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Qiu Y, Li Y, Chen Z, Chai N, Liang X, Zhang D, Wei Z. Application of the advance incision in robotic-assisted laparoscopic rectal anterior resection. Front Surg 2023; 10:1141672. [PMID: 36960211 PMCID: PMC10028139 DOI: 10.3389/fsurg.2023.1141672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
Background The incidence of rectal cancer is increasing each year. Robotic surgery is being used more frequently in the surgical treatment of rectal cancer; however, several problems associated with robotic surgery persist, such as docking the robot repeatedly to perform auxiliary incisions and difficulty exposing the operative field of obese patients. Herein we introduce a new technology that effectively improves the operability and convenience of robotic rectal surgery. Objectives To simplify the surgical procedure, enhance operability, and improve healing of the surgical incision, we developed an advance incision (AI) technique for robotic-assisted laparoscopic rectal anterior resection, and compared its safety and feasibility with those of intraoperative incision. Methods Between January 2016 and October 2021, 102 patients with rectal cancer underwent robotic-assisted laparoscopic rectal anterior resection with an AI or intraoperative incision (iOI) incisions. We compared the perioperative, incisional, and oncologic outcomes between groups. Results No significant differences in the operating time, blood loss, time to first passage of flatus, time to first passage of stool, duration of hospitalization, and rate of overall postoperative complications were observed between groups. The mean time to perform auxiliary incisions was shorter in the AI group than in the iOI group (14.14 vs. 19.77 min; p < 0.05). The average incision length was shorter in the AI group than in the iOI group (6.12 vs. 7.29 cm; p < 0.05). Postoperative incision pain (visual analogue scale) was lower in the AI group than in the iOI group (2.5 vs. 2.9 p = 0.048). No significant differences in incision infection, incision hematoma, incision healing time, and long-term incision complications, including incision hernia and intestinal obstruction, were observed between groups. The recurrence (AI group vs. iOI group = 4.0% vs. 5.77%) and metastasis rates (AI group vs. iOI group = 6.0% vs. 5.77%) of cancer were similar between groups. Conclusion The advance incision is a safe and effective technique for robotic-assisted laparoscopic rectal anterior resection, which simplifies the surgical procedure, enhances operability, and improves healing of the surgical incision.
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Affiliation(s)
- Yuhao Qiu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Li
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhenzhou Chen
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ninghui Chai
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xianping Liang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dahong Zhang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Zhengqiang Wei
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Brisinda G, Chiarello MM, Pepe G, Cariati M, Fico V, Mirco P, Bianchi V. Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors. World J Clin Cases 2022; 10:13321-13336. [PMID: 36683625 PMCID: PMC9850997 DOI: 10.12998/wjcc.v10.i36.13321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.
AIM To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.
METHODS To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.
RESULTS The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.
CONCLUSION Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
| | | | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Paolo Mirco
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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Bouland T, Sabbagh C, Allart K K, Pellegrin A, Regimbeau JM. Is a Defunctioning Stoma Necessary After Left Colectomy in High-risk Patients for Anastomotic Leak? Surg Laparosc Endosc Percutan Tech 2022; 32:677-682. [PMID: 36468892 DOI: 10.1097/sle.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/07/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Left colectomy is associated with a 7% risk of anastomotic leak. In 2011, a prediction score for AL [the colon leakage score (CLS)] was developed. The aim was to evaluate the impact of a defunctioning stoma on AL and its consequences after left colectomy in high-risk patients. PATIENTS From January 2012 to June 2019, high-risk patients who underwent a left colectomy with anastomosis were included in this retrospective, single-center study. Two groups of patients were defined: patients undergoing a left colectomy with an anastomosis without a defunctioning stoma (no-stoma group) and those with a defunctioning stoma (stoma group). The primary endpoint was the rate of anastomotic leakage. RESULTS Ninety-two patients were included in this study. The anastomotic leakage rate was 16.4% in the no-stoma group and 21.6% in the stoma group ( P =0.5). A conservative approach was applied to 11.2% in the no-stoma group and 50% in the stoma group ( P =0.1). The severe morbidity rate was 14.5% in the no-stoma group and 21.6% in the stoma group ( P =0.4). The rate of unplanned admissions was 7% in the no-stoma group and 27% in the stoma group ( P =0.01). CONCLUSION A defunctioning stoma does not appear to reduce the rate of AL in high-risk patients, but its impact on the management of AL remains unclear.
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Affiliation(s)
- Tressy Bouland
- Department of Digestive Surgery
- Simplification of Surgical Patient Care Research Unit, University of Picardie Jules Verne, Amiens, France
| | - Charles Sabbagh
- Department of Digestive Surgery
- Simplification of Surgical Patient Care Research Unit, University of Picardie Jules Verne, Amiens, France
| | - Kevin Allart K
- Department of Digestive Surgery
- Simplification of Surgical Patient Care Research Unit, University of Picardie Jules Verne, Amiens, France
| | - Alexandra Pellegrin
- Department of Digestive Surgery
- Simplification of Surgical Patient Care Research Unit, University of Picardie Jules Verne, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery
- Simplification of Surgical Patient Care Research Unit, University of Picardie Jules Verne, Amiens, France
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Sciuto A, Peltrini R, Andreoli F, Di Santo Albini AG, Di Nuzzo MM, Pirozzi N, Filotico M, Lauria F, Boccia G, D’Ambra M, Lionetti R, De Werra C, Pirozzi F, Corcione F. Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases. J Clin Med 2022; 11:jcm11092632. [PMID: 35566757 PMCID: PMC9104879 DOI: 10.3390/jcm11092632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.
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Affiliation(s)
- Antonio Sciuto
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
- Department of Electrical Engineering and Information Technology, University of Naples Federico II, 80125 Naples, Italy
- Correspondence:
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Andreoli
- Department of Minimally Invasive Surgery, Cristo Re Hospital, 00167 Rome, Italy;
| | - Andrea Gianmario Di Santo Albini
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Maria Michela Di Nuzzo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Nello Pirozzi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Giuseppe Boccia
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Michele D’Ambra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Carlo De Werra
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria delle Grazie Hospital, 80078 Pozzuoli, Italy;
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.P.); (A.G.D.S.A.); (M.M.D.N.); (N.P.); (M.F.); (F.L.); (G.B.); (M.D.); (R.L.); (C.D.W.); (F.C.)
