ileoanal pouch (PF), cases are often detailed without distinguishing the exact cause and corresponding treatment. The aim of our study was to classify causes of PF and corresponding surgical treatment options, and to establish efficacy of surgical approach per cause. METHODS This retrospective study included all consecutive adult patients with chronic PF surgically treated at our tertiary hospital between July 2014 and March 2021. Patients were classified according to a proposed sub-classification for surgical related chronic PF. Results were reported accordingly. RESULTS A total of 59 procedures were completed in 50 patients (64% male, median age 45 years [IQR 34.5-54.3]) for chronic PF. Most patients had refractory ulcerative colitis as indication for their restorative proctocolectomy (68%). All patients could be categorized according to the sub-classification. Reasons for chronic PF were septic complications (n = 25), pouch body complications (n = 12), outlet problems (n = 11), cuff problems (n = 8), retained rectum (n = 2), and inlet problems (n = 1). For these indications, 17 pouches were excised, 10 pouch reconstructions were performed, and 32 pouch revision procedures were performed. The various procedures had different complication rates. Technical success rates of redo surgery for the different causes varied from 0 to 100%, with a 75% success rate for septic causes. CONCLUSIONS Our sub-classification for chronic PF and corresponding treatments is suitable for all included patients. Outcomes varied between causes and subsequent management. Chronic PF was predominantly caused by septic complications with redo surgery achieving a 75% technical success rate.
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5
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Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis. Surg Today 2022; 53:718-727. [DOI: 10.1007/s00595-022-02603-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/25/2022] [Indexed: 11/18/2022]
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6
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Ryckx A, Leonard D, Bachmann R, Remue C, Charles S, Kartheuser A. Single center experience with salvage surgery for chronic pelvic sepsis. Updates Surg 2022; 74:1925-1931. [PMID: 35999324 DOI: 10.1007/s13304-022-01359-6] [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: 10/25/2021] [Accepted: 07/30/2022] [Indexed: 11/28/2022]
Abstract
Chronic pelvic sepsis eventually requires salvage surgery in half of all patients. The goal of surgery is to resolve pelvic inflammation while restoring intestinal continuity. Our salvage procedure achieves this by bringing a healthy conduit into the pelvis and creating an anastomosis beyond the source of sepsis. We aimed to review our single center experience with this procedure for the treatment of chronic pelvic sepsis. All patients requiring the procedure from 2010 to 2018 were retrospectively reviewed using a prospective database. Morbidity and mortality were evaluated, and restoration of bowel continuity at 1-year rate was the endpoint. Twenty patients were included. The main indication was pelvic sepsis after anastomotic leak (AL). The median age was 60 (42-86) years and the median BMI was 26 (18-37) kg/m2. The median time carrying a stoma before the intervention was 15 months, and median time to intervention was 32 months. All patients had a diverting stoma. There were no death and overall morbidity reached 60%, and AL rate was 10%. At 1 year, 70% of the patients had their intestinal continuity restored. In expert hands, salvage surgery for chronic pelvic sepsis has acceptable morbidity rates, an acceptable rate of AL, and a bowel restoration success rate 70% at 1 year, and is a valuable option for patients failing conservative treatment.
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Affiliation(s)
- Andries Ryckx
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Daniel Leonard
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Radu Bachmann
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Christophe Remue
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Suttor Charles
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium
| | - Alex Kartheuser
- Head of Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, 10, Avenue Hippocrate, 1200, Brussels, Belgium.
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7
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Re-do laparoscopic esophagojejunostomy for anastomotic stenosis after laparoscopic total gastrectomy in gastric cancer. Langenbecks Arch Surg 2022; 407:3133-3139. [PMID: 35982288 DOI: 10.1007/s00423-022-02632-3] [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: 03/04/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Anastomotic stenosis of esophagojejunostomy after total gastrectomy has a substantial impact on the postoperative quality of life of the patient. If conservative treatment doesn't work, surgical intervention should be considered. However, redoing esophagojejunostomy is an extremely demanding procedure. Especially in the case where the primary surgery was performed laparoscopically, it is an unmet problem to maintain minimal invasiveness in re-do surgery. METHODS We report 3 cases of re-do esophagojejunostomy laparoscopically performed for anastomotic stenosis after laparoscopic total gastrectomy in gastric cancer, in whom endoscopic balloon dilation did not work. RESULTS Each patient underwent a re-do esophagojejunostomy laparoscopically. The mean operation time was 293 min, and the mean blood loss was 56 ml. There was no anastomosis-related complication, and they were discharged from hospital on 11-16 postoperative days. At the time of discharge, oral food intake was 100% in each patient. One year after the operation, follow-up endoscopic exams showed no anastomotic stenosis. CONCLUSION Re-do laparoscopic esophagojejunostomy for anastomotic stenosis after laparoscopic total gastrectomy was safely and successfully performed. It brings patients minimal invasiveness continuously from the initial surgery. Re-do laparoscopic esophagojejunostomy could be one of the options for anastomotic stenosis resistant to conservative treatment.
