Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?

A novel circumferential continuous reinforcing suture for anastomosis after laparoscopic resection for rectal cancer and sigmoid cancer: a retrospective case-controlled study

INTRODUCTION

This study aimed to investigate the effectiveness of a novel method for anastomosis reinforcement to minimize the occurrence of anastomotic complications after surgical resection of rectal and sigmoid cancer.

METHODS

We recruited 378 patients who underwent laparoscopic rectal anterior resection of rectal cancer and sigmoid cancer in SYSUCC. The occurrence rates of intraoperative bleeding, operation time, and postoperative anastomotic complications were compared between the treatment group receiving anastomotic reinforcement and the control group without anastomotic reinforcement.

RESULTS

The incidence of anastomotic leakage in the treatment group was significantly lower than that in the control group (1.59% vs. 11.64%, p < 0.001). Following the application of inverse probability of treatment weighting (IPTW) to adjust for factors influencing the occurrence of anastomotic leakage, the incidence of anastomotic leakage remained significantly lower in the treatment group compared to the control group (2.54% vs. 12.08%, p < 0.001).

CONCLUSION

The circumferential continuous anastomosis reinforcing suture method, recommended for laparoscopic surgery for rectal and sigmoid cancer, has the potential to effectively minimize the occurrence of anastomotic complications.

Effectiveness of anastomotic reinforcement sutures in reducing anastomotic leakage risk after laparoscopic rectal cancer surgery: a pooled and integration analysis

Background and objectives

Anastomotic leakage (AL) is one of the most serious complications after laparoscopic anus-preserving surgery for rectal cancer, which significantly prolongs the patient's hospital stay, leads to dysfunction, and even increases the patient's perioperative morbidity and mortality, and little is known about the effectiveness of anastomotic reinforcement sutures to prevent AL. Thus, this study was conducted to evaluate the efficacy of anastomotic reinforcement sutures as a means to prevent AL during laparoscopic surgery for rectal cancer.

Methods

A comprehensive and systematic search was performed in the literature database by combining subject and free terms up to 10 October 2023. The overall literature included was integrated and analyzed using Stata 12.0 software and Review Manager version 5.4 software to assess the effect of anastomotic reinforcement sutures on the incidence of AL.

Results

A total of 2,452 patients from 14 studies were included, and an integrated analysis showed that the use of anastomotic reinforcement sutures significantly reduced the incidence of AL [odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.18-0.37; P < 0.00001; I2 = 0%]. However, the findings confirmed whether or not the anastomosis reinforced with sutures did not affect the incidence of anastomotic stenosis (OR = 0.69; 95% CI, 0.37-1.32; P = 0.27; I2 = 0%). We performed subgroup analyses of the results of the study, the randomized controlled studies (OR = 0.31; 95% CI, 0.15-0.65; P < 0.001) as well as retrospective studies (OR = 0.28; 95% CI, 0.19-0.41; P < 0.001), 3-0 sutures (OR = 0.28; 95% CI, 0.17-0.45; P < 0.001) versus 4-0 sutures (OR = 0.26; 95% CI, 0.13-0.53; P < 0.001), barbed wire sutures (OR = 0.26; 95% CI, 0.14-0.48; P < 0.001) versus non-barbed wire sutures (OR = 0.30; 95% CI, 0.20-0.46; P < 0.001), interrupted (OR = 0.30, 95% CI, 0.20-0.46; P < 0.001) versus continuous sutures (OR = 0.29, 95% CI, 0.16-0.51; P < 0.001) to the anastomosis, full-thickness suture (OR = 0.29; 95% CI, 0.16-0.51; P < 0.001) versus sutured with the seromuscular layer (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001), anastomotic sutured in one (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001) versus non-one circle (OR = 0.30; 95% CI, 0.20-0.44; P < 0.001), and reinforcing sutures to the dog-ear area (OR = 0.26; 95% CI, 0.14-0.50; P < 0.001) versus the non-dog-ear area (OR = 0.30; 95% CI, 0.20-0.45; P < 0.001), which have suggested that there is no significant difference between each other and that all of them reduce the incidence of AL.

Conclusions

This study provides evidence that performing reinforcement suturing of the anastomosis during laparoscopic rectal surgery significantly lowers the incidence of postoperative AL but has no significant effect on anastomotic stenosis. It is important to note that further randomized controlled studies are required to confirm this conclusion.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022368631.

Efficacy of reinforcing sutures for prevention of anastomotic leakage after low anterior resection for rectal cancer: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Anastomotic leakage is a serious complication following surgery for cancer of the rectum. It is not clear whether reinforcing sutures could prevent anastomotic leakage. Therefore, this study aims at evaluating the efficacy of reinforcing sutures on anastomotic leakage.

METHODS

We searched PubMed, Embase, and the Cochrane Library databases from inception to January 31, 2023. We included studies comparing anastomosis with reinforcing sutures to anastomosis without reinforcing sutures after low anterior resection. Risk of bias was assessed by the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies. The overall quality of evidence for primary outcome was assessed using Grading of Recommendations Assessment, Development, and Evaluations methodology.

RESULTS

Two RCTs (345 patients) and four observational studies (783 patients) were included. Anastomotic leakage occurred in 4.4% (24 of 548) of patients with reinforcing sutures and 11.9% (69 of 580) of patients without reinforcing sutures. Meta-analysis showed a lower incidence of anastomotic leakage (RR, 0.41; 95% CI 0.25 to 0.66, low certainty) in patients with reinforcing sutures. Operative time (WMD, -3.66; 95% CI -18.58 to 11.25) and reoperation for anastomotic leakage (RR, 0.69; 95% CI 0.23 to 2.08) were similar between patients with reinforcing sutures and those without reinforcing sutures.

CONCLUSIONS

While observational data suggest that, there is a clear benefit in terms of reducing the risk of anastomotic leakage with the use of reinforcing sutures, RCT data are less clear. Further large, prospective studies are warranted to determine whether a true clinically important benefit exists with this technique.

Clinical efficacy of anastomotic reinforcement suture in preventing anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis

PURPOSE

Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, with an incidence of about 10%, and the efficacy of reinforced sutures for preventing AL remains contentious. This study investigated the safety and effectiveness of reinforcement sutures for preventing AL after rectal cancer surgery.

METHODS

The present authors conducted