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de la Plaza Llamas R, Parés D, Soria Aledó V, Cabezali Sánchez R, Ruiz Marín M, Senent Boza A, Romero Simó M, Alonso Hernández N, Vallverdú-Cartié H, Mayol Martínez J. Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey. Cir Esp 2024:S2173-5077(24)00096-6. [PMID: 38615908 DOI: 10.1016/j.cireng.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.
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Affiliation(s)
- Roberto de la Plaza Llamas
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain.
| | - David Parés
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Víctor Soria Aledó
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario JM Morales Meseguer, Murcia, Spain
| | | | - Miguel Ruiz Marín
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Ana Senent Boza
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manuel Romero Simó
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis de Alicante, Spain
| | - Natalia Alonso Hernández
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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Ingwersen EW, van der Beek PJK, Dekker JWT, van Dieren S, Daams F. One Decade of Declining Use of Defunctioning Stomas After Rectal Cancer Surgery in the Netherlands: Are We on the Right Track? Dis Colon Rectum 2023; 66:1003-1011. [PMID: 36607894 DOI: 10.1097/dcr.0000000000002625] [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: 01/07/2023]
Abstract
BACKGROUND The beneficial effect of a defunctioning stoma in mitigating the consequences of anastomotic leakage after rectal cancer surgery is still debated. OBJECTIVE This study aims to reflect on a decade of rectal cancer surgery in terms of stoma construction and anastomotic leakage. DESIGN Retrospective observational study. SETTING This study used data from the Dutch Colorectal Audit from 2011 to 2020. PATIENTS Patients undergoing rectal cancer surgery with a primary anastomosis. MAIN OUTCOME MEASURES Primary outcome was anastomotic leakage. Secondary outcomes were minor complications, admission to intensive care, length of stay, readmission, and patient death. RESULTS A total of 13,263 patients were included in this study. A defunctioning stoma was constructed in 7106 patients (53.6%). Patients with a defunctioning stoma were less likely to develop anastomotic leakage (7.9% vs 13.0%), and if anastomotic leakage occurred, fewer patients needed surgical reintervention (37.7% vs 81.1%). An annual decrease in the construction of a defunctioning stoma was seen (69.8% in 2011 vs 51.8% in 2015 vs 29.7% in 2020), accompanied by a 5% increase in anastomotic leakage (9.1% in 2011 vs 14.1% in 2020). A defunctioning stoma was associated with a higher occurrence of minor complications, increased admissions to the intensive care unit, longer length of stay, and more readmissions within 90 days. LIMITATION This retrospective study is susceptible to confounders by indications, and there could be risk factors for anastomotic leakage and the use of a stoma that were not regarded. CONCLUSIONS The reduction in defunctioning stomas is paralleled with an increase in anastomotic leakage. However, patients with a defunctioning stoma also showed more minor complications, a prolonged length of stay, more intensive care admissions, and more readmissions. In our opinion, the trade-offs of selective use should be individually considered. See Video Abstract at http://links.lww.com/DCR/C137 . UNA DCADA DISMINUYENDO EL USO DE ESTOMAS DISFUNCIONANTES EN LOS CASOS DE CNCER DE RECTO EN HOLANDA ESTAMOS HACIENDO LO CORRECTO ANTECEDENTES:Aún se debate el efecto benéfico de la confección de un estoma disfuncionante para limitar las consecuencias de la fuga anastomótica en los casos de cirugía por cáncer de recto.OBJETIVO:Reflexiones sobre una década de cirugía por cáncer de recto en términos de confección de estomas y de fugas anastomóticas.DISEÑO:Estudio retrospectivo y observacional.AJUSTE:El presente estudio utilizó datos de la Auditoría Colorectal Holandesa entre 2011 y 2020.PACIENTES:Todos aquellos intervenidos por cáncer de recto con anastomosis primaria.