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5
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Burke JR, Helliwell J, Wong J, Quyn A, Herrick S, Jayne D. The use of mesenchymal stem cells in animal models for gastrointestinal anastomotic leak: A systematic review. Colorectal Dis 2021; 23:3123-3140. [PMID: 34363723 DOI: 10.1111/codi.15864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/29/2021] [Accepted: 07/29/2021] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leak is the most feared complication of gastrointestinal surgery. Mesenchymal stem cell technology is used clinically to promote wound healing; however, the safety and efficacy of this technology on anastomotic healing has yet to be defined. The aim of this study was to investigate whether mesenchymal stem cells confer any benefit when applied to animal models for gastrointestinal anastomotic leak, identify the methodology and how efficacy is assessed. METHODS The MEDLINE, EMBASE, WebofScience and Cochrane Library databases were interrogated between 1 January1947 to 1 May 2020. All studies where mesenchymal stem cells were applied to laboratory animal leak models to demonstrate a healing effect were considered. All experimental and histological outcomes were examined. Compliance to ARRIVE and current International Consensus was assessed. RESULTS A total of 1205 studies were screened. Twelve studies reported on 438 gastrointestinal anastomoses in four species using 11 models; seven in the colon. No studies utilised a model with a known leak rate. Significant variance was observed in histological outcomes with efficacy demonstrated in five out of 12 studies. One study demonstrated a benefit in leak rate. Colorectal studies had a greater median ARRIVE compliance, 60.8% (IQR 63.2-64.5) compared to noncolorectal 45.4% (IQR 43.8-49.0). CONCLUSIONS Mesenchymal stem cell delivery to an animal anastomosis is safe and feasible. Use may confer benefit but findings are currently limited to surrogate histological outcomes. There is consistency in outcome measures reported but variance in how this is assessed. Poor compliance to ARRIVE but good compliance to current international consensus in leak models of the colon was observed.
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Affiliation(s)
- Joshua Richard Burke
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Jack Helliwell
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Jason Wong
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Aaron Quyn
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Sarah Herrick
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - David Jayne
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
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Choy KT, Yang TWW, Heriot A, Warrier SK, Kong JC. Does rectal tube/transanal stent placement after an anterior resection for rectal cancer reduce anastomotic leak? A systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:1123-1132. [PMID: 33515307 DOI: 10.1007/s00384-021-03851-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is increasing evidence that either a transanal stent (TAS) or rectal tube (RT) can decrease the risk of anastomotic leakage (AL) after anterior resection for rectal cancer, in which a diverting stoma may not be required. OBJECTIVES The aim of this review was to investigate the efficacy and safety of RT/TAS in preventing AL after anterior resections. DATA SOURCES An up-to-date systematic review was performed on the available literature between 2000 and 2020 on PubMed, EMBASE, Medline and Cochrane Library databases. STUDY SELECTION All studies reporting on anterior resections in adults, comparing transanal tube/stent versus non-tube/stent, were analysed. MAIN OUTCOME MEASURE The primary outcome was rates of AL, whereas secondary outcomes compared associated unplanned re-operation for AL and hospital length of stay (LOS). RESULTS Two randomized controlled trials and 13 observational studies were included, with 1714 patients receiving RT/TAS and 1741 patients without. There were 119 (7%) patients with AL in the RT/TAS group compared to 216 (12.3%) patients in the non-RT/TAS group (OR: 0.48, 95% CI: 0.38-0.62, p < 0.001). There were 47 (2.9%) patients with AL complications requiring surgery in the RT/TAS group compared to 132 (8%) patients in the non-RT/TAS group (OR: 0.29, 95% CI: 0.20-0.42, p < 0.001) and no significant difference identified with the standardized mean difference (SMD) favouring the RT/TAS group for hospital LOS (SMD: -0.23, 95% CI: -0.51 to 0.06, p = 0.115). CONCLUSION The use of RT/TAS post restorative anterior resection for rectal cancer should be considered, given the benefits shown from this meta-analysis.
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Affiliation(s)
- Kay T Choy
- Department of Surgery, Austin Hospital, 145 Studley Rd, Heidelberg, VIC, 3084, Australia.
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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7
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Review of Colonic Anastomotic Leakage and Prevention Methods. J Clin Med 2020; 9:jcm9124061. [PMID: 33339209 PMCID: PMC7765607 DOI: 10.3390/jcm9124061] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022] Open
Abstract
Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.
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8
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De Hous N, Lefevre JH, D'Urso A, Van den Broeck S, Komen N. Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature. Colorectal Dis 2020; 22:1496-1505. [PMID: 32268451 DOI: 10.1111/codi.15055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. METHOD A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. RESULTS The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. CONCLUSION Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.
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Affiliation(s)
- N De Hous
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - J H Lefevre
- Department of Digestive Surgery, Saint-Antoine Hospital, Sorbonne University, Paris, France
| | - A D'Urso
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - S Van den Broeck
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
| | - N Komen
- Department of Abdominal Surgery, University Hospital of Antwerp, University of Antwerp, Edegem, Belgium
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9
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Dumble C, Morgan T, Wells CI, Bissett I, O'Grady G. The impact of transanal tube design for preventing anastomotic leak in anterior resection: a systematic review and meta-analysis. Tech Coloproctol 2020; 25:59-68. [PMID: 33125604 DOI: 10.1007/s10151-020-02354-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- C Dumble
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - T Morgan
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand.
