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Sharabiany S, Joosten JJ, Musters GD, Talboom K, Tanis PJ, Bemelman WA, Hompes R. Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre. Colorectal Dis 2024; 26:650-659. [PMID: 38418896 DOI: 10.1111/codi.16863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024]
Abstract
AIM Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre. METHOD Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome. RESULTS In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567). CONCLUSION High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.
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Affiliation(s)
- Sarah Sharabiany
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna J Joosten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Meng LH, Mo XW, Yang BY, Qin HQ, Song QZ, He XX, Li Q, Wang Z, Mo CL, Yang GH. To explore the pathogenesis of anterior resection syndrome by magnetic resonance imaging rectal defecography. World J Gastrointest Surg 2024; 16:529-538. [PMID: 38463367 PMCID: PMC10921216 DOI: 10.4240/wjgs.v16.i2.529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/26/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Over 90% of rectal cancer patients develop low anterior resection syndrome (LARS) after sphincter-preserving resection. The current globally recognized evaluation method has many drawbacks and its subjectivity is too strong, which hinders the research and treatment of LARS. AIM To evaluate the anorectal function after colorectal cancer surgery by quantifying the index of magnetic resonance imaging (MRI) defecography, and pathogenesis of LARS. METHODS We evaluated 34 patients using the standard LARS score, and a new LARS evaluation index was established using the dynamic images of MRI defecography to verify the LARS score. RESULTS In the LARS score model, there were 10 (29.41%) mild and 24 (70.58%) severe cases of LARS. The comparison of defecation rate between the two groups was 29.36 ± 14.17% versus 46.83 ± 18.62% (P = 0.004); and MRI-rectal compliance (MRI-RC) score was 3.63 ± 1.96 versus 7.0 ± 3.21 (P = 0.001). Severe and mild LARS had significant differences using the two evaluation methods. There was a significant negative correlation between LARS and MRI-RC score (P < 0.001), and they had a negative correlation with defecation rate (P = 0.028). CONCLUSION MRI defecography and standard LARS score can both be used as an evaluation index to study the pathogenesis of LARS.
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Affiliation(s)
- Ling-Hou Meng
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xian-Wei Mo
- Department of Colorectal and Anal Surgery, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Bing-Yu Yang
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Hai-Quan Qin
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Qing-Zhou Song
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Xin-Xin He
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Qiang Li
- Department of Radiology, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Zheng Wang
- Department of Radiology, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Chang-Lin Mo
- Department of Gastrointestinal Surgery, Guangxi Clinical Research Center for Colorectal Cancer, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guo-Hai Yang
- First Department of Chemotherapy, Guangxi Medical University Cancer Hospital, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Kreisel SI, Sparenberg S, Sharabiany S, Hompes R, Lapid O, van der Horst CMAM, Musters GD, Tanis PJ. Gluteal Fasciocutaneous Flap Reconstruction After Salvage Surgery for Pelvic Sepsis. Dis Colon Rectum 2023; 66:1570-1577. [PMID: 36940299 DOI: 10.1097/dcr.0000000000002648] [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: 03/22/2023]
Abstract
BACKGROUND Chronic pelvic sepsis mostly originates from complicated pelvic surgery and failed interventions. This is a challenging condition that often requires extensive salvage surgery consisting of complete debridement with source control and filling of the dead space with well-vascularized tissue. OBJECTIVE This study aimed to describe the outcomes of gluteal fasciocutaneous flaps for the treatment of secondary pelvic sepsis. DESIGN Retrospective single-center cohort study. SETTINGS Tertiary referral center. PATIENTS Patients who underwent salvage surgery for secondary pelvic sepsis between 2012 and 2020 using a gluteal flap were included in this study. MAIN OUTCOME MEASURES Percentage of complete wound healing. RESULTS In total, 27 patients were included, of whom 22 underwent index rectal resection for cancer and 21 had undergone (chemo)radiotherapy. A median of 3 (interquartile range, 1-5) surgical and 1 (interquartile range, 1-4) radiological interventions preceded salvage surgery during a median period of 62 (interquartile range, 20-124) months. Salvage surgery included partial sacrectomy in 20 patients. The gluteal flap consisted of a V-Y flap in 16 patients, superior gluteal artery perforator flap in 8 patients, and a gluteal turnover flap in 3 patients. Median hospital stay was 9 (interquartile range, 6-18) days. During a median follow-up of 18 (interquartile range, 6-34) months, wound complications occurred in 41%, with a reintervention rate of 30%. The median time to wound healing was 69 (interquartile range, 33-154) days, with a complete healing rate of 89% at the end of follow-up. LIMITATIONS Retrospective design and heterogeneous patient population. CONCLUSIONS In patients undergoing major salvage surgery for chronic pelvic sepsis, the use of gluteal fasciocutaneous flaps is a promising solution because of the high success rate, limited risks, and relatively simple technique. See Video Abstract at http://links.lww.com/DCR/C160 . RECONSTRUCCIN CON COLGAJO FASCIOCUTNEO GLTEO DESPUS DE UNA CIRUGA DE RESCATE POR SEPSIS PLVICA ANTECEDENTES:La sepsis pélvica crónica esta causada principalmente por cirugías pélvicas complicadas e intervenciones fallidas. Esta es una condición desafiante que a menudo requiere una cirugía de rescate extensa que consiste en un desbridamiento completo controlando el orígen infeccioso y rellenando el espacio muerto con tejido bien vascularizado, como por ejemplo un colgajo de tejido autólogo. La pared abdominal (colgajo de recto abdominal) o la pierna (colgajo de gracilis) se utilizan principalmente como sitios donantes para esta indicación, mientras