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la fuga anastomótica. Los resultados secundarios fueron las complicaciones menores, la permanencia en cuidados intensivos, la duración de la hospitalización, las rehospitalizaciones y las causas de muerte en los pacientes.RESULTADOS:Un total de 13.263 pacientes fueron incluidos en el presente estudio. Se confeccionó un estoma disfuncionante en 7.106 (53,6%) pacientes. Aquellos portadores de un estoma disfuncionante tenían menos probabilidades de desarrollar una fuga anastomótica (7,9 % frente a 13,0 %) y, si ocurría una fuga anastomótica, menos pacientes necesitaban reintervención quirúrgica (37,7 % frente a 81,1 %). Se observó una disminución anual en la confección de un estoma disfuncionante (69,8 % en 2011 frente a 51,8 % en 2015 frente a 29,7 % en 2020), acompañada de un aumento del 5 % en la fuga anastomótica (9,1 % en 2011 frente a 14,1 % en 2020). Un estoma disfuncionante se asoció con una mayor incidencia de complicaciones menores, permanencia en la unidad de cuidados intensivos, una estadía más prolongada y más rehospitalizaciones dentro de los 90 días.LIMITACIÓN:Estudio retrospectivo susceptible de factores de confusión según las indicaciones, donde podrían no haber sido considerados ciertos factores de riesgo con relación a la fuga anastomótica y a la confección de un estoma disfuncionante.CONCLUSIÓN:La reducción de estomas disfuncionantes es paralela con el aumento de la fuga anastomótica. Sin embargo, los pacientes con un estoma disfuncionante también mostraron más complicaciones menores, una estadía prolongada, más admisiones a cuidados intensivos y más rehospitalizaciones. En nuestra opinión, las ventajas y desventajas del uso selectivo de estomas disfuncionantes deben ser consideradas caso por caso. Consulte Video Resumen en https://links.lww.com/DCR/C137 . (Traducción-Dr. Xavier Delgadillo ).
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Affiliation(s)
- Erik W Ingwersen
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Paulien J K van der Beek
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jan Willem T Dekker
- Department of Gastrointestinal Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Susan van Dieren
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
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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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Liu C, Zhang J, Li L, Zhang L, Shang L, Ma Y. Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study. Langenbecks Arch Surg 2023; 408:151. [PMID: 37055576 PMCID: PMC10102083 DOI: 10.1007/s00423-023-02886-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Protective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision. METHODS A retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured. RESULTS Univariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure. CONCLUSION Compared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.
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Affiliation(s)
- Chao Liu
- Department of Laser Cosmetic Clinic, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jizhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Li Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Liang Shang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Yan Ma
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
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Barnard J, Milne T, Teo K, Weston M, Israel L, Peng SL. Causes and costs of delayed closure of ileostomies in rectal cancer patients in Australasian units. ANZ J Surg 2023; 93:636-642. [PMID: 36203387 DOI: 10.1111/ans.18092] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Defunctioning loop ileostomies (DLIs) are a frequent adjunct to rectal cancer surgery. Delayed closure of DLIs is common and associated with increased morbidity. The reasons for delayed DLI closure are often unknown. The economic burden of delayed DLI closure is not quantified. The present study aimed to determine the reasons for, and economic burden of, delayed DLI closure. METHODS Clinical and economic data were audited from a prospective database of patients in two Australasian colorectal cancer centres. Patients treated at each unit with low/ultra-low anterior resection for rectal cancer with formation of DLI between January 2014 and December 2019 were included. Post-operative complication rate, stoma-related complication rate and costs of hospital admissions and stoma care were recorded and analysed. Multivariate linear regression analysis was used to investigate risk factors for delay to closure. RESULTS 146 patients underwent low/ultra-low anterior resection with DLI; 135 patients (92.5%) underwent reversal. The median duration to reversal was 7 months (IQR 4.5-9.5). Sixty-six percent of patients underwent reversal >6 months after their index surgery. Neoadjuvant and adjuvant chemotherapy were associated with delayed reversal (P < 0.001). Non-English speakers waited longer for DLI closure (P = 0.028). The costs of outpatient stoma care (P < 0.001), post-operative care (P = 0.004), and total cost of treatment (P = 0.014) were significantly higher in the delayed closure group, with a total cost of treatment difference of $3854 NZD per patient. CONCLUSIONS Causes of delay include systemic factors and demographic factors that can be addressed directly, addressing such causes may alleviate a significant economic burden.