| | - C I Wells
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - I Bissett
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland Hospital Clinical Support Block, 2 Park Rd, Grafton, Auckland, 1023, New Zealand
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10
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Reischl S, Wilhelm D, Friess H, Neumann PA. Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects. Langenbecks Arch Surg 2020; 406:971-980. [PMID: 32803330 PMCID: PMC8208906 DOI: 10.1007/s00423-020-01957-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Stefan Reischl
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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11
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D'Urso A, Komen N, Lefevre JH. Intraluminal flexible sheath for the protection of low anastomosis after anterior resection: results from a First-In-Human trial on 15 patients. Surg Endosc 2019; 34:5107-5116. [PMID: 31802217 DOI: 10.1007/s00464-019-07279-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 11/23/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Defunctioning ostomy is commonly used to protect patients from anastomotic leakage complications after low anterior resection, but is fraught with its own deleterious effects. This first-in-human study examines the safety and preliminary efficacy of Colovac, an anastomosis protection device. The Colovac consists of a flexible bypass sheath, placed in the lumen of colon and anchored above the anastomosis using a vacuum stent. METHODS 15 patients underwent anterior resection (AR) with anastomosis protection by Colovac at 3 European centers. After 14 days, the anastomosis integrity was examined by CT scan and endoscopy. The device was then endoscopically removed. Data regarding demographics, surgical details, 30 day post-operative complications, and patient satisfaction were collected prospectively. RESULTS 15 patients (10 male) underwent laparoscopic AR with Colovac placement. Preoperative neoadjuvant therapy was administered to 54% of patients. Device placement was uneventful in all patients with a median duration of 7 min and placement was judged as easy or very easy in 93% of the cases. Patients did not report major discomfort during the 14 days. Endoscopic removal (10 min) was judged as easy or very easy in 87% of the cases. Absence of feces below the Colovac anchoring site was observed in 100% of the cases. 4 anastomotic leakages were observed (including 3 device migrations). Overall 5 patients (33%) required a planned stoma creation. At 3 months, 1 had already been closed. CONCLUSION Colovac provides a minimally invasive protection of the anastomosis during the healing process by avoiding the need for a diverting ostomy for two-thirds of patients who will not experience anastomotic complications and allowing safe conversion to the standard of care for patients requiring extended anastomotic protection. A larger study is ongoing to confirm these results.
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Affiliation(s)
- Antonio D'Urso
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Niels Komen
- Department of Abdominal Surgery, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France.
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12
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Khosrovani C, Birnbaum DJ, Berdah S, Beyer-Berjot L. Assessment of a Vacuum-Based Intra-Colonic Diverting Device: A Preclinical Study. Surg Innov 2019; 26:581-587. [PMID: 31185816 DOI: 10.1177/1553350619851670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. Anastomotic leak is the main complication after low colorectal anastomosis. Defunctioning ileostomy is therefore recommended, which carries its own morbidity. The aim of this study was to assess the technical feasibility, safety, and preliminary efficacy of a vacuum-based intra-colonic diverting device (Colovac) to reduce the impact of anastomotic leak. Methods. This prospective preclinical study was conducted on living swine. The device was surgically inserted transanally, proximal to a colorectal anastomosis, and removed endoscopically at day 14. Then, open surgery was performed to look for deep sepsis and/or anastomotic leak, and the remaining colorectal anastomosis was resected for histopathological analysis. The endpoints were successful insertion and delivery of the device, postoperative morbidity, successful maintaining of the device, and absence of feces spillage and/or abscess in the abdominal cavity. Results. The Colovac was inserted in 22 swine. Stent migration occurred in 7 of the first 8 specimens, leading to natural expulsion of the device. After diet adaptation, a subsequent group of 14 swine was undertaken, of which 13 did not show any sign of migration post-implantation. Disconnection of the suction drain occurred in 1 case, leading to device expulsion on day 10. Colovac retrieval was achieved successfully in 13 cases. The endoscopic assessment of the anchorage site showed limited mucosal injury, whereas histopathological findings revealed mild hyperplasia. One swine died prematurely of postoperative colonic ischemia. Conclusion. This new device appears to be safe in the swine model and may prevent peritonitis or abscess due to colorectal anastomotic leak.
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Affiliation(s)
- Charam Khosrovani
- 1 Department of Digestive Surgery, Capio-Fontvert Clinic, Sorgues, France
| | - David Jérémie Birnbaum
- 2 Centre for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.,3 Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Stéphane Berdah
- 2 Centre for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.,3 Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Laura Beyer-Berjot
- 2 Centre for Surgical Teaching and Research (CERC), Aix-Marseille University, Marseille, France.,3 Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
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13
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Ye W, Zhu Z, Liu G, Chen B, Zeng J, Gao J, Wang S, Cai H, Xu G, Huang Z. Application of the cuff rectum drainage tube in total mesorectal excision for low rectal cancer: A retrospective case-controlled study. Medicine (Baltimore) 2019; 98:e15939. [PMID: 31169715 PMCID: PMC6571267 DOI: 10.1097/md.0000000000015939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To investigate therapeutic effect of cuff rectum drainage tube (CDT) in preventing the postoperative complications of total mesorectal excision (TME) and promoting the recovery of the patients.The clinical data of 84 cases of low rectal cancer performed TME from June 2015 to June 2017 in the First Affiliated Hospital of Xiamen University were analyzed retrospectively. All the cases were performed anus-retained operation without preventive colostomy. Patients were divided into 2 groups according to the material of the anorectal drainage tube placed in the colonic cavity. Group I (CDT group) was transanal cuff rectal drainage tube placement (Patent No. ZL 201320384337.8) (n = 48), and group II (conventional group) was transanal clinical conventional drainage tube placement (n = 36). Anastomotic fistula incidence, the time of anal exsufflation, postoperative first ambulation time, intestinal function recovery time, the incidence of interrelated complications of drainage tube and postoperative hospital stay between 2 groups were analyzed retrospectively.Both postoperative first ambulation and anal exhaust time in CDT group were shorter than those in the conventional group ([2.3 ± 0.4] d vs [3.0 ± 0.2] d, P < .05; [3.3 ± 0.3] d vs [3.9 ± 0.5] d, P < .05). Meanwhile, the postoperative hospital stay of CDT group was significantly decreased than that in the conventional group ([10.3 ± 1.6] d vs [11.8 ± 1.1] d, P < .05). Significant different occurrence of complications existed in anastomotic fistula (2.1% [1/48] vs 16.7% [6/36], P < .05), frequent defecation (8.3% [4/48] vs 27.8% [10/36], P < .05), defecating unfinished feeling (12.5% [6/48] vs 30.6% [11/36], P < .05), drainage tube complication (4.2% [2/48] vs 22.2% [8/36], P < .05).The cuff rectum drainage tube may reduce incidence of anastomotic fistula after TME, shorten postoperative first ambulation and anal exsufflation time, enable faster recovery with good toleration and decrease postoperative hospital stay.
