Delayed anastomotic leakage following laparoscopic intersphincteric resection for lower rectal cancer: report of four cases and literature review

Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection

BACKGROUND AND AIM

Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR).

METHODS

A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three-year disease-free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non-RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires.

RESULTS

The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non-left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3-year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05).

CONCLUSIONS

Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL.

Can the Single-stapling Technique Following Intersphincteric Resection with Transanal Total Mesorectal Excision Become the New Standard Anastomosis?

For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.

Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study

PURPOSE

To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes.

METHODS

Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results.

RESULTS

Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks.

CONCLUSION

AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised.

TRIAL REGISTRATION

Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.

Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study

Background

The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach.

Methods

We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36).

Results

The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups.

Conclusions

TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background

Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR.

Methods

A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR.

Results

Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter.

Conclusions

The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

Influence of concurrent capecitabine based chemoradiotherapy with bevacizumab on the survival rate, late toxicity and health-related quality of life in locally advanced rectal cancer: a prospective phase II CRAB trial

Background

Few studies reported early results on efficacy, toxicity of combined modality treatment for locally advanced rectal cancer (LARC) by adding bevacizumab to preoperative chemoradiotherapy, but long-term data on survival, and late complications are lacking. Further, none of the studies reported on the assessment of quality of life (QOL).

Patients and methods

After more than 5 years of follow-up, we updated the results of our previous phase II trial in 61 patients with LARC treated with neoadjuvant capecitabine, radiotherapy and bevacizumab (CRAB study) before surgery and adjuvant chemotherapy. Secondary endpoints of updated analysis were local control (LC), disease free (DFS) and overall survival (OS), late toxicity and longitudinal health related QOL (before starting the treatment and one year after the treatment) with questionnaire EORTC QLQ-C30 and EORTC QLQ-CR38.

Results

Median follow-up was 67 months. During the follow-up period, 16 patients (26.7%) died. The 5-year OS, DFS and LC rate were 72.2%, 70% and 92.4%. Patients with pathological positive nodes or pathological T3–4 tumors had significantly worse survival than patients with pathological negative nodes or T0–2 tumors. Nine patients (14.8%) developed grade ³3 late complications of combined modality treatment, first event 12 months and last 87 months after operation (median time 48 months). Based on EORTC QLQ-C30 scores one year after treatment there were no significant changes in global QOL and three symptoms (pain, insomnia and diarrhea), but physical and social functioning significantly decreased. Based on QLQ-CR38 scores body image scores significantly increase, problems with weight loss significantly decrease, but sexual dysfunction in men and chemotherapy side effects significantly increase.

Conclusions

Patients with LARC and high risk factors, such as positive pathological lymph nodes and high pathological T stage, deserve more aggressive treatment in the light of improving long-term survival results. Patients after multimodality treatment should be given greater attention to the regulation of individual aspects of quality of life and the occurrence of late side effects.

Comparison of overall survival and quality of life between patients undergoing anal reconstruction and patients undergoing traditional lower abdominal stoma after radical resection

BACKGROUND

Miles procedure is often necessary for patients with low rectal carcinoma. However, this operation often affects the quality of life of patients, to evaluate the advantages of improved operation (anal reconstruction), the quality of life and survival between patients undergoing anal reconstruction and patients undergoing traditional lower abdominal stoma after radical resection were analyzed.

METHODS

The clinical data of 43 patients with low situated rectal carcinoma were retrospectively analyzed. 23 patients with left lower abdominal stoma after radical resection (Miles procedure) were divided into group A, and 20 patients with reconstruction of the anus in situ after radical resection were in group B. All patients were investigated by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38 questionnaire, the clinical data are recorded. Independent sample T test was used to analyze the difference in quality of life between group A and group B at 3, 6, and 12 months after surgery, and Kaplan-Meier was used to compare the difference in overall survival between group A and group B.

RESULTS

The results of T test showed that there were statistical significance in global health status and physical functioning between group A and group B at 3 and 6 months, but no statistical significance at 12 months (P = 0.024, P = 0.019, P = 0.115 for global health status; P = 0.004, P = 0.006, P = 0.065 for physical functioning, respectively). Emotional functioning and social functioning were also statistically significant between group A and group B at 3, 6, and 12 months (P = 0.041, P = 0.040, P = 0.034 for Emotional functioning; P = 0.020, P = 0.009, P = 0.032 for social functioning, respectively). This study also found that there was no statistical significance in body image and sexual functioning between group A and group B at 3 months, but there was statistical significance at 6 and 12 months(P = 0.098, P = 0.035, P = 0.045 for body image; P = 0.110, P = 0.048, P = 0.047 for sexual functioning, respectively). There were statistically significant about sexual enjoyment and defecation problems at 3, 6, and 12 months (P = 0.023, P = 0.028, P = 0.050 for sexual enjoyment; P = 0.013, P = 0.011, P = 0.050 for defecation problems, respectively).The results of Kaplan-Meier showed that the overall survival (OS) between group A and group B was not statistically significant (χ² = 0.600, P = 0.439).

CONCLUSIONS

There was no difference in survival time between group A and group B, but compared with the patients with left lower abdominal stoma(group A), the quality of life was better in patients with reconstruction of the anus in situ (group B). It is significant to improve the traditional lower abdominal stoma operation.