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8
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Calmels M, Collard MK, O'Connell L, Voron T, Debove C, Chafai N, Parc Y, Lefevre JH. Redo-surgery after failed colorectal or coloanal anastomosis: Morbidity, mortality and factors predictive of success. A retrospective study of 200 patients. Colorectal Dis 2022; 24:511-519. [PMID: 34914160 DOI: 10.1111/codi.16025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 12/22/2022]
Abstract
AIM In cases of anastomotic failure after colorectal (CRA) or coloanal anastomosis (CAA), revision of the anastomosis is an ambitious surgical option that can be proposed in order to maintain bowel continuity. Our aim was to assess postoperative morbidity, risk of failure and risk factor for failure in patients after CRA or CAA. METHODS All consecutive patients who underwent redo-CRA/CAA in our institution between 2007-2018 were retrospectively included. The success of redo-CRA/CAA was defined by the restoration of bowel continuity 12 months after the surgery. RESULTS Two hundred patients (114 male: 57%) were analyzed. The indication for redo-CRA/CAA was chronic pelvic infection in 74 patients (37%), recto-vaginal or urinary fistula in 59 patients (30%), anastomotic stenosis in 36 patients (18%) and redo anastomosis after previous anastomosis takedown in 31 patients (15%). Twenty-three percent of the patients developed a severe postoperative complication. Anastomotic leakage was diagnosed in 39 patients (20%). One-year-success of the redo-CRA/CAA was obtained in 80% of patients. In multivariate analysis, only obesity was associated with redo-CRA/CAA failure (p = 0.042). We elaborated a pre-operative predictive score of success using the four variables: male sex, age > 60 years, obesity and history of pelvic radiotherapy. The success of redo-CRA/CAA was 92%, 86%, 80% and 62% for a preoperative predictive score value of 0, 1, 2 and ≥3, respectively (p = 0.010). CONCLUSIONS In case of failure of primary CRA/CAA, bowel continuity can be saved in 4 out of 5 patients by redo-CRA/CAA despite 23% suffering severe postoperative morbidity.
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Affiliation(s)
- Mélanie Calmels
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Maxime K Collard
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Thibault Voron
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Clotilde Debove
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Najim Chafai
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Yann Parc
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Jérémie H Lefevre
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
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9
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Talboom K, Tanis PJ, Bemelman WA, Hompes R. Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How? Clin Colon Rectal Surg 2022; 35:155-164. [PMID: 35237112 PMCID: PMC8885159 DOI: 10.1055/s-0041-1742117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.
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Affiliation(s)
- K. Talboom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands,Address for correspondence P. J. Tanis, MD, PhD Department of Surgery, Amsterdam UMCDe Boelelaan 1117, 1081 HV AmsterdamThe Netherlands
| | - W. A. Bemelman
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - R. Hompes
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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10
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Mandarino FV, Barchi A, Biamonte P, Esposito D, Azzolini F, Fanti L, Danese S. The prophylactic use of endoscopic vacuum therapy for anastomotic dehiscence after rectal anterior resection: is it feasible for redo surgery? Tech Coloproctol 2022; 26:319-320. [PMID: 34981274 DOI: 10.1007/s10151-021-02566-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/22/2021] [Indexed: 12/14/2022]
Affiliation(s)
- F V Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
| | - A Barchi
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - P Biamonte
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - D Esposito
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Azzolini
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - L Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.,Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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11
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Keller DS, Talboom K, van Helsdingen CPM, Hompes R. Treatment Modalities for Anastomotic Leakage in Rectal Cancer Surgery. Clin Colon Rectal Surg 2021; 34:431-438. [PMID: 34853566 DOI: 10.1055/s-0041-1736465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University of California at Davis Medical Center, Sacramento, California
| | - K Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - C P M van Helsdingen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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12
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Labiad C, Monsinjon M, Giacca M, Panis Y. Second redo surgery after two consecutive failures of a colorectal or coloanal anastomosis: is it reasonable? Int J Colorectal Dis 2021; 36:2057-2060. [PMID: 34169331 DOI: 10.1007/s00384-021-03982-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Colorectal redo surgery is well known to be a difficult procedure, associated with a high risk of failure. The aim of this study was to look into patients presenting two consecutive failed colorectal (CRA) or coloanal (CAA) anastomosis who underwent a second redo surgery (i.e., third anastomosis). METHODS A retrospective study based on a prospective database of second redo surgeries of CRA or CAA, in an expert center. Sixteen patients between 2005 and 2020 were analyzed. RESULTS After a mean follow-up of 28 ± 26 months, success of surgery (defined as no stoma at the end of follow-up) was reported in 10/16 patients (63%). One patient with chronic anastomotic leakage and another with early colonic ischemia had no defunctioning stoma reversal. In the remaining four patients with a failed second redo surgery, a definitive stoma was ultimately created for fistula recurrence (n = 1), poor functional results (n = 2), or local cancer recurrence (n = 1). Two risk factors for failure of this second redo surgery were significantly found in a univariate analysis: (1) nature of the primary anastomosis: 3/13 s redo surgeries failed (23%) if a CRA was first made and 3/3 (100%) if it was a CAA (p = 0.036); (2) age: patients with a failed second redo surgery were older (p = 0.04). CONCLUSION A 63% rate of success of second redo surgery was observed after two failed CRA or CAA. Although a demanding procedure, it can be proposed to carefully selected and motivated patients.