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Affiliation(s)
- Weipeng Ye
- Department of Clinical Medicine, Fujian Medical University, Fuzhou
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Zhipeng Zhu
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Gang Liu
- Department of Breast Surgery, The Third Hospital of Nanchang City, Key Laboratory of Breast Diseases, Nanchang, Jiangxi
| | - Borong Chen
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Junjie Zeng
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Jin Gao
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Shengjie Wang
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Hejie Cai
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
| | - Guoxing Xu
- Endoscopy Center, The First Affiliated Hospital of Xiamen University, Xiamen, P.R. China
| | - Zhengjie Huang
- Department of Clinical Medicine, Fujian Medical University, Fuzhou
- Department of Gastrointestinal Surgery, Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian
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14
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Boersema GS, Vennix S, Wu Z, Te Lintel Hekkert M, Duncker DJG, Lam KH, Menon AG, Kleinrensink GJ, Lange JF. Reinforcement of the colon anastomosis with cyanoacrylate glue: a porcine model. J Surg Res 2017; 217:84-91. [DOI: 10.1016/j.jss.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/16/2017] [Accepted: 05/01/2017] [Indexed: 01/11/2023]
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15
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Bakker IS, Morks AN, ten Cate Hoedemaker HO, Burgerhof JGM, Leuvenink HG, van Praagh JB, Ploeg RJ, Havenga K, Bakker IS, Morks AN, ten Cate Hoedemaker HO, Leuvenink HG, Ploeg RJ, Havenga K, van Etten B, Lange JFM, Hemmer PHJ, Burgerhof JGM, Sonneveld DJA, Tanis PJ, Wegdam JA, Jonk A, Lutke Holzik MF, Bosker RJI, Lamme B, Spillenaar Bilgen EJ, Bremers AJ, van der Mijle HC, Hoff C, de Vries DP, Logeman F, Sietses C, Lesanka Versluijs-Ossewaarde FN, Leijtens JW, Tobon Morales RE, Neijenhuis PA, Kloppenberg FW, Schasfoort R, Bleeker WA, Hess D, Rosman C, Wit F, Ton van Engelenburg KC, Pronk A, Bonsing BA, Dekker JW, Consten EC, Patijn GA, Bogdan Rajcs S, Csapó Z, Bálint A, Harsányi L, István G, Horisberger K, Bader F, Kutup A, Mariette C, Cebrián F. Randomized clinical trial of biodegradeable intraluminal sheath to prevent anastomotic leak after stapled colorectal anastomosis. Br J Surg 2017; 104:1010-1019. [DOI: 10.1002/bjs.10534] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/09/2016] [Accepted: 02/08/2017] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Anastomotic leakage is a potential major complication after colorectal surgery. The C-seal was developed to help reduce the clinical leakage rate. It is an intraluminal sheath that is stapled proximal to a colorectal anastomosis, covering it intraluminally and thus preventing intestinal leakage in case of anastomotic dehiscence. The C-seal trial was initiated to evaluate the efficacy of the C-seal in reducing anastomotic leakage in stapled colorectal anastomoses.
Methods
This RCT was performed in 41 hospitals in the Netherlands, Germany, France, Hungary and Spain. Patients undergoing elective surgery with a stapled colorectal anastomosis less than 15 cm from the anal verge were eligible. Included patients were randomized to the C-seal and control groups, stratified for centre, anastomotic height and intention to create a defunctioning stoma. Primary outcome was anastomotic leakage requiring invasive treatment.
Results
Between December 2011 and December 2013, 402 patients were included in the trial, 202 in the C-seal group and 200 in the control group. Anastomotic leakage was diagnosed in 31 patients (7·7 per cent), with a 10·4 per cent leak rate in the C-seal group and 5·0 per cent in the control group (P = 0·060). Male sex showed a trend towards a higher leak rate (P = 0·055). Construction of a defunctioning stoma led to a lower leakage rate, although this was not significant (P = 0·095).
Conclusion
C-seal application in stapled colorectal anastomoses does not reduce anastomotic leakage. Registration number: NTR3080 (http://www.trialregister.nl/trialreg/index.asp).
