Fecal Volume after Laparoscopic Low Anterior Resection Predicts Anastomotic Leakage

Clinical Impact of Transanal Drainage Tube on Anastomosis Leakage Following Minimally Invasive Resection Without Diverting Stoma in Patients With Rectal Cancer: A Propensity Score-matched Analysis

OBJECTIVES

As one of the most serious complications of rectal cancer (RC) surgery, preventing anastomotic leakage (AL) is crucial. Several studies have suggested a positive role of the transanal drainage tube (TaDT) in AL prevention. However, whether TaDT is beneficial for AL in patients with RC remains controversial. The present study aimed to evaluate the clinical impact of TaDT on AL following minimally invasive resection without diverting stoma (DS) in patients with RC.

MATERIALS AND METHODS

We retrospectively analyzed 392 consecutive patients with RC who had undergone minimally invasive resection without DS between 2010 and 2021. Propensity score matching (PSM) was performed to reduce selection bias. AL was classified as grade A, B, or C.

RESULTS

A TaDT was used in 214 patients overall. After PSM, we enrolled 316 patients (n=158 in each group). Before PSM, significant group-dependent differences were observed in terms of age, American Society of Anesthesiologists physical status, and the use of antiplatelet/anticoagulant agents. The frequency of AL was 7.3% in the overall cohort and was significantly lower in the TaDT group (3.7%) than in the non-TaDT group (11.8%). The rate of grade B AL was significantly lower in the TaDT group than in the non-TaDT group (before PSM, P <0.01; after PSM, P =0.02). However, no significant differences between groups were found for grade C AL. Moreover, multivariate analysis identified the lack of a TaDT as an independent risk factor for AL in the overall and matched cohorts [before PSM, odds ratio, 3.64, P <0.01; after PSM, odds ratio, 2.91, P =0.02].

CONCLUSION

These results indicated that TaDT may play a beneficial role in preventing AL, particularly of grade B, for patients with RC undergoing minimally invasive resection without DS. However, further randomized controlled trials, including patient-reported outcomes, are still needed to understand better the role of TaDT in preventing ALs in patients with RC undergoing minimally invasive resection without DS.

Significance of information obtained during transanal drainage tube placement after anterior resection of colorectal cancer

Introduction

It has recently been reported that the placement of a transanal drainage tube after rectal cancer surgery reduces the rate of anastomotic leakage. However, transanal drainage tube cannot completely prevent anastomotic leakage and the management of transanal drainage tube needs to devise. We investigated the information obtained during transanal drainage tube placement and evaluated the relationship between these factors and anastomotic leakage.

Patients and methods

Fifty-one patients who underwent anterior resection of rectal cancer was retrospectively reviewed. transanal drainage tube was placed for more than 5 days after surgery. The daily fecal volume from transanal drainage tube was measured on postoperative day 1–5, and the defecation during transanal drainage tube placement was investigated.

Results

Anastomotic leakage during transanal drainage tube placement occurred in 4 patients. The anastomotic leakage rate during transanal drainage tube placement in patients whose maximum daily fecal volume or total fecal volume from the transanal drainage tube during postoperative days 1–5 was large was significantly higher than that in patients whose fecal volume was small. The anastomotic leakage rate of the patients with intentional defecation during transanal drainage tube placement was significantly higher than that of the patients without intentional defecation during transanal drainage tube placement. The maximum daily fecal volume and the total fecal volume from the transanal drainage tube during postoperative days 1–5 in patients who experienced intentional defecation during transanal drainage tube placement was significantly higher than that of patients without intentional defecation during transanal drainage tube placement.

Conclusion

A large fecal volume from transanal drainage tube after anterior rectal resection or intentional defecation in patients with transanal drainage tube placement were suggested to be risk factors for anastomotic leakage.

Oral antibiotics and a low-residue diet reduce the incidence of anastomotic leakage after left-sided colorectal surgery: a retrospective cohort study

PURPOSE

Anastomotic leakage is a potential complication after colorectal surgery. We investigated the effects of oral antibiotics and a low-residue diet on the incidence of anastomotic leakage after left-sided colorectal surgery.