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Affiliation(s)
- Camélia Labiad
- Department of Colorectal Surgery, Pôle Des Maladies de L'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.,Sorbonne Université, 15-21 rue de l'Ecole de Médecine, 75006, Paris, France
| | - Marie Monsinjon
- Department of Colorectal Surgery, Pôle Des Maladies de L'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Massimo Giacca
- Department of Colorectal Surgery, Pôle Des Maladies de L'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle Des Maladies de L'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
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13
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Functional Outcomes and Quality of Life after Redo Anastomosis in Patients With Rectal Cancer: An International Multicenter Comparative Cohort Study. Dis Colon Rectum 2021; 64:822-832. [PMID: 33902088 DOI: 10.1097/dcr.0000000000002025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN This study was designed as an international multicenter comparative cohort study. SETTINGS The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS This study is limited by the possible response bias. CONCLUSIONS Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.
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14
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Kienle P, Magdeburg JR. [Chronic anastomotic leak after low rectal resection-an unsolved problem?]. Chirurg 2021; 92:605-611. [PMID: 33852017 DOI: 10.1007/s00104-021-01400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 11/27/2022]
Abstract
There is no generally accepted definition of a chronic anastomotic leak, which often presents as a chronic sinus. The corresponding time interval required from primary anastomotic construction ranges from 2 months to 12 months. Between 2% and 16% of all patients develop this complication after low anterior rectal resection. Due to the heterogeneous presentation and configuration of chronic leaks there are no valid comparable data on how to manage this problem. A variety of therapeutic options are used, sometimes combined or additively. The choice of therapeutic option depends very much on the individual case. The following options are used: debridement of the persisting cavity/fistula system, wide deroofing of the cavity into the lumen, endosponge with vacuum, stent implantation, advancement flap with simultaneous drainage of the cavity, fibrin glue instillation and as a last resort a redo low anastomosis. The healing rate in the available literature is generally over 70%. In selected cases a stoma reversal can be done for persisting cavities (wide entry of the cavity into the neorectum, no relevant distal stenosis). Overall, the available poor to moderate evidence suggests that 70-85% of patients with a chronic anastomotic leak, defined as stoma reversal, are treated successfully; however, there is some concern of a relevant publication bias of the published data so that the results may be less impressive in the clinical reality.
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Affiliation(s)
- Peter Kienle
- Allgemein-und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik gGmbH, Bassermannstraße 1, 68165, Mannheim, Deutschland.
| | - Jörn Richard Magdeburg
- Allgemein-und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik gGmbH, Bassermannstraße 1, 68165, Mannheim, Deutschland
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15
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Transanal Minimally Invasive Surgery: An Effective Approach for Patients Who Require Redo Pelvic Surgery for Anastomotic Failure. Dis Colon Rectum 2021; 64:349-354. [PMID: 33395138 DOI: 10.1097/dcr.0000000000001845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery. OBJECTIVE This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a single tertiary-care institution. PATIENTS Consecutive patients undergoing transanal minimally invasive redo proctectomy were included. INTERVENTIONS Transanal minimally invasive redo proctectomy was performed. MAIN OUTCOME MEASURES The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution. RESULTS Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months. LIMITATIONS This study was limited by its small sample size and its single-institution focus. CONCLUSION For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.