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Affiliation(s)
- I S Bakker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A N Morks
- Department of Surgery, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - H O ten Cate Hoedemaker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J G M Burgerhof
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H G Leuvenink
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J B van Praagh
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - R J Ploeg
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - K Havenga
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - I S Bakker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A N Morks
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H O ten Cate Hoedemaker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H G Leuvenink
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - R J Ploeg
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K Havenga
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - B van Etten
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J F M Lange
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - P H J Hemmer
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J G M Burgerhof
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | | | - P J Tanis
- Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Wegdam
- Elkerliek Ziekenhuis, Helmond, The Netherlands
| | - A Jonk
- Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands
| | | | | | - B Lamme
- Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - A J Bremers
- Radboud University, Nijmegen Medical Centre, The Netherlands
| | | | - C Hoff
- Medical Centre, Leeuwarden, The Netherlands
| | - D P de Vries
- Ommelander Ziekenhuis Group, Winschoten, The Netherlands
| | - F Logeman
- Beatrix Hospital, Gorinchem, The Netherlands
| | - C Sietses
- Gelderse Vallei Hospital, Ede, The Netherlands
| | | | | | | | | | | | | | | | - D Hess
- Antonius Hospital, Sneek, The Netherlands
| | - C Rosman
- Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - F Wit
- Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - A Pronk
- Diakonessenhuis, Utrecht, The Netherlands
| | - B A Bonsing
- Leiden University Medical Centre, The Netherlands
| | - J W Dekker
- Reinier de Graaf Hospital, Delft, The Netherlands
| | - E C Consten
- Meander Medical Centre, Amersfoort, The Netherlands
| | | | - S Bogdan Rajcs
- Szabolcs-Szatmár-Bereg County Hospitals, Jósa András University Teaching Hospital, Nyíregyháza, Hungary
| | - Z Csapó
- Flór Ferenc Hospital of County Pest, Kistarcsa, Hungary
| | - A Bálint
- Szent Imre Hospital, Budapest, Hungary
| | - L Harsányi
- Semmelweis University, First Department of surgery, Budapest, Hungary
| | - G István
- Semmelweis University, Second Department of Surgery, Budapest, Hungary
| | - K Horisberger
- University Medical Centre Mannheim, University of Heidelberg, Germany
| | - F Bader
- Klinikum Rechts der Isar, Technische Universität München, Germany
| | - A Kutup
- University Medical Centre Hamburg–Eppendorf, Germany
| | - C Mariette
- Claude Huriez University Hospital, Lille, France
| | - F Cebrián
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Bosmans JWAM, Jongen ACHM, Boonen BTC, van Rijn S, Scognamiglio F, Stucchi L, Gijbels MJJ, Marsich E, Bouvy ND. Comparison of three different application routes of butyrate to improve colonic anastomotic strength in rats. Int J Colorectal Dis 2017; 32:305-313. [PMID: 27942836 PMCID: PMC5316396 DOI: 10.1007/s00384-016-2718-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Despite extensive research, anastomotic leakage (AL) remains one of the most dreaded complications after colorectal surgery. Since butyrate enemas are known to enhance anastomotic healing, several administration routes have been explored in this study. METHODS Three intraluminal approaches involving butyrate were investigated: (1) butyrin-elucidating patch, (2) a single injection of hyaluronan-butyrate (HA-But) prior to construction of the proximal anastomosis and (3) rectal hyaluronan-butyrate (HA-But) enemas designed for distal anastomoses. The main outcome was AL and secondary outcomes were bursting pressure, histological analysis of the anastomosis, zymography to detect MMP activity and qPCR for gene expression of MMP2, MMP9, MUC2 and TFF3. RESULTS Neither the patches nor the injections led to a reduction of AL in experiments 1 and 2. In experiment 3, a significant reduction of AL was accomplished with the (HA-But) enema compared to the control group together with a higher bursting pressure. Histological analysis detected only an increased inflammation in experiment 2 in the hyaluronan injection group compared to the control group. No other differences were found regarding wound healing. Zymography identified a decreased proenzyme of MMP9 when HA-But was administered as a rectal enema. qPCR did not show any significant differences between groups in any experiment. CONCLUSION Butyrate enemas are effective in the enhancement of colonic anastomosis. Enhanced butyrate-based approaches designed to reduce AL in animal models for both proximal and distal anastomoses were not more effective than were butyrate enemas alone. Further research should focus on how exogenous butyrate can improve anastomotic healing after gastrointestinal surgery.
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Affiliation(s)
- J W A M Bosmans
- Department of General Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
- NUTRIM School for Nutrition and Translation Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | - A C H M Jongen
- Department of General Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- NUTRIM School for Nutrition and Translation Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - B T C Boonen
- Department of General Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - S van Rijn
- Department of General Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- NUTRIM School for Nutrition and Translation Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - F Scognamiglio
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - L Stucchi
- SIGEA Srl, AREA Science Park, Trieste, Italy
| | - M J J Gijbels
- Departments of Pathology and Molecular Genetics, CARIM, Maastricht University, Maastricht, The Netherlands
- Department of Medical Biochemistry, Academic Medical Center, Maastricht, the Netherlands
| | - E Marsich
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- NUTRIM School for Nutrition and Translation Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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17
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Yang CS, Choi GS, Park JS, Park SY, Kim HJ, Choi JI, Han KS. Rectal tube drainage reduces major anastomotic leakage after minimally invasive rectal cancer surgery. Colorectal Dis 2016; 18:O445-O452. [PMID: 27611180 DOI: 10.1111/codi.13506] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/23/2016] [Indexed: 12/25/2022]
Abstract
AIM Anastomotic leakage is the most serious complication following low anterior resection for rectal cancer and is a major cause of postoperative morbidity and mortality. The object of the present study was to investigate whether rectal tube drainage can reduce anastomotic leakage after minimally invasive rectal cancer surgery. METHOD Three hundred and seventy-four patients who underwent laparoscopic or robotic LAR for tumours located ≤ 15 cm above the anal verge between 1 April 2012 and 31 October 2014 were assessed retrospectively. Of these, 107 with intermediate risk of anastomotic leakage received transanal rectal tube drainage. The rectal tube group was matched by propensity score analysis with patients not having rectal tube drainage, giving 204 patients in the study. Covariates for propensity score analysis included age, sex, body mass index, tumour height from the anal verge and preoperative chemoradiation. RESULTS Patient demographics, tumour location, preoperative chemoradiation and operative results were similar between the two groups. The overall leakage rate was 10.8% (22/204), with no significant difference between the rectal tube group (9.8%) and the nonrectal tube group (11.8%, P = 0.652). Of the patients with anastomotic leakage, major leakage requiring reoperation developed in 11.8% of those without and 3.9% of those with a rectal tube. On multivariate analysis, age over 65 years and nonuse of a rectal tube were found to be independent risk factors for major anastomotic leakage. CONCLUSION Rectal tube placement may be a safe and effective method of reducing the rate of major anastomotic leakage, alleviating the clinical course of leakage following minimally invasive rectal cancer surgery.