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Affiliation(s)
- Jon Barnard
- Coloreectal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tony Milne
- General Surgery, Nelson Hospital, Nelson, New Zealand
| | - Keith Teo
- General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Maree Weston
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Lincoln Israel
- General Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Sze-Lin Peng
- General Surgery, Middlemore Hospital, Auckland, New Zealand
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Xu W, Wells CI, McGuinness M, Varghese C, Keane C, Liu C, O'Grady G, Bissett IP, Harmston C. Characterising nationwide reasons for unplanned hospital readmission after colorectal cancer surgery. Colorectal Dis 2023; 25:861-871. [PMID: 36587285 DOI: 10.1111/codi.16467] [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: 09/20/2022] [Revised: 11/10/2022] [Accepted: 11/27/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Readmissions after colorectal cancer surgery are common, despite advancements in surgical care, and have a significant impact on both individual patients and overall healthcare costs. The aim of this study was to determine the 30-and 90 days readmission rate after colorectal cancer surgery, and to investigate the risk factors and clinical reasons for unplanned readmissions. METHOD A multicenter, population-based study including all patients discharged after index colorectal cancer resection from 2010 to 2020 in Aotearoa New Zealand (AoNZ) was completed. The Ministry of Health National Minimum Dataset was used. Rates of readmission at 30 days and 90 days were calculated. Mixed-effect logistic regression models were built to investigate factors associated with unplanned readmission. Reasons for readmission were described. RESULTS Data were obtained on 16,885 patients. Unplanned 30-day and 90-day hospital readmission rates were 15.1% and 23.7% respectively. The main readmission risk factors were comorbidities, advanced disease, and postoperative complications. Hospital level variation was not present. Despite risk adjustment, R2 value of models was low (30 days: 4.3%, 90 days: 5.2%). The most common reasons for readmission were gastrointestinal causes (32.1%) and wound complications (14.4%). Rates of readmission did not improve over the 11 years study period (p = 0.876). CONCLUSION Readmissions following colorectal resections in AoNZ are higher than other comparable healthcare systems and rates have remained constant over time. While patient comorbidities and postoperative complications are associated with readmission, the explanatory value of these variables is poor. To reduce unplanned readmissions, efforts should be focused on prevention and early detection of post-discharge complications.
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Affiliation(s)
- William Xu
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of General Surgery, Counties Manukau District Health Board, Auckland, New Zealand
| | - Matthew McGuinness
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Northland District Health Board, Whangarei, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Northland District Health Board, Whangarei, New Zealand
| | - Chen Liu
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Christopher Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Northland District Health Board, Whangarei, New Zealand
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Bak M, Jaffry K, Tan PY. A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report. Int J Surg Case Rep 2022; 101:107814. [PMID: 36462234 PMCID: PMC9712665 DOI: 10.1016/j.ijscr.2022.107814] [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: 10/29/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review. CASE PRESENTATION A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology. DISCUSSION Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging. CONCLUSION Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.
