Mitigating the Consequences of Anastomotic Leakage After Laparoscopic Rectal Cancer Resection

Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients

OBJECTIVE

To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes.

METHODS

A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared.

RESULTS

For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05).

CONCLUSION

Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.

Prediction model of anastomotic leakage after anterior resection for rectal cancer-based on nomogram and multivariate analysis with 1995 patients

BACKGROUND

Postoperative anastomotic leakage for rectal cancer shows higher morbidity with grievous concomitant symptoms. Accurate assessment of the incidence of anastomotic leakage, multivariate analysis, and establishment of a scientific prediction model can be useful to dispose of its possible severe clinical consequences.

METHODS

This retrospective study collected 1995 consecutive patients who underwent anterior resection of rectal cancer with primary anastomosis at Northern Jiangsu People's Hospital between January 2016 and June 2022. Independent risk factors associated with anastomotic leakage were analyzed by univariate and multivariate logistic regression. The chosen independent risk factors were used to construct a nomogram risk prediction model whose availability was evaluated by using a bootstrapped-concordance index and calibration plots with R software.

RESULTS

A total of 1995 patients who underwent anterior resection for rectal cancer were included while 120 patients were diagnosed with anastomotic leakage, an incidence of 6.0%. Univariate analysis and its concomitant multivariate cox regression analysis indicated that independent risk factors associated with anastomotic leakage included male gender (odds ratio (OR) = 2.873), diabetes (OR = 2.480), neoadjuvant therapy (OR = 5.283), tumor's distance from the anus verge < 5 cm (OR = 5.824), tumor size ≥ 5 cm (OR = 4.888), and the blood lose > 50 mL (OR = 9.606).We established a nomogram prediction model with proper applicability (concordance index, 0.83) and the calibration curve to justify its predictive ability that the predicted occurrence probability keeps a high degree of consistency with the actual occurrence probability. Meanwhile, the area under the receiver operating characteristic (ROC) curve was 0.83.

CONCLUSIONS

The characteristics of patients and tumor surgery-related conditions can affect the incidence of anastomotic leakage. However, whether the surgical method will affect morbidity is still controversial. Our nomogram can be seen as an effective instrument to predict anastomotic leakage after anterior resection for rectal cancer precisely.

Analysis of Risk Factors for Anastomotic Leakage After Laparoscopic Anterior Resection of Rectal Cancer and Construction of a Nomogram Prediction Model

Objective

To explore the risk factors of anastomotic leakage (AL) after laparoscopic anterior resection (AR) of rectal cancer and establish a nomogram prediction model.

Methods

Clinical and surgical data of patients who underwent AR of rectal cancer at Sichuan Cancer Hospital from January 2017 to December 2020 were retrospectively collected. Univariate and multivariate logistic regression analyses were used to screen the independent risk factors of AL after AR. A nomogram risk prediction model was established based on the selected independent risk factors and the predictive performance of nomogram was evaluated.

Results

A 1013 patients undergoing laparoscopic AR were included, of which 67 had AL, with an incidence of 6.6%. Univariate and multivariate logistic regression analyses showed that male gender, tumors distance from the anus verge of ≤ 5cm, tumors distance from the anus verge of 5–10cm, circumferential tumor growth, operation time ≥ 240min, and no diverting stoma were independent risk factors for AL after AR. A nomogram prediction model was established based on these results. The calibration curve showed that the predicted occurrence probability of the nomogram model was in good agreement with the actual occurrence probability. The area under the receiver operating characteristic (ROC) curve was 0.749.

Conclusion

The nomogram prediction model based on the independent risk factors of patients undergoing AL after AR can effectively predict the probability of AL.

The impact of transanal tube design for preventing anastomotic leak in anterior resection: a systematic review and meta-analysis

BACKGROUND

Placement of a transanal tube (TAT) into the rectum is a strategy used to attempt to prevent anastomotic leak (AL) in anterior resection surgery. There is a wide variation in materials and tube design in devices used as TATs and previous meta-analyses have not considered TAT design in their analyses. This study reviews the impact that design of TAT has on AL rates.

METHODS

A systematic review of the literature was performed with the aim of identifying studies evaluating the use of TATs for preventing AL and then defining the design of TATs. Studies were then compared in groups based on TAT design in a meta-analysis to evaluate whether design is an important variable in outcomes.

RESULTS

Thirty-three studies were included. There was a wide variety of tubes used as TATs. On meta-analysis, catheter-type TATs were associated with a substantially lower rate of AL (OR: 0.46; 95% CI 0.30, 0.68). By contrast, stent-type TATs were not associated with any reduction in the incidence of AL (OR: 1.06, 95% CI 0.50, 2.22). Catheter-type TATs were also associated with substantial reductions in the rate of reoperation (OR: 0.32; 95% CI 0.20, 0.50), whereas stent-type TATs showed no benefit in the rate of reoperation (OR: 0.79; 95% CI 0.37, 1.65).

CONCLUSIONS

Off-the-shelf catheter-type transanal tubes appeared effective in preventing AL, whereas custom-designed stent-type TATs were not demonstrated to be effective; although high quality evidence is limited. TAT design should be an important consideration in further research of the use of TATs in anterior resection surgery.

Prediction model for anastomotic leakage after laparoscopic rectal cancer resection

Objective

This study was performed to identify risk factors for anastomotic leakage (AL) and combine these factors to create a prediction model for the risk of AL after laparoscopic rectal cancer resection.

Methods

This retrospective study involved 185 patients with rectal cancer who underwent laparoscopic resection from March 2012 to February 2017. Five risk factors were analyzed by multivariate analysis. A prediction model was established by combining the risk factors from the multivariate analysis, and the accuracy of the model was evaluated by a receiver operating characteristic curve.