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Affiliation(s)
- C-S Yang
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - G-S Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - J S Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - S Y Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - H J Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - J-I Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - K S Han
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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18
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Liu L, Huang Q, Wang J, Chen Q, Lin R, Ge B. Protection of low rectal anastomosis with a new tube ileostomy using a biofragmentable anastomosis ring: A retrospective study. Medicine (Baltimore) 2016; 95:e5345. [PMID: 27828857 PMCID: PMC5106063 DOI: 10.1097/md.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A temporarily defunctioning stoma, while effective at reducing symptomatic anastomotic leakage after low anterior resection (LAR) of rectal cancer, and its subsequent closure, is associated with significant morbidity. Here, we devised a new tube ileostomy using a biofragmentable anastomosis ring (TIB) with no need for reversal.This is a retrospective cohort study. From June 2011 to March 2015, TIBs were performed on 31 consecutive patients with mid- or low-rectal cancer who underwent elective laparoscopic LARs. From January 2008 to May 2011, 25 similarly diseased patients underwent elective laparoscopic LARs and conventional loop ileostomy (LI) and were included as controls. All of the anastomotic sites were within 6 cm of the anal verge. Demographic, clinical feature, and operative data were recorded.The demographic features of both groups were similar. The TIB mean surgical duration was significantly lower than in the LI group (215 ± 28 vs 245 ± 54 min, P = 0.010). Because of readmission for stoma closure, the total hospital stay of the LI group was longer than that of the TIB group (38.1 ± 26.5 vs 19.1 ± 7.9 days, respectively, P = 0.002). Ileal content was completely diverted by TIB for 13.7 ± 2.1 (range, 10-19) days postoperatively. The drainage tube was removed on postoperative day 27.8 ± 6.9 (range, 20-44), and the mean continued duration of the discharge tract, before fistula healing, was 4.5 ± 1.9 (range, 2-10) days. Postoperative complications of the 2 modalities were not significant. In the TIB group, 1 rectovaginal fistula occurred 30 days postsurgery. In the LI group, 1 rectovaginal fistula occurred 3 months after stoma closure. Both complications were treated with transverse colostomy. No major TIB associated complications were observed in the present study.TIB is a safe, feasible, effective, but time-limited diversion technique, which may reduce symptomatic anastomosis leakage after LAR for rectal cancer.
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Affiliation(s)
| | | | | | | | | | - Bujun Ge
- Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Correspondence: Bujun Ge, Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, 389 XinCun Road, Shanghai 200065, China (e-mail: )
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Willenz U, Wasserberg N, Botero-Anug AM, Greenberg R. Feasibility of an Intraluminal Bypass Device in Low Colorectal Anastomosis. Surg Innov 2015; 23:298-304. [DOI: 10.1177/1553350615617250] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background: The Cologuard CG-100 is a novel intraluminal bypass device designed to reduce the clinical outcomes associated with low colorectal anastomotic leak. The device is inserted transanally, anchored to the colon above the anastomosis, and deployed intraluminally to cover the anastomosis from within. The purpose of this study was to evaluate the safety and performance of the device in a porcine model. Method: Twelve pigs underwent low colorectal anastomosis with insertion of the Cologuard CG-100 device. Contrast material injection, abdominal X-ray, and histologic studies were used to evaluate sealing quality, device positioning, and tissue damage, respectively. The surgeons completed a usability and satisfaction questionnaire after completion of the procedure. Results: Absolute sealing was observed in all 4 animals euthanized immediately after surgery. In the other 8 animals, the device was kept in situ for 10 days and then extracted. X-ray films with injection of contrast material through a designated injection tube before device removal showed that the sheath and ring were correctly placed. No leak was demonstrated. There were no device-related adverse events, and no critical histological abnormalities were noted in the bowel area that was compressed by the device. The device was found to be easy to insert, position, and extract. Conclusion: The Cologuard CG-100 device efficiently reduced contact between fecal content and low colorectal anastomosis in a porcine model and is easily deployed and extracted. It holds promise for possible clinical use pending further studies.
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Affiliation(s)
- Udi Willenz
- The Institute of Animal Research, Kibbutz Lahav, Israel
| | - Nir Wasserberg
- Rabin Medical Center, Petach Tikva, Israel
- Tel Aviv University, Tel Aviv, Israel
| | | | - Ron Greenberg
- Tel Aviv University, Tel Aviv, Israel
- Tel Aviv Medical Center, Tel Aviv, Israel
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Lee SY, Kim CH, Kim YJ, Kim HR. Impact of anal decompression on anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis. Langenbecks Arch Surg 2015; 400:791-6. [PMID: 26318026 DOI: 10.1007/s00423-015-1336-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/21/2015] [Indexed: 12/22/2022]
Abstract
PURPOSE The effectiveness of a transanal drainage tube for the prevention of anastomotic leakage (AL) is still uncertain. This study aimed to investigate the impact of anal decompression on AL after rectal cancer surgery. METHODS We retrospectively reviewed 536 rectal cancer patients who underwent low anterior resection without diverting stoma, with (n = 154) or without (n = 382) placing of a transanal drainage tube, between January 2005 and December 2014. Risk factors for AL were analyzed, and propensity score matching analysis was used to compensate for the differences in baseline characteristics. RESULTS AL occurred in 50 (9.3%) of the patients. Male sex (odds ratio [OR] 3.097, p = 0.005), high ASA score (OR 3.505, p = 0.025), and neoadjuvant chemoradiation (OR 2.506, p = 0.018) were independent predictors of AL on multivariable analysis. After propensity score matching, transanal drainage tube tended to lessen rates of grade C AL with definite peritonitis (1.9 vs. 5.8%, p = 0.077), although there was no difference in the incidence of AL in patients with or without transanal drainage tubes (5.8 vs. 9.1%, p = 0.278). CONCLUSIONS Placement of a transanal drainage tube was not associated with a reduction in the total incidence of AL after low anterior resection for rectal cancer.
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Affiliation(s)
- Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, 519-763, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, 519-763, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, 519-763, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, 519-763, Korea.