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Affiliation(s)
- Marek Bak
- Department of General Surgery, Monash Health, Melbourne, Victoria, Australia,Corresponding author at: Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.
| | - Kumail Jaffry
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Pee Yau Tan
- Department of General Surgery, Monash Health, Melbourne, Victoria, Australia
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Jiang WZ, Xu JM, Xing JD, Qiu HZ, Wang ZQ, Kang L, Deng HJ, Chen WP, Zhang QT, Du XH, Yang CK, Guo YC, Zhong M, Ye K, You J, Xu DB, Li XX, Xiong ZG, Tao KX, Ding KF, Zang WD, Feng Y, Pan ZZ, Wu AW, Huang F, Huang Y, Wei Y, Su XQ, Chi P. Short-term Outcomes of Laparoscopy-Assisted vs Open Surgery for Patients With Low Rectal Cancer: The LASRE Randomized Clinical Trial. JAMA Oncol 2022; 8:2796439. [PMID: 36107416 PMCID: PMC9478880 DOI: 10.1001/jamaoncol.2022.4079] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/18/2022] [Indexed: 08/12/2023]
Abstract
Importance The efficacy of laparoscopic vs open surgery for patients with low rectal cancer has not been established. Objective To compare the short-term efficacy of laparoscopic surgery vs open surgery for treatment of low rectal cancer. Design, Setting, and Participants This multicenter, noninferiority randomized clinical trial was conducted in 22 tertiary hospitals across China. Patients scheduled for curative-intent resection of low rectal cancer were randomized at a 2:1 ratio to undergo laparoscopic or open surgery. Between November 2013 and June 2018, 1070 patients were randomized to laparoscopic (n = 712) or open (n = 358) surgery. The planned follow-up was 5 years. Data analysis was performed from April 2021 to March 2022. Interventions Eligible patients were randomized to receive either laparoscopic or open surgery. Main Outcomes and Measures The short-term outcomes included pathologic outcomes, surgical outcomes, postoperative recovery, and 30-day postoperative complications and mortality. Results A total of 1039 patients (685 in laparoscopic and 354 in open surgery) were included in the modified intention-to-treat analysis (median [range] age, 57 [20-75] years; 620 men [59.7%]; clinical TNM stage II/III disease in 659 patients). The rate of complete mesorectal excision was 85.3% (521 of 685) in the laparoscopic group vs 85.8% (266 of 354) in the open group (difference, -0.5%; 95% CI, -5.1% to 4.5%; P = .78). The rate of negative circumferential and distal resection margins was 98.2% (673 of 685) vs 99.7% (353 of 354) (difference, -1.5%; 95% CI, -2.8% to 0.0%; P = .09) and 99.4% (681 of 685) vs 100% (354 of 354) (difference, -0.6%; 95% CI, -1.5% to 0.5%; P = .36), respectively. The median number of retrieved lymph nodes was 13.0 vs 12.0 (difference, 1.0; 95% CI, 0.1-1.9; P = .39). The laparoscopic group had a higher rate of sphincter preservation (491 of 685 [71.7%] vs 230 of 354 [65.0%]; difference, 6.7%; 95% CI, 0.8%-12.8%; P = .03) and shorter duration of hospitalization (8.0 vs 9.0 days; difference, -1.0; 95% CI, -1.7 to -0.3; P = .008). There was no significant difference in postoperative complications rate between the 2 groups (89 of 685 [13.0%] vs 61 of 354 [17.2%]; difference, -4.2%; 95% CI, -9.1% to -0.3%; P = .07). No patient died within 30 days. Conclusions and Relevance In this randomized clinical trial of patients with low rectal cancer, laparoscopic surgery performed by experienced surgeons was shown to provide pathologic outcomes comparable to open surgery, with a higher sphincter preservation rate and favorable postoperative recovery. Trial Registration ClinicalTrials.gov Identifier: NCT01899547.