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16
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Luo S, Zhang X, Hou Y, Hu H, Dong J, Wang L, Kang L. Transanal and transabdominal combined endoscopic resection of rectal stenosis and anal reconstruction based on transanal endoscopic technique. Surg Endosc 2021; 35:6827-6835. [PMID: 33398554 DOI: 10.1007/s00464-020-08188-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/17/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To propose a method for the resection of the rectal anastomotic stenosis and anal reconstruction based on the transanal endoscopic technique through a transanal and transabdominal combined endoscopic resection, and to verify its clinical effectiveness. METHODS Thirty-eight patients with anastomotic stenosis were admitted to the Sixth Affiliated Hospital, Sun Yat-sen University, China, from January 2016 to September 2019. Patients were divided into an experimental group (17 patients) and a control group (21 patients) subjected to the removal of the intestinal stenosis followed by anal reconstruction, they underwent transanal and transabdominal endoscopic surgery and traditional transabdominal surgery, respectively. Data on intraoperative blood loss, operation time, postoperative recovery, and prognosis were collected. RESULTS (1) The median intraoperative blood loss was approximately 100 ml, without conversion to laparotomy during the surgery and intraoperative complications. The safety of the surgical operation was improved. (2) The operation time was shortened compared to previous reports, and the median operative time was 193 min. The average time of transanal endoscopic dissociation to the retroperitoneal fold was 76 min. (3) Laparoscopic assistance was carried out on 14 of the17 patients, and the incision was reduced. (4) The short-term curative effect was quite satisfactory, without permanent stoma. The average time to recover food intake after the surgery was 1.5 days. The average ambulation time was 3 days. Within 30 days after the surgery, one case suffered anastomotic leakage and then underwent refunctioning stoma through a second surgery. One patient suffered from intestinal obstruction, and the condition was improved through a conservative treatment. One case experienced delayed abdominal wound healing. CONCLUSION The transanal and transabdominal endoscopic resection of the rectal anastomotic stenosis and anal reconstruction reduced the difficulty of the surgery, improved its safety, shortened the operation time, decreased the operative complications, and enabled patients to recover well after surgery.
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Affiliation(s)
- Shuangling Luo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, Guangdong, China
| | - Xingwei Zhang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, Guangdong, China
| | - Yujie Hou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, Guangdong, China
| | - Huanxin Hu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, Guangdong, China
| | - Jianghui Dong
- UniSA Clinical & Health Sciences, and UniSA Cancer Research Institute, University of South Australa, Adelaide, SA, 5001, Australia
| | - Liping Wang
- UniSA Clinical & Health Sciences, and UniSA Cancer Research Institute, University of South Australa, Adelaide, SA, 5001, Australia.
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510655, Guangdong, China. .,Guangdong Institute of Gastroenterology, and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 510655, Guangdong, China.
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17
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Functional outcomes of patients undergoing successful redo surgery after failed primary colorectal or coloanal anastomosis for rectal cancer. Surgery 2020; 169:782-789. [PMID: 33276975 DOI: 10.1016/j.surg.2020.10.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND After a failure of a colorectal or coloanal anastomosis, redo anastomotic surgery aims to avoid the risk of permanent stoma but, overall, to provide a satisfactory functional result and quality of life. Very limited data exist regarding the long-term results after a successful redo anastomosis. The present study aimed to report the long-term functional outcomes and quality of life in patients after a successful redo colorectal anastomosis or coloanal anastomosis. METHODS Between 2007 and 2018, all patients who had a successful restoration of bowel continuity after a failed primary anastomosis performed for a rectal cancer were included. Functional outcomes and quality of life were assessed using the low anterior rectal syndrome score and the Gastrointestinal Quality of Life Index. RESULTS One hundred and twenty-seven patients were eligible for inclusion in this study, with long-term functional outcomes assessed in 73 patients (57%). After a median follow-up of 69 months, 31 patients presented no or minor low anterior rectal syndrome (42%), whereas 31 patients reported a major low anterior rectal syndrome (42%). A definitive stoma was confectioned in 11 patients (15%), despite the technical success of redo anastomosis due to poor functional results. Only operative interval <36 months was associated with a poor functional outcome (P = .001), whereas all other factors such as pelvic radiotherapy were not (P = .848). An absence of major low anterior rectal syndrome was the only factor associated with improved quality of life (P = .001). CONCLUSION After successful redo colorectal anastomosis or coloanal anastomosis, good functional outcomes can be achieved in almost half of patients with a well-preserved quality of life but requires a prolonged postoperative period of rehabilitation.
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18
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Lam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. Best Pract Res Clin Gastroenterol 2020; 48-49:101705. [PMID: 33317788 DOI: 10.1016/j.bpg.2020.101705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/19/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.