Results

The overall AL rate was 17.84%. The multivariate analysis identified the following independent risk factors for AL: high body mass index (odds ratio [OR], 3.009; 95% confidence interval [CI], 1.127–7.125), preoperative radiochemotherapy (OR, 3.778; 95% CI, 1.168–12.219), larger tumor size (OR, 2.710; 95% CI, 1.119–6.562), and longer surgical time (OR, 2.476; 95% CI, 1.033–5.932). We established a prediction model that can evaluate the risk of AL by determining the predictive probability. The area under the curve for the model’s predictive performance was 0.70 (95% CI, 0.598–0.795).

Conclusion

A prediction model was created to predict the risk of AL after laparoscopic rectal cancer resection.

Early Versus Routine Stoma Closure in Patients With Colorectal Resection: A Meta-Analysis of 7 Randomized Controlled Trials

Background. A substantial proportion of patients undergoing colorectal surgery receive a temporary stoma, and the timing for stoma closure remains unclear. The aim of this study was to evaluate the safety and feasibility of early stoma closure (ESC) compared with routine stoma closure (RSC) after colorectal surgery. Methods. We comprehensively searched PubMed, Embase, and the Cochrane Library for randomized controlled trials that compared ESC and RSC after colorectal surgery. Results. A total of 7 randomized controlled trials with 814 enrolled patients were identified for this meta-analysis. There were no significant differences between the ESC and RSC groups regarding the complications of stoma closure (26.8% and 16.6%, respectively; odds ratio [OR]: 1.30; 95% confidence interval [CI]: 0.89-1.90; P = .17). A subgroup analysis was conducted by Clavien-Dindo grade of complication, and no significant difference was observed in any subgroup ( P > .05). However, the ESC group had a significantly higher risk of wound complications than the RSC group (17.6% and 7.8%, respectively; OR: 2.61; 95% CI: 1.43-4.76; P = .002), and the RSC group had more cases of small bowel obstruction than the ESC group (3.1% and 8.4%, respectively; OR: 0.37; 95% CI: 0.15-0.87; P = .02). Conclusions. ESC is a safe and effective therapeutic approach in patients who have undergone colorectal surgery; it is associated with a reduced risk of bowel obstruction but a higher risk of wound complications.

Preventive effect of diverting stoma on anastomotic leakage after laparoscopic low anterior resection with double stapling technique reconstruction applied based on risk stratification

INTRODUCTION

During laparoscopic low anterior resection with double stapling technique reconstruction, it is necessary to securely implement rectal transection and anastomosis to prevent anastomotic leakage (AL). However, risk factors and preventive measures for AL are not known sufficiently. Therefore, this study aimed to elucidate risk factors associated with AL and to clarify strategies to prevent it.

METHODS

We analyzed a total of 296 cases with rectal cancer who had undergone laparoscopic low anterior resection with double stapling technique reconstruction at the National Cancer Center Hospital East. The relationship between AL and patient, tumor, and treatment characteristics were retrospectively investigated.

RESULTS

There were 186 male and 110 female patients with a median age of 62. Overall, AL occurred in 24 cases (8.1%). Being a man, having an anal verge distance ≤7 cm, and undergoing neoadjuvant chemotherapy were associated with an elevated risk for AL (P = 0.0005, 0.0034, and 0.0222, respectively). Neither an anal drainage tube nor diverting stoma creation correlated with incidence of AL. Multivariate analysis demonstrated that being a man (odds ratio = 18.0; 95% confidence interval: 2.4-138) and having an anal verge distance ≤7 cm (odds ratio = 3.8; 95% confidence interval: 1.5-9.4) were significant risk factors. These two factors were present in 61 cases, including 14 who developed AL (23.0%). In this high-risk group, diverting stoma creation significantly reduced the occurrence of AL (P = 0.0363), but an anal drainage tube had no effect on incidence of AL (P = 0.3399).

CONCLUSION

We identified the high-risk population for AL after laparoscopic low anterior resection with double stapling technique reconstruction based on two factors. This will enable surgeons to appropriately recommend diverting stoma creation.

Comparative study between transanal tube and loop ileostomy in low anterior resection for mid rectal cancer: a retrospective single center trial

Purpose

To investigate the efficacy and safety of the transanal tube (TAT) in preventing anastomotic leak (AL) in rectal cancer surgery.

Methods

Clinical data of the patients who underwent curative surgery for mid rectal cancer from February 2010 to February 2014 were reviewed retrospectively. Rectal cancers arising 5 to 10 cm above the anal verge were selected. Patients were divided into the ileostomy, TAT, or no-protection groups. Postoperative complications including AL and postoperative course were compared.

Results

We included 137 patients: 67, 35, and 35 patients were included in the ileostomy, TAT, and no-protection groups, respectively. Operation time was longer in the ileostomy group (P = 0.029), and more estimated blood loss was observed (P = 0.018). AL occurred in 5 patients (7.5%) in the ileostomy group, 1 patients (2.9%) in the TAT group, and 6 patients (17.1%) in the no-protection group (P = 0.125). Patients in the ileostomy group resumed diet more than 1 day earlier than those in the other groups (P = 0.000). Patients in the no-protection group had about 1 or 2 days longer postoperative hospital stay (P = 0.048). The ileostomy group showed higher late complication rates than the other groups as complications associated with the stoma itself or repair operation developed (P = 0.019).

Conclusion

For mid rectal cancer surgery, the TAT supports anastomotic site protection and diverts ileostomy-related complications. Further large scale randomized controlled studies are needed to gain more evidence and expand the range of TAT usage.