Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis

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.

The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: A propensity score-matched study

BACKGROUND

The protective efficacy of transanal tube for anastomosis was compared with that of diverting stoma in patients with rectal cancer treated with neoadjuvant chemoradiotherapy.

METHODS

We included consecutive patients with rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery from January 2013 to December 2019. The patients were grouped into transanal tube or diverting stoma, according to the protection methods they received. Propensity score-matching with 1:1 ratio was done. The primary outcome was the incidence of anastomotic leakage.

RESULTS

Of the 656 eligible patients, 207 (31.6%) and 385 (58.7%) patients were grouped into transanal tube and diverting stoma, respectively, and 64 (9.7%) patients who did not undergo either transanal tube or diverting stoma were excluded. After matching, the incidence of anastomotic leakage was 9.7% and 10.6% in diverting stoma and transanal tube, respectively (P = .871). The overall morbidity was 23.2% and 15.0% in diverting stoma and transanal tube, respectively (P = .045). In the multivariate analysis, tumor size >2.5 cm and level of anastomosis <4 cm were significant risk factors for anastomotic leakage. In a subgroup analysis for patients with the level of anastomosis >4 cm, the incidence of anastomotic leakage was not significantly different between the transanal tube and diverting stoma groups. However, for patients with a level of anastomosis <4 cm, the incidence of grade C anastomotic leakage was significantly greater in the transanal tube than in the diverting stoma group (2.5% vs 9.9%, P = .040).

CONCLUSION

The protective efficacy of transanal tube may be comparable to diverting stoma, especially for those with a level of anastomosis >4 cm.

Impacts of trans‐anal tube placement in patients with sigmoid colon cancer: Risk verification analysis using inverse probability weighting analysis

Purpose

Anastomotic leakage (AL) is a serious postoperative complication that affects short- and long-term outcomes. The use of a trans-anal drainage tube (TDT) is reported to prevent AL in rectal cancer patients, but its value in sigmoid colon cancer patients is unknown.

Methods

Admitted to the study were 379 patients who underwent surgery for sigmoid colon cancer between 2016 and 2020. Patients were divided into two groups according to the placement (n = 197) or nonplacement of a TDT (n = 182). To determine the factors affecting the association between TDT placement and AL, we estimated average treatment effects by stratifying each factor using the inverse probability of treatment weighting method. The association between prognosis and AL was evaluated in each identified factor.

Results

Factors associated with postsurgical insertion of a TDT were advanced age, male sex, high body mass index (BMI), poor performance status, and presence of comorbidities. TDT placement was associated with a significantly lower AL in male patients (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.07-0.73; P = .013) and for BMI ≥ 25 kg/m² (OR, 0.13; 95% CI, 0.02-0.65; P = .013). In addition, there was a significant association of AL with poor prognosis in patients with BMI ≥ 25 kg/m² (P = .043), age > 75 y (P = .021), and pathological node-positive disease (P = .015).

Conclusion

Sigmoid colon cancer patients with BMI ≥ 25 kg/m² are the most appropriate candidates for postoperative TDT insertion, in terms of reduced incidence of AL and improved prognosis.

Postoperative colon perforation due to the tip of the transanal decompression tube after laparoscopic low anterior resection: A case report

A 66-year-old man underwent laparoscopic low anterior resection for rectal cancer. A transanal decompression tube (24Fr Nelaton catheter) was placed laparoscopically during the surgery. Contrast enema on postoperative day 5 showed perforation of the sigmoid colon around the tip of the tube, and emergency laparotomy was performed. Perforation of the posterior sigmoid colon located on the proximal side of the colorectal anastomosis at the level of the promontorium was identified. Closure of the perforation site, lavage drainage, and a diverting loop ileostomy were performed. Although a transanal decompression tube is useful in preventing anastomotic leakage, tube-related colon perforation should be noted, and controversies about the safety of laparoscopically transanal decompression tube placement should be resolved. Adequate management for tube placement should be discussed.

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.