METHODS

Outcomes were retrospectively compared between 64 patients who underwent mechanical bowel preparation alone (group A) and 183 patients who underwent mechanical bowel preparation with addition of oral kanamycin and metronidazole (group B) on the day before left-sided colorectal surgery. After surgery, patients in group A received a normal diet containing dietary fiber and those in group B received a low-residue diet. The primary outcome was the incidence of anastomotic leakage. Secondary outcomes were rates of other postoperative complications, length of postoperative hospital stay, and laboratory data.

RESULTS

Anastomotic leakage, surgical site infection, and diarrhea were less common in group B than in group A (4.9% vs 18.8%, 6.6% vs 23.4%, and 25.7% vs 43.8%, respectively). Postoperative C-reactive protein levels were significantly lower in group B. The median postoperative hospital stay was significantly shorter in group B than in group A (8 days vs 9 days, P = 0.010). Adaptive double least absolute shrinkage and selection operator regression revealed that use of preoperative oral antibiotics and a postoperative low-residue diet were associated with lower incidence of anastomotic leakage (odds ratio 0.163, 95% confidence interval 0.062-0.430; P < 0.001).

CONCLUSION

Oral antibiotics and a low-residue diet reduced the incidence of anastomotic leakage and shortened the postoperative hospital stay by 1 day.

Correlation between Colon Perfusion and Postoperative Fecal Output through a Transanal Drainage Tube during Laparoscopic Low Anterior Resection

In order to prevent anastomotic leakage (AL) following rectal surgery, various solutions—such as intraoperative indocyanine green (ICG) angiography and transanal drainage tubes (TDT)—have been proposed. This study investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection (LAR). A total of 59 rectal cancer patients who underwent laparoscopic LAR with both intraoperative ICG angiography and postoperative TDT placement were retrospectively analyzed. The relationship between intestinal perfusion and fecal volume through TDT was examined. Based on the ICG fluorescence, the transection site was shifted more proximally in 20 cases (33.9%). Symptomatic AL occurred in seven patients (11.8%). The AL rate of the patients whose daily fecal volume exceeded 100 mL/day in 2 or more days was significantly higher than that of those whose daily fecal volume exceeded it in 0 or 1 day (44.4% vs. 6.0%; p < 0.01). Univariate and multivariate analyses showed that the need for a proximal shift of the transection site was significantly associated with a high fecal volume. The quantitative analysis of ICG fluorescence indicated that Fmax (the fluorescence difference between the baseline and maximum) was significantly associated with fecal volume through TDT.

The effects of preoperative intestinal dysbacteriosis on postoperative recovery in colorectal cancer surgery: a prospective cohort study

Background

Accumulating evidence suggests a critical role of intestinal dysbacteriosis in surgical site infections and anastomotic leakage after abdominal surgery. However, a direct correlation between pre-existing dysbacteriosis and postoperative infectious complications has not yet been established clinically.

Methods

A total of 353 consecutive patients who underwent colorectal cancer (CRC) surgery were enrolled. Gram-stained faecal smears were tested at admission and the first defecation after surgery. Intestinal dysbacteriosis was graded into three groups: normal or slightly decreased intestinal microflora (grade 1), moderate dysbacteriosis (grade 2), and severe dysbacteriosis (grade 3). Clinical outcomes were postoperative infections and anastomotic leakage within 30 days after surgery.

Results

At the preoperative assessment, 268 (75.9%) patients had normal or slightly decreased intestinal microflora, 58 (16.4%) patients had moderate dysbacteriosis, and 27 (7.6%) patients had severe dysbacteriosis. The patients with preoperative dysbacteriosis had a higher rate of early postoperative diarrhoea (grade 2: OR = 4.53, 95% CI 2.28–9.00, grade 3: OR = 4.52, 95% CI 1.81–11.31), total complications (grade 3 40.7% vs. grade 2 25.9% vs. grade 1 12.7%, P < 0.001), and anastomotic leakage (grade 3 11.1% vs. grade 2 5.2% vs. grade 1 1.5%, P = 0.002). An interaction effect among preoperative dysbacteriosis and early postoperative diarrhoea on total complications was observed in rectal cancer patients (P for interaction = 0.007).

Conclusions

An imbalance of the intestinal microbiome exists in a considerable proportion of CRC patients before surgery. Preoperative dysbacteriosis is associated with higher rates of early postoperative diarrhoea, which further correlates with infectious complications and anastomotic leakage. However, the contribution of preoperative dysbacteriosis to the occurrence of anastomotic leakage needs to be clarified in further studies.