que los colgajos glúteos pueden ser alternativas atractivas.OBJETIVO:Describir los resultados de los colgajos fasciocutáneos glúteos en el tratamiento de la sepsis pélvica secundaria.DISEÑO:Estudio de cohortes retrospectivo en un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Todos aquellos que se sometieron a cirugía de rescate por sepsis pélvica secundaria entre 2012 y 2020 utilizando un colgajo fasciocutáneo glúteo.PRINCIPALES MEDIDAS DE RESULTADO:El porcentaje de cicatrización completa de la herida.RESULTADOS:En total, se incluyeron 27 pacientes, de los cuales 22 fueron sometidos a resección rectal por cáncer indicada y 21 pacientes que habían recibido (quimio)radioterapia. Una mediana de tres (RIC 1-5) intervenciones quirúrgicas y una (RIC 1-4) intervenciones radiológicas precedieron a la cirugía de rescate durante una mediana de 62 (RIC 20-124) meses.La cirugía de rescate incluyó una resección parcial del sacro en 20 pacientes. El colgajo fasciocutáneo glúteo consistió en la confección de un colgajo en V-Y en 16 pacientes, un colgajo incluyendo la perforante de la arteria glútea superior en 8 y un colgajo de rotación de músculo glúteo en 3 pacientes.La mediana de estancia hospitalaria fue de nueve (RIC 6-18) días. Durante una mediana de seguimiento de 18 (IQR 6-34) meses, se produjeron complicaciones de la herida en el 41%, con una tasa de reintervención del 30%.La mediana de tiempo hasta la cicatrización de la herida fue de 69 (IQR 33-154) días con una tasa de cicatrización completa del 89 % al final del seguimiento cicatricial.LIMITACIONES:Diseño retrospectivo y población heterogénea de pacientes.CONCLUSIONES:En pacientes sometidos a cirugía mayor de rescate por sepsis pélvica crónica, el uso de colgajos fasciocutáneos glúteos es una solución prometedora debido a la alta tasa de éxito, los riesgos limitados y la técnica relativamente simple. Video Resumen en http://links.lww.com/DCR/C160 . (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Saskia I Kreisel
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Sparenberg
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Oren Lapid
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Chantal M A M van der Horst
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, The Netherlands
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Planellas P, Cornejo L, Ortega N, Delisau O, Farrés R. Transanal minimally invasive surgery for rectal anastomotic complications after colorectal surgery. Tech Coloproctol 2023; 27:1123-1124. [PMID: 37358670 DOI: 10.1007/s10151-023-02834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Affiliation(s)
- P Planellas
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Girona, Spain.
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Avinguda de França S/N, 17007, Girona, Spain.
- Biomedical Research Institute (IDIBGI), Girona, Spain.
| | - L Cornejo
- Biomedical Research Institute (IDIBGI), Girona, Spain
| | - N Ortega
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Avinguda de França S/N, 17007, Girona, Spain
| | - O Delisau
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Avinguda de França S/N, 17007, Girona, Spain
| | - R Farrés
- Colorectal Surgery Unit, Department of General and Digestive Surgery, University Hospital of Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona Biomedical Research Institute (IDIBGI), Avinguda de França S/N, 17007, Girona, Spain
- Biomedical Research Institute (IDIBGI), Girona, Spain
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Lavryk OA, Bandi B, Shawki SF, Floruta C, Xue J, Valente MA, Steele SR, Hull TL. Turnbull-Cutait abdominoperineal pull-through operation: The Cleveland Clinic experience in the 21st century. Colorectal Dis 2022; 24:1184-1191. [PMID: 35490348 DOI: 10.1111/codi.16163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023]
Abstract
AIM The Turnbull-Cutait pull-through procedure (TCO) restores intestinal continuity in the setting of chronic pelvic sepsis, colorectal anastomotic leak, complex pelvic fistulas and technical challenges related to complicated rectal cancer. The aim of this study was to evaluate the outcomes of the TCO for salvaging complex pelvic conditions and to compare it to hand-sewn immediate coloanal anastomosis (CAA). METHODS This is a retrospective single-institution study where we searched a prospectively maintained database to identify patients who underwent the TCO. Patient demographics, operative indications and outcomes were analysed. TCO success was defined as maintenance of intestinal continuity and being stoma-free. Kaplan-Meier analysis was employed for stoma-free survival analysis. RESULTS A total of 81 patients with TCO and 129 patients with CAA were included. The TCO success rate was 69% at a median of 1.4 years' follow-up with 25 (31%) patients ending up with a permanent stoma compared to 22 (17%) in the CAA group with a median follow-up of 4 years (P = 0.03). The Kaplan-Meier cumulative incidence of TCO success at 1, 3 and 5 years was 79%, 60% and 51%, respectively, compared to 91%, 81% and 73% after CAA. CONCLUSION The TCO has a high success rate for patients with complex pelvic conditions who may be facing a permanent stoma as their only option.
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Affiliation(s)
- Olga A Lavryk
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bethany Bandi
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Crina Floruta
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jia Xue
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Clinical Practice Guidelines in Colorectal Surgery: Do We Need to Randomize Everything? Dis Colon Rectum 2022; 65:1159-1161. [PMID: 35982521 DOI: 10.1097/dcr.0000000000002581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Talboom K, Greijdanus NG, van Workum F, Ubels S, Rosman C, Hompes R, de Wilt JHW, Tanis PJ. International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study. Int J Colorectal Dis 2022; 37:2049-2059. [PMID: 36002748 PMCID: PMC9436864 DOI: 10.1007/s00384-022-04240-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Little is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide. METHODS In this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases). RESULTS In total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy. CONCLUSION This TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
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