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Affiliation(s)
- David Lam
- Senior Clinical Fellow in Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - Oliver Jones
- Consultant Colorectal Surgeon and Clinical Director of Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
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19
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Hahn SJ, Hill SS, Davids JS, Sturrock PR, Alavi K, Maykel JA. Endoluminal vacuum-assisted therapy and transanal minimally invasive surgery closure of leak following ileal pouch-anal anastomosis - a video vignette. Colorectal Dis 2020; 22:1797-1798. [PMID: 32584488 DOI: 10.1111/codi.15218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/05/2020] [Indexed: 02/08/2023]
Affiliation(s)
- S J Hahn
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - S S Hill
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - J S Davids
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - P R Sturrock
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - K Alavi
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - J A Maykel
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
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20
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Caille C, Collard M, Moszkowicz D, Prost À la Denise J, Maggiori L, Panis Y. Reversal of Hartmann's procedure in patients following failed colorectal or coloanal anastomosis: an analysis of 45 consecutive cases. Colorectal Dis 2020; 22:203-211. [PMID: 31536670 DOI: 10.1111/codi.14854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/15/2019] [Indexed: 02/08/2023]
Abstract
AIM This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA). METHODS All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included. RESULTS From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump < 7.5 cm in length as the only independent risk factor for long-term persistent stoma. Among stoma-free patients, low anterior resection syndrome (LARS) score was ≤ 20 (normal) in 43%, between 21 and 29 (minor LARS) in 33% and ≥ 30 (major LARS) in 24% of the patients. CONCLUSION HR can be recommended in patients following a failed CRA or CAA. It permits 78% of patients to be free of stoma. A short length of the remnant rectal stump is the only predictive factor of persistent stoma in these patients.
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Affiliation(s)
- C Caille
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - M Collard
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - D Moszkowicz
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - J Prost À la Denise
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Assistance Publique - Hôpitaux de Paris (AP-HP), Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France
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Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection. Dis Colon Rectum 2019; 62:1458-1466. [PMID: 31567923 DOI: 10.1097/dcr.0000000000001483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted in a tertiary referral center. PATIENTS All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES Primary end points were procedural characteristics and 90-day major complications. RESULTS In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS A limitation of this study is the relatively small sample size. CONCLUSIONS This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis.El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica.Este es un estudio de cohorte retrospectiva.Este estudio se realizó en un centro de referencia terciario.Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018.La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional.Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días.En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente.La limitación de este estudio es el tamaño relativamente pequeño de la muestra.Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.
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Kitaguchi D, Nishizawa Y, Sasaki T, Tsukada Y, Ikeda K, Ito M. Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors. Colorectal Dis 2019; 21:1304-1311. [PMID: 31199545 DOI: 10.1111/codi.14728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 05/12/2019] [Indexed: 02/08/2023]
Abstract
AIM In patients with a previous history of rectal anastomotic leakage (AL), the surgical indications and timing for closure of a diverting stoma have to be carefully judged. Even if AL has apparently healed before stoma closure, re-leakage may occur after closure. The aim of this study was to determine the incidence and risk factors for recurrent AL following stoma closure. We also examined the treatment strategies aiming to minimize the risk of recurrent AL. METHODS From January 2009 to December 2016, 1008 patients underwent sphincter-saving surgery [low anterior resection, all-sphincter-preserving rectal resection with hand-sewn coloanal anastomosis (CAA) and intersphincteric resection (ISR)] for primary rectal cancer with curative intent at our hospital. A total of 69 patients with AL with a Clavien-Dindo Grade III or more who subsequently underwent closure of a diverting stoma were retrospectively reviewed for this study. RESULTS The incidence of recurrent leakage after stoma closure in this series was 13% overall with an incidence of 25% in the CAA/ISR group and 5% in the low anterior resection group. Significant risk factors included hand-sewn anastomosis (P = 0.0257) compared to stapled anastomosis, ischaemia at the anastomotic site as the cause of initial AL (P < 0.001) and a shorter interval between confirmation of healing and stoma closure (P = 0.00952). CONCLUSION Ischaemia at the anastomotic site was the main risk factor for recurrent leakage, particularly after CAA/ISR. Additional treatment options before stoma closure should be considered to avoid re-leakage in such cases.
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Affiliation(s)
- D Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Y Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - T Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Y Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - K Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
| | - M Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan
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Kim CH. Anastomotic Sinus Developed From Leakage in Rectal Cancer Resection: When Can We Reverse the Defunctioning Stoma? Ann Coloproctol 2019; 35:1-2. [PMID: 30879277 PMCID: PMC6425244 DOI: 10.3393/ac.2018.12.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Gwangju, Korea
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