Trial registration ChiCTR, ChiCTR1800018755. Registered 8 October 2018—Retrospectively registered, http://www.chictr.org.cn/ChiCTR1800018755.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-02035-6.

Retrospective Risk Analysis for Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery in a Single Institute

PURPOSE

Anastomotic leakage (AL) is one of the most serious complications after laparoscopic low anterior resection (LALAR) for rectal cancer. The aim of the present study was to investigate the risk factors for AL after LALAR.

METHODS

A retrospective study was conducted of 103 patients who underwent LALAR in a single institute between October 2008 and January 2018. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with AL.

RESULTS

The overall incidence of AL was 9.7% (10/103). After anastomosis using the double-stapling technique, a transanal tube was placed in 88 patients (85.4%). A diverting stoma was created in 26 patients (25.2%). The univariate analysis showed that a younger age (P = 0.014), higher stage (P = 0.048), deeper depth of tumor invasion (P = 0.028), larger tumor circumference (P = 0.024), longer operation time (P = 0.015), and early postoperative diarrhea (P = 0.002) were associated with AL. The multivariate logistic regression analysis revealed early postoperative diarrhea (odds ratio [OR] 16.513, 95% confidence interval [CI] 2.393-113.971, P = 0.004) a younger age (10-year increments; OR 0.351, 95% CI 0.147-0.839, P = 0.019), operative time (10-min increments; OR 1.089, 95% CI 1.012-1.172, P = 0.022), and higher stage (OR 10.605, 95% CI 1.279-87.919, P = 0.029) were independent risk factors for AL CONCLUSION: Our findings suggest that tumor progression accompanied by a high stage, long operative time, and insufficient bowel preparation and early postoperative diarrhea due to a large tumor circumference may be risk factors of AL after LALAR for rectal cancer.

Laparoscopic anterior resection with or without transanal tube for rectal cancer patients - A multicenter randomized controlled trial

BACKGROUND

In rectal cancer surgery, insertion of transanal tube has been shown to have efficacy to prevent anastomotic leakage. This randomized controlled study aims to clarify the incidence of anastomotic leakage with or without transanal tube in patients with rectal cancer.

METHODS

Patients who underwent elective low anterior resection were randomly allocated to either have transanal tube insertion or not for five days after surgery. We examined the incidence of anastomotic leakage, postoperative 30-day morbidity and mortality.

RESULTS

157 patients were randomized to the transanal tube group or the no-transanal tube group. Symptomatic anastomotic leakage occurred in six patients (7.6%) of the former group and eight patients (10.3%) in the latter group, without significant difference (p = 0.559). There was also no significant difference in morbidity between groups (p = 0.633) and no mortality was detected.

CONCLUSIONS

Transanal tube insertion had no significant benefit towards prevention of anastomotic leakage in rectal cancer surgery.

Impact of transanal drainage tube on anastomotic leakage after laparoscopic low anterior resection

BACKGROUND

Although a few reports have suggested transanal drainage tube (TDT) can reduce the pressure in the anastomotic portion, it remains unclear whether TDT can prevent anastomotic leakage (AL). In addition, little is known about the relationship between AL and daily fecal volume through TDT. This study investigated the role of TDT for the prevention of AL following laparoscopic low anterior resection (LAR).

METHODS

This is a retrospective analysis of a prospectively maintained database of 201 rectal cancer patients who underwent laparoscopic LAR. The relationship between AL and daily fecal volume through TDT was examined.

RESULTS

AL occurred in 25 patients. Based on the TDT grouping, AL occurred in 10.7% (19/178) of the TDT group, whereas it occurred in 26.1% (6/23) of the non-TDT group (P = 0.046). In the 178 patients with TDT placement, the daily fecal volumes on postoperative days (PODs) 2-5 were significantly higher compared with those on POD 1 (P < 0.05). The daily fecal volume was observed to be gradually increasing until POD 3 or 4 (median, 25 or 23 ml/day, respectively) and then significantly decreasing on POD 5 (10 ml/day) (P < 0.05). The AL rate of the patients whose daily fecal volume exceeded 100 ml/day in two or more days was significantly higher than that of those in 0 or 1 day (26.9 vs. 7.9%; P < 0.01).

CONCLUSIONS

TDT could be efficient to prevent AL following laparoscopic LAR. Postoperative fecal volume may be a reliable predictor of AL.