Role of transanal drainage tubes in preventing anastomotic leakage after low anterior resection: a meta-analysis of randomized controlled trials

BACKGROUND

The transanal drainage tube (TDT) is thought to reduce the incidence of anastomotic leakage (AL) in patients with low anterior resection (LAR). However, results from different clinical trials are inconsistent, although nearly all meta-analyses agree on the efficacy. In contrast to results of many previous studies, 2 recent independent randomized controlled trials (RCTs) suggest that the use of TDT does not prevent AL. We performed a meta-analysis including only RCTs to compare patients with TDTs vs. those without TDTs in terms of AL rate.

METHODS

A systematic literature search was performed in the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov and WHO/ICTRP from inception until February 14, 2022. RCTs that evaluated the role of TDTs in AL prevention in patients who underwent LAR for rectal cancer were included. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by two authors independently, and random-effects models were implemented. The main outcome was AL, and the secondary outcome was the grade of AL.

RESULTS

Three RCTs were included involving a total of 1115 participants (559 patients in the TDT group and 556 in the non-TDT group). No significant difference in the AL rate was detected (RR = 0.69, 95% confidence interval (CI) 0.42-1.15, p = 0.15, I² = 21%, very low certainty evidence). The incidence of grade C AL was possibly lower in the TDT group (RR = 0.33, 95% CI 0.11-1.01, p = 0.05, very low certainty evidence), while the rate of grade B AL was similar between the two groups (RR = 1.17, 95% CI 0.66-2.08, p = 0.59, very low certainty evidence).

CONCLUSIONS

The present meta-analysis suggests that TDTs are not effective in reducing the overall incidence of AL, but possibly have a potential benefit in reducing the occurrence of grade C AL in patients with LAR. Based on the current limited data and existing heterogeneity, the inclusion of larger populations and the identification of more uniform indications for TDT need to be addressed in future studies.

Effect of the transanal drainage tube on preventing anastomotic leakage after laparoscopic surgery for rectal cancer: a systematic review and meta-analysis

PURPOSE

Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, and transanal drainage tube (TDT) efficacy is still contentious. This study aimed to evaluate the TDT effect on AL prevention.

METHODS

All relevant papers were searched by using a predefined search strategy (two randomized controlled trials (RCTs), one prospective study, and four retrospective studies). Meta-analysis was conducted to estimate AL and re-operation pooled rates.

RESULTS

A total of 7 studies (1556 patients) were included: No significant statistic difference was found between two groups on AL rate (odds ratio (OR) 0.61, P = 0.11) and re-operation rate (OR 0.52, P = 0.10). For subgroup analysis, significant statistic difference was found between two groups on AL rate (OR 0.29, P = 0.002) and re-operation rate (OR 0.15, P = 0.04) in patients without neoadjuvant therapy. As for patients without diverting stoma, the AL rate (OR 0.35, P = 0.002) was significantly lower than that in patients without TDT.

CONCLUSIONS

TDT may reduce AL morbidity and re-operation rate for patients without high risk of AL, but may be useless for those in high-risk situations.

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.

Surgical Treatment of Low-Lying Rectal Cancer: Updates

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

Intraoperative fluorescence angiography and risk factors of anastomotic leakage in mini-invasive low rectal resections

BACKGROUND

One of the prerequisites for proper healing of the anastomosis after a colorectal resection is adequate blood supply to the connected intestinal segments. It has been proposed that adequate visualization of the blood flow using indocyanine green (ICG) could lead to the reduction in the incidence of anastomotic leakage (AL). The aim of this study was to assess the effectiveness of intraoperative fluorescence angiography (FA) in decreasing the incidence of AL after minimally invasive low anterior resection (LAR) with total mesorectal excision (TME) in rectal cancer patients and to determine predictors of anastomotic leak.

METHODS

From August 2015 to January 2019, data from 100 patients who underwent mini-invasive TME for rectal cancer using FA with indocyanine green (ICG) were prospectively collected and analyzed. They were compared with retrospectively analyzed data from a historical control group operated by one team of surgeons before the introduction of FA from November 2012 to August 2015 (100 patients). All patients from both groups were operated sequentially in one oncological center in Nový Jičín.

