Smoking and tumor obstruction are risk factors for anastomotic leakage after laparoscopic anterior resection during rectal cancer treatment

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.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients

OBJECTIVE

Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients.

METHODS

A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019.

RESULTS

The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001).

CONCLUSION

The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.

Preoperative diagnosis of obstructive colitis in colorectal cancer patients who underwent self-expandable metallic stent insertion as a bridge to surgery

PURPOSE

Obstructive colitis (OC) is a risk factor of anastomotic leakage in colorectal cancer resection. We aimed to clarify the relationship between the severity of OC and clinicopathological findings and to detect predictive factors of OC.

METHODS

We retrospectively reviewed 43 cases of colectomy after self-expandable metallic stent placement for left-sided colorectal cancer. Preoperative diagnosis of OC was made by multiple modalities (initial computed tomography (CT), presurgical CT, and colonoscopy). We classified OC macroscopically in resected specimens into five groups (Grade 0: none, 1: mild [mild edema], 2: moderate [severe edema, redness, erosion], 3: severe [ulceration, bleeding], 4: very severe [necrosis, perforation]), and investigated the relationship between the preoperative assessment, surgical findings and the severity of OC.

RESULTS

OC of Grade 2 or more (53.5%) was significantly correlated with severe edema in initial CT. There was no significant correlation between OC and anastomosis rate. The creation of covering stoma was significantly higher in the Grade 2 or more OC group. No leakage was observed in either group.

CONCLUSIONS

Initial CT may be most useful for prediction of OC. It is important to make a preoperative diagnosis of OC by combining multiple modalities, which enables to determine the appropriate location for resection, anastomosis, and construction of a covering stoma.

Impact of COVID-19 Outbreak on Stoma Surgery and Stoma Clinic Service: A Retrospective Study at a Single Japanese Referral Hospital

AIM

The impact of the COVID-19 pandemic on medical practice has been frequently reported from Western countries, but there have been few studies in other areas, especially regarding stoma surgery and stoma care.

METHODS

We investigated the numbers of all operations and stoma-related surgeries at our hospital in 2019 and 2020. The cumulative numbers of consultations at our ostomy clinic and patient population stratified by the period of having a stoma were compared between these calendar years. The frequency of ostomy clinic visit by individual patients within the first year after stoma creation and stoma-related complications per consultation were also analyzed.

RESULTS

The number of elective surgeries decreased by approximately 10% from 2019 to 2020, but the numbers of stoma creation and closure procedures did not differ. The total numbers of consultations at our ostomy clinic were also similar between these years. However, the percentage of patients with a stoma for less than a year who visited our ostomy clinic increased from 49.7% in 2019 to 53.5% in 2020, whereas the visitation rate for other patients decreased. Moreover, patients with a stoma for less than a year visited the ostomy clinic more frequently in 2020 (0.42/month) than in 2019 (0.30/month, p=0.032). There were fewer grade 2 or more severe peristomal complications in 2020 (11% vs 17% in 2019, p < 0.001) at our ostomy clinic.

CONCLUSION

The COVID-19 outbreak led to a shift in the patient population at ostomy clinics of new stoma patients, which may have resulted in fewer peristomal complications.

Fluorescence angiography vs. direct palpation for bowel viability evaluation with strangulated bowel obstruction

PURPOSE

In surgery for strangulated bowel obstruction, intestinal blood flow (IBF) is usually evaluated by observing bowel colour, peristalsis, intestinal temperature and arterial pulsations in the mesentery. We investigated whether indocyanine green (ICG) fluorescence angiography (ICG-FA) is an effective alternative to palpation.

METHODS

Thirty-eight patients who underwent emergency surgery for strangulated bowel obstruction from January 2017 to April 2021 were divided into two groups: (i) the ICG + group, in which ICG was used during laparoscopic surgery (n = 16), and (ii) the ICG - group, in which palpation without ICG was used during open surgery (n = 22). Starting in July 2019, ICG and laparoscopic surgery were applied in all cases except emergency cases when the fluorescence laparoscope was not ready. Surgical outcomes and patient characteristics were compared.

RESULTS

Patient characteristics, the operative duration and postoperative hospitalization duration did not significantly differ between the groups. Bowel resection was performed in 4 cases (25%) among ICG + patients and 11 cases (50%) among ICG - patients. The ratios of pathological findings (ischaemia:mucosal necrosis:transmural necrosis) were 0:2:2 and 1:6:4 in the two groups, respectively. Blood loss was measured with gauze and suction tubes and was 1 (0-5) mL in the ICG + group and 12.5 (0-73) mL in the ICG - group (p = 0.002). Postoperative complications occurred in 1 case (6.3%) in the ICG + group and 9 cases (40.9%) in the ICG - group (p = 0.025).

CONCLUSION

Although there were few intestinal resections in the ICG + group, the rate of pathological necrosis tended to be high, and no complications due to ineligibility were noted in the intestinal preservation group. During laparoscopic surgery, ICG-FA is useful as a substitute for palpation and has the potential to improve surgical outcomes.

CLINICAL TRIAL REGISTRATION

Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2019-40.