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Kim MK, Won DY, Lee JK, Kang WK, Kim JG, Oh ST. Comparative study between transanal tube and loop ileostomy in low anterior resection for mid rectal cancer: a retrospective single center trial. Ann Surg Treat Res 2015; 88:260-8. [PMID: 25960989 PMCID: PMC4422879 DOI: 10.4174/astr.2015.88.5.260] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 11/03/2014] [Accepted: 11/26/2014] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Min-Ki Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dae-Youn Won
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jin-Kwon Lee
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Won-Kyung Kang
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jun-Gi Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Seong Taek Oh
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Ye F, Chen D, Wang D, Lin J, Zheng S. Use of Valtrac™-secured intracolonic bypass in laparoscopic rectal cancer resection. Medicine (Baltimore) 2014; 93:e224. [PMID: 25546660 PMCID: PMC4602602 DOI: 10.1097/md.0000000000000224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The occurrence of anastomotic leakage (AL) remains a major concern in the early postoperative stage. Because of the relatively high morbidity and mortality of AL in patients with laparoscopic low rectal cancer who receive an anterior resection, a fecal diverting method is usually introduced. The Valtrac™-secured intracolonic bypass (VIB) was used in open rectal resection, and played a role of protecting the anastomotic site. This study was designed to assess the efficacy and safety of the VIB in protecting laparoscopic low rectal anastomosis and to compare the efficacy and complications of VIB with those of loop ileostomy (LI). Medical records of the 43 patients with rectal cancer who underwent elective laparoscopic low anterior resection and received VIB procedure or LI between May 2011 and May 2013 were retrospectively analyzed, including the patients' demographics, clinical features, and operative data. Twenty-four patients received a VIB and 19 patients a LI procedure. Most of the demographics and clinical features of the groups, including Dukes stages, were similar. However, the median distance of the tumor edge from the anus verge in the VIB group was significantly longer (7.5 cm; inter-quartile range [IQR] 7.0-9.5 cm) than that of the L1 group (6.0 cm; IQR 6.0-7.0 cm). None of the patients developed clinical AL. The comparisons between the LI and the VIB groups were adjusted for the significant differences in the tumor level of the groups. After adjustment, the LI group experienced longer overall postoperative hospital stay (14.0 days, IQR: 12.0, 16.0 days; P < 0.001) and incurred higher costs ($6300 (IQR: $5900, $6600)) than the VIB group (7.0 days, $4800; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (n = 2), stoma bleeding (n = 1), and wound infection after closure (n = 2). No BAR-related complications occurred. The mean time to Valtrac™ ring loosening was 14.1 ± 3.2 days. The VIB procedure, as a good partner with the laparoscopic rectal cancer resection, appears to be a safe and effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis.
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Affiliation(s)
- Feng Ye
- From the Department of Colorectal Surgery (FY, DC, DW, JL); and Department of General Surgery, the First Affiliated Hospital, Zhejiang University, No. 79, Qinchun Road, Hangzhou, China (SZ)
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Asari SAL, Cho MS, Kim NK. Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center. Eur J Surg Oncol 2014; 41:175-85. [PMID: 25468455 DOI: 10.1016/j.ejso.2014.10.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 09/25/2014] [Accepted: 10/17/2014] [Indexed: 02/09/2023] Open
Abstract
Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.
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Affiliation(s)
- S A L Asari
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea
| | - M S Cho
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea
| | - N K Kim
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea.
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Fayek IS. Evaluation of stapled versus hand-sewn techniques for colo- rectal anastomosis after low anterior resection of mid-rectal carcinoma: a study on 50 patients. Asian Pac J Cancer Prev 2014; 15:5427-31. [PMID: 25041013 DOI: 10.7314/apjcp.2014.15.13.5427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AIM To evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection of mid-rectal carcinoma. PATIENTS AND METHODS A prospective study of fifty patients who underwent colo-rectal anastomosis following low anterior resection (LAR) of T2 mid-rectal cancers at the Egyptian National Cancer Institute during the time period from June 2010 to June 2013 was conducted. Classification was into two groups; a stapled anastomosis group I (25 patients) and a hand-sewn anastomosis group II (25 patients). All operations are evaluated regarding intra-operative complications such as anastomotic line bleeding, visceral injuries or major blood loss. The anastomotic time and operative time are documented for each operation. All patients are evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus. RESULTS The distance of the tumor from the anal verge was 9.6 ± 2.0 cm in group I and 9.9 ± 2.4 cm in group II. The mean operative time was 191.5 ± 16.2 min in the stapled group and 208 ± 18.6 min in the sutured group (p=0.002). The mean anastomotic times were 9.0 ± 1.9 min and 19.7 ± 12.2 min (p=0.001). Anastomotic leakage developed in three (12.0%) patients in the stapled group and in four (16.0%) patients in the sutured group (p=1.000). Post-operative ileus was observed in 3 patients in group I and one patient in group II. Wound infection developed in three (12.0%) patients in the stapled group and four (16.0%) patients in the sutured group (p=1.000). CONCLUSION Colo-rectal anastomosis after low anterior resection for mid rectal carcinoma can be conducted safely either by stapling or hand-sewn techniques; however the stapling technique showed shorter anastomotic and operative times with no significant advantages regarding intra- or post-operative complications or hospital stay.
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Affiliation(s)
- Ihab Samy Fayek
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt E-mail :
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Bioabsorbable staple line reinforcement in restorative proctectomy and anterior resection: a randomized study. Dis Colon Rectum 2014; 57:324-30. [PMID: 24509454 DOI: 10.1097/dcr.0000000000000065] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Anastomotic complications, including leaks, strictures/stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJECTIVE The aim of this study was to assess whether the use of a synthetic, bioabsorbable staple line reinforcement material with circular staplers would reduce postoperative anastomotic leakage in patients with a colorectal, coloanal, or ileoanal anastomosis. DESIGN This was a randomized study that compared outcomes in patients in whom the reinforcement material was used with those in patients who were not given the material. SETTINGS This study was conducted at several centers in the United States. PATIENTS The 258 patients (123 in the reinforcement group and 135 control subjects) underwent surgery for a variety of conditions, but most (n = 200) were treated for rectal cancer. MAIN OUTCOME MEASURES The main outcome measures were occurrence of anastomotic leaks and other complications according to the study protocol. RESULTS There were no significant differences in the 2 study groups with respect to age, BMI, ASA physical status, operating time, diagnosis, previous chemoradiotherapy, surgical technique, or 30-day complications, except for a higher rate of small-bowel obstruction (p = 0.03) and anastomotic stricture (p = 0.006) in the control group. The overall anastomotic leak rate was 12% (bioabsorbable staple line reinforcement, 11.4%; no bioabsorbable staple line reinforcement, 12.6%). LIMITATIONS The study was nonblinded and was terminated at the first planned interim analysis because of insufficient power to detect an intergroup difference in anastomotic leak rate in the time allotted for the investigation. CONCLUSIONS Reinforcing the circular staple line in colorectal anastomoses with bioabsorbable material did not significantly affect the anastomotic leak rate but may have reduced anastomotic strictures. Most strictures did not require an anastomotic revision or delay in stoma closure. The bioabsorbable material may positively affect some aspects of the healing of circular stapled colorectal anastomoses; however, additional research on factors associated with anastomotic leakage is needed.