RESULTS

The incidence of AL was significantly lower in the ICG group (19% vs. 9%, p = 0.042, χ² test). In fifteen patients in the ICG group (15%), the resection line was moved due to insufficient perfusion. Using Pearson's χ² test, diabetes (p = 0.036) and application of a transanal drain (NoCoil) (p = 0.032) were identified as other risk factors (RFs) for AL.

CONCLUSION

The use of ICG to visualize tissue perfusion in low rectal resections for cancer can lead to a reduction of AL.

Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects

PURPOSE

In most cases, traditional techniques to perform an anastomosis following gastrointestinal resections lead to successful healing. However, despite focused research in the field, in certain high-risk situations leakage rates remain almost unchanged. Here, additional techniques may help the surgeon to protect the anastomosis and prevent leakage. We give an overview of some of the latest developments on experimental and clinical techniques for induction of anastomotic healing.

METHODS

We performed a review of the current literature on approaches to improve anastomotic healing.

RESULTS

Many promising approaches with a high clinical potential are in the developmental pipeline. Highly experimental approaches like inhibition of matrix metalloproteinases, stem cell therapy, hyperbaric oxygen therapy, induction of the hypoxic adaptive response, and the administration of growth factors are still in the preclinical phase. Other more clinical developments aim to strengthen the anastomotic suture line mechanically while shielding it from the influence of the microbiome. Among them are gluing, seaming the staple line, attachment of laminar biomaterials, and temporary intraluminal tubes. In addition, individualized bowel preparation, selectively reducing certain detrimental microbial populations could become the next stage of bowel preparation. Compression anastomoses are evolving as an equivalent technique additional to established hand-sewn and stapled anastomoses. Fluorescence angiography and flexible endoscopy could complement intraoperative quality control additionally to the air leak tests. Virtual ileostomy is a concept to prepare the bowel for the easy formation of a stoma in case of leakage.

CONCLUSION

A variety of promising diagnostic and prophylactic measures that may support the surgeon in identifying high-risk anastomoses and support them according to their potential deficits is currently in development.

How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review

Anastomosis leakage (AL) after colorectal surgery is an embarrassing problem. It is associated with poor consequence. This review aims to summarize published evidence on prevention of AL after colorectal surgery and provide recommendations according to the Oxford Centre for Evidence-Based Medicine. We conducted bibliographic research on January 15, 2020, of PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. We retained meta-analysis, reviews, and randomized clinical trials. We concluded that mechanical bowel preparation did not reduce AL. It seems that oral antibiotic or oral antibiotic with mechanical bowel preparation could reduce the risk of AL. The surgical approach did not affect the AL rate. The low ligation of the inferior mesenteric artery could reduce the AL rate. The mechanical anastomosis is superior to handsewn anastomosis only in case of right colectomies, with similar results in rectal surgery between the 2 anastomosis techniques. In the case of right colectomies, this anastomosis could be performed intracorporeally or extracorporeally with similar outcomes. The air leak test did not reduce AL. There is no interest of external drainage in colonic surgery but drains reduced the rate of AL and rate of reoperation after low anterior resection. The transanal tube reduced the rate of AL.

Colorectal anastomosis dehiscence: a call for more detailed morphological classification

Introduction

A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology.

Aim

To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications.

Material and methods

This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7^th and 10^th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist.

Results

Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference.

Conclusions

Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Does a transanal drainage tube reduce anastomotic leakage? A matched cohort study in 144 patients undergoing laparoscopic sphincter-saving surgery for rectal cancer

BACKGROUND

The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS).

METHODS

A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL.

RESULTS

A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0-5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04-8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36-23.53]) were associated with AL.

CONCLUSIONS

Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer.