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Affiliation(s)
- Wei-Zhong Jiang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian-Min Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jia-Di Xing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Hui-Zhong Qiu
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zi-Qiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hai-Jun Deng
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Ping Chen
- Department of Colorectal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences & Zhejiang Cancer Hospital, Hangzhou, China
| | - Qing-Tong Zhang
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Xiao-Hui Du
- Department of General Surgery, General Hospital of PLA, Beijing, China
| | - Chun-Kang Yang
- Department of Gastrointestinal Oncological Surgery, Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Yin-Cong Guo
- Department of Colorectal & Anal Surgery, Zhangzhou Affiliated Hospital, Fujian Medical University, Zhangzhou, China
| | - Ming Zhong
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Ye
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Jun You
- Department of Gastrointestinal Oncological Surgery, The First Affiliated Hospital, Xiamen University, Xiamen, China
| | - Dong-Bo Xu
- Department of Colorectal & Anal Surgery, Longyan Affiliated Hospital, Fujian Medical University, Longyan, China
| | - Xin-Xiang Li
- Department of Colorectal Surgery, Fudan University Cancer Center, Shanghai, China
| | - Zhi-Guo Xiong
- Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China
| | - Kai-Xiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke-Feng Ding
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei-Dong Zang
- Department of Gastrointestinal Oncological Surgery, Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Yong Feng
- Department of Colorectal Oncological Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - Zhi-Zhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ai-Wen Wu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Feng Huang
- Department of Gastrointestinal Oncological Surgery, Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiang-Qian Su
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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9
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Rouanet P, Selvy M, Jarlier M, Bugnon C, Carrier G, Mourregot A, Colombo PE, Taoum C. Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort. Ann Surg Oncol 2022; 29:2514-2524. [PMID: 34994889 DOI: 10.1245/s10434-021-11197-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA). METHODS In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded. RESULTS Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p = 0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p = 0.064), disease-free survival was 67.0% and 55.8%, respectively (p = 0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p = 0.084). The long-term, stoma-free rate was 89.1% overall. CONCLUSIONS Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.
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Affiliation(s)
- Philippe Rouanet
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France.
| | - Marie Selvy
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Marta Jarlier
- Biometrics Unit, Montpellier Cancer Institute, Montpellier, France
| | - Caroline Bugnon
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Guillaume Carrier
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Anne Mourregot
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | | | - Christophe Taoum
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
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10
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Cerdán-Santacruz C, Vailati BB, São Julião GP, Habr-Gama A, Pérez RO. Watch and wait: Why, to whom and how. Surg Oncol 2022; 43:101774. [DOI: 10.1016/j.suronc.2022.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/26/2022]
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11
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Clark DA, Stevenson A, Lumley J, Petersen D, Harris C, Steffens D, Solomon M. Does an ileostomy cover the surgeon or the anastomosis? ANZ J Surg 2022; 92:19-20. [PMID: 35212109 DOI: 10.1111/ans.17364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 12/12/2022]
Affiliation(s)
- David A Clark
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, University of Queensland, Brisbane, Queensland, Australia.,Department of Surgery, St Vincent's Private Hospital Northside, Brisbane, Queensland, Australia
| | - Andrew Stevenson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, University of Queensland, Brisbane, Queensland, Australia.,Department of Surgery, St Vincent's Private Hospital Northside, Brisbane, Queensland, Australia
| | - John Lumley
- Department of Surgery, The Wesley Private Hospital, Brisbane, Queensland, Australia
| | - Damien Petersen
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Craig Harris
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Daniel Steffens
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
| | - Michael Solomon
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
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12
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13
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Higashijima J, Kono T, Shimada M, Sugitani A, Kashihara H, Takasu C, Nishi M, Tokunaga T, Yoshikawa K. High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection. Front Surg 2021; 8:756873. [PMID: 34966775 PMCID: PMC8710543 DOI: 10.3389/fsurg.2021.756873] [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: 08/11/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR). Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis. Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation. Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.
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Affiliation(s)
- Jun Higashijima
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Toru Kono
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan.,Center for Clinical and Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.,Advanced Surgery Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Mitsuo Shimada
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Ayumu Sugitani
- Center for Clinical and Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Hideya Kashihara
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Chie Takasu
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Masaaki Nishi
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Takuya Tokunaga
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
| | - Kozo Yoshikawa
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, The University of Tokushima, Tokushima, Japan
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