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Prevention of leakage by sealing colon anastomosis: experimental study in a mouse model. J Surg Res 2013; 184:819-24. [PMID: 23764314 DOI: 10.1016/j.jss.2013.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 03/22/2013] [Accepted: 04/05/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND In colorectal surgery, anastomotic leakage (AL) is the most significant complication. Sealants applied around the colon anastomosis may help prevent AL by giving the anastomosis time to heal by mechanically supporting the anastomosis and preventing bacteria leaking into the peritoneal cavity. The aim of this study is to compare commercially available sealants on their efficacy of preventing leakage in a validated mouse model for AL. METHODS Six sealants (Evicel, Omnex, VascuSeal, PleuraSeal, BioGlue, and Colle Chirurgicale Cardial) were applied around an anastomosis constructed with five interrupted sutures in mice, and compared with a control group without sealant. Outcome measures were AL, anastomotic bursting pressure, and death. RESULTS In the control group there was a 40% death rate with a 50% rate of AL. None of the sealants were able to diminish the rate of AL. Furthermore, use of the majority of sealants resulted in failure to thrive, increased rates of ileus, and higher mortality rates. CONCLUSIONS If sealing of a colorectal anastomosis could achieve a reduction of incidence of clinical AL, this would be a promising tool for prevention of leakage in colorectal surgery. In this study, we found no evidence that sealants reduce leakage rates in a mouse model for AL. However, the negative results of this study make us emphasize the need of systemic research, investigating histologic tissue reaction of the bowel to different sealants, the capacity of sealants to form a watertight barrier, their time of degradation, and finally their results in large animal models for AL.
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Daams F, Monkhorst K, van den Broek J, Slieker JC, Jeekel J, Lange JF. Local ischaemia does not influence anastomotic healing: an experimental study. ACTA ACUST UNITED AC 2013; 50:24-31. [PMID: 23548268 DOI: 10.1159/000348411] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 01/28/2013] [Indexed: 12/19/2022]
Abstract
The role of local ischaemia in the pathogenesis of colorectal anastomotic leakage (AL) is not known. This study investigates the role of local ischaemia caused by sutures in an experimental colonic anastomosis model. 36 mice were assigned to three types of anastomosis, all using running sutures; in the first group 5 stitches were used, in the second group 12 stitches were used, and in the third group at least 30 stitches were used. After 7 days the mice were re-operated, signs of AL were scored, and coronal sections of the anastomosis were histologically analyzed. The distribution of weight was not significantly different between the three groups. Mortality was 44% and not significantly different between the groups (group 1: 5/12, group 2: 4/12, and group 3: 7/12, p = 0.72). Faecal and purulent AL were observed in 6 animals in group 1, 2 in group 2, and 3 in group 3 (group 1: 50%, group 2: 17%, and group 3: 25%, p = 0.19). The distance between the two colonic edges (group 1: 0.51 μm, group 2: 1.34 μm, and group 3: 0.53 μm, p = 0.18), the diameter of the lumen at the site of the anastomosis (group 1: 2.92 μm, group 2: 4.06 μm, and group 3: 3.2 μm, p = 0.9), and the largest diameter of the lumen proximally to the anastomosis (group 1: 2.05 μm, group 2: 3.1 μm, and group 3: 2.6 μm, p = 0.25) were not different between the groups. Histological parameters of wound healing were not significantly different for the three groups. In this study no macroscopic and microscopic differences were observed between colon anastomosis with 5 stitches versus 12 and >30 stitches. This might indicate that local ischaemia does not negatively influence colonic wound healing.
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Affiliation(s)
- F Daams
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Liu K, Yu H, Zhang M, Yu Y, Wang Y, Cai X. Sutureless primary repair of colonic perforation with a degradable stent in a porcine model of fecal peritonitis. Int J Colorectal Dis 2012; 27:1607-17. [PMID: 22664946 DOI: 10.1007/s00384-012-1511-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Colonic perforation with fecal peritonitis is a life-threatening clinical condition. For these patients, a two-stage operation of fecal diversion and a postponed colostomy closure is generally recommended. Accordingly, a simple and feasible primary repair technique was explored. METHODS A sutureless banding method using a biodegradable stent and a porcine model of artificial colonic perforation were introduced. The colonic perforation model was created successfully with an open procedure in 34 pigs. The primary repair with a stent or the conventional hand-sewn control was performed 72 h later. Morbidity and mortality were recorded. Pigs in each group were also sacrificed to evaluate the healing on postoperative days (PODs) 3, 7, 14, and 90. The peripheral white blood cell counts, albumin, anastomotic bursting pressure, hydroxyproline contents, and histology data were evaluated. RESULTS There were 17 pigs in either group. Four pigs (23.5 %) of the control group died, but no mortality occurred in the stent group. There were no significant differences in white blood cell counts and albumin. Though anastomotic hydroxyproline contents between the two groups were comparable, the collagen per protein ratio on POD 14 in the stent group was higher, as well as the bursting pressure on PODs 3 and 7. Microscopically, the local inflammation of the cut edges in the control group was more severe, and the collagen synthesis started later. CONCLUSIONS A sutureless primary repair of a colonic perforation with a degradable stent is a feasible method in a porcine model of fecal peritonitis.
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Affiliation(s)
- Kun Liu
- Department of Hepatobiliary Surgery, Qingdao Municipal Hospital, Ocean University of China, Qingdao, China
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Current world literature. Curr Opin Oncol 2012; 24:587-95. [PMID: 22886074 DOI: 10.1097/cco.0b013e32835793f1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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