A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study

Purpose. Protective ileostomy (PI) during anterior resection (AR) for rectal cancer decreases the incidence of anastomotic leakage (AL) and its subsequent complications, but it may itself be the cause of morbidity. The aim is to report our protocol in the management of selected patients with borderline risk to develop AL after laparoscopic AR and ghost ileostomy (GI) creation. Methods. Patients who underwent AR were stratified based on the risk to develop AL. Steps to avoid PI were splenic flexure mobilization, reduced pelvic bleeding, to employ different stapler charge if neoadjuvant chemo-radiotherapy is performed, to perform a horizontal section of the rectum, to evaluate the anastomotic vascularization with a fluorescence angiography, to perform a side-to-end anastomosis, intraoperative methylene blue test, pelvic and transanal drainage tubes placement, and the GI creation. After surgery, inflammatory blood markers were monitored to detect potential leakages. Results. Twelve patients were included. In one case, the specimen proximal section was changed after fluorescence angiography. There were no conversions in this group of patients. One postoperative AL occurred and was treated with radiological drainage placement, not being necessary to convert the GI. PI was avoided in 100% of cases. Conclusions. Patients' characteristics cannot be changed, but several steps were used to avoid routine PI creation. The present protocol could be a valuable option to avoid PI in selected patients. Further studies with a wider sample size, and defined criteria to stratify the patients based on the risk to develop AL, are required.

Preventive strategies for anastomotic leakage after colorectal resections: A review

Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.

Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection

Purpose

We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL).

Methods

Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL.

Results

Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m² (range, 20–35 kg/m²). The median tumor distance from the anal verge was 8 cm (range, 4–12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation.

Conclusion

These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.

Pelvic and Lower Gastrointestinal Tract Anatomical Characterization of the Average Male

OBJECTIVE

Colorectal surgeons report difficulty in positioning surgical devices in males, particularly those with a narrower pelvis. The objectives of this study were to (1) characterize the anatomy of the pelvis and surrounding soft tissue from magnetic resonance and computed tomography scans from 10 average males (175 cm, 78 kg) and (2) develop a model representing the mean configuration to assess variability.

METHODS

The anatomy was characterized from existing scans using segmentation and registration techniques. Size and shape variation in the pelvis and soft tissue morphology was characterized using the Generalized Procrustes Analysis to compute the mean configuration.

RESULTS

There was considerable variability in volume of the psoas, connective tissue, and pelvis and in surface area of the mesorectum, pelvis, and connective tissue. Subject height was positively correlated with mesorectum surface area (P = .028, R² = 0.47) and pelvis volume ( P = .041, R² = 0.43). The anterior-posterior distance between the inferior pelvic floor muscle and pubic symphysis was positively correlated with subject height ( P = .043, r = 0.65). The angle between the superior mesorectum and sacral promontory was negatively correlated with subject height ( P = .042, r = -0.65). The pelvic inlet was positively correlated with subject weight ( P = .001, r = 0.89).

CONCLUSIONS

There was considerable variability in organ volume and surface area among average males with some correlations to subject height and weight. A physical trainer model created from these data helped surgeons trial and assess device prototypes in a controllable environment.

Outcomes of transanal tube placement in anterior resection: A meta-analysis and systematic review

BACKGROUND

In recent years, transanal tube placement was reported to be an effective procedure preventing anastomotic leakage after anterior resection of rectal cancer. However, this procedure is still controversial owing to inconsistent results found in previous studies.

METHODS

A comprehensive literature search was performed using Pubmed, Embase, Cochrane library from the databases inception up until June 21, 2018. The methodological quality of randomized controlled trials and cohort studies were evaluated by Cochrane Collaboration's tool for assessing risk of bias and Newcastle-Ottawa Scale, respectively. Statistical analysis was performed using the RevMan 5.3 software.

RESULTS

1 randomized controlled trial and 9 cohort studies were included in our meta-analysis. The randomized controlled trial was proven to be low risk according to the Cochrane Collaboration's tool for assessing risk of bias. All of the cohort studies proved a high quality according to the Newcastle-Ottawa Scale. Patients in transanal tube group had more disadvantageous preoperative demographic characteristics than patients in non-transanal tube group. The anastomotic leak rate was lower in the transanal tube group. Patients in the transanal tube group tended to have lower reoperation rates and shorter hospital stays compared with patients in the non-transanal tube group.

CONCLUSION

Despite various unfavorable preoperative characteristics, anastomotic leakage after anterior resection was lower in patients who received transanal tube placement compared with the control group. Transanal tube placement may be an alternative procedure of defunctioning stoma. A large sample size, multicenter RCT was needed to prove our results.

Male sex and history of ischemic heart disease are major risk factors for anastomotic leakage after laparoscopic anterior resection in patients with rectal cancer

Background

Anastomotic leakage (AL) is the most serious and common complication of surgery for rectal cancer, and associated risk factors remain unknown despite developments in laparoscopic surgery. The present study aimed to determine risk factors for AL after laparoscopic anterior resection (AR) of rectal cancer.

Methods

This retrospective cohort study extracted information from a prospective database of all consecutive colorectal resections that proceeded at Nippon Medical School Hospital between January 2011 and December 2015 (n = 865). We identified 154 patients with rectal cancer treated by elective laparoscopic AR with anastomosis using primary double-stapling. Clinical variables and comorbidity, habits, and surgery-related variables were assessed by univariate and multivariate analyses to determine preoperative risk factors for clinical AL.

Results

The overall rate of clinical AL was 11.7% (18 of 154 patients), and 5 (27.8%) of 18 patients required revised laparotomy. Data from males were analyzed because AL occurred only in males. Univariate analysis of male patients (n = 100) significantly associated preoperative creatinine values (p = 0.03) and a history of ischemic heart disease (IHD) (p = 0.012) with AL. The frequency of AL tended to increase (p = 0.06) when patients had low AR (p = 0.06) and transanal drainage. Having AL significantly prolonged hospital stays compared with patients without leakage (36.2 vs. 11.1 days; p <  0.01). Multivariate analysis identified a history of IHD (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.27–17.5; p = 0.025] as an independent risk factor for AL.

Conclusions

Male sex and a history of IHD are possible risk factors for AL after elective laparoscopic rectal cancer surgery.

An updated meta-analysis of transanal drainage tube for prevention of anastomotic leak in anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage (AL) is one of the most serious complications after anterior resection for rectal cancer. Transanal drainage tube (TDT) placement is widely used to reduce AL, but its efficacy remains controversial. We performed a meta-analysis to evaluate the effectiveness of TDT for prevention of AL, using updated evidence.

METHODS

Randomized controlled trials (RCTs) and cohort studies evaluating the effectiveness of TDT for prevention of AL after anterior resection for rectal cancer were identified by using a predefined search strategy. Meta-analysis was performed to estimate the pooled rates of AL, reoperation, anastomotic bleeding and mortality separately.

RESULTS

One RCT and ten cohort studies which including 1170 cases with TDT and 1262 cases without TDT were considered eligible for inclusion. Meta-analysis showed that the TDT group was associated with a significant lower rates of AL (RR: 0.42, 95% CI: 0.31-0.58, P < 0.00001) and reoperation (RR: 0.29, 95% CI: 0.19-0.45, P < 0.00001). There was no significant difference in anastomotic bleeding rate and mortality between the two groups.

CONCLUSIONS

TDT placement is associated with significant lower rates of AL and reoperation, hence it is likely to be an effective method of preventing and reducing AL after rectal cancer surgery.

Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial

PURPOSE

The aim of this study was to determine the risk factors for anastomotic leakage after laparoscopic rectal surgery.

METHODS

We conducted a prospective trial involving 395 patients with stage 0/I rectal carcinoma who underwent laparoscopic low anterior resection using a double stapling technique. Data concerning variables related to patient background, tumors and surgical factors were evaluated. The outcomes with respect to anastomotic leakage were recorded, and univariate and multivariate analyses were performed to identify relevant risk factors.

RESULTS

The overall anastomotic leakage rate was 8.4%. A univariate analysis showed male gender (P = 0.006) and preoperative blood sugar level (P = 0.0034) to be significantly associated with anastomotic leakage. The variables of gender, preoperative blood sugar level, American Society of Anesthesiologists (ASA) classification (P = 0.15), transanal decompression tube (P = 0.06) and number of stapler cartridges used for rectal transection (P = 0.18) were selected for the multivariate analysis because of their P values being <0.2. The multivariate analysis identified male gender (odds ratio 4.12, P = 0.006) and the absence of a transanal decompression tube (odds ratio 3.11, P = 0.0484) as independent risk factors predicting anastomotic leakage.

CONCLUSIONS

Male gender and the absence of a transanal decompression tube appeared to be independent risk factors for anastomotic leakage. Insertion of a transanal decompression tube may help prevent anastomotic leakage after low anterior resection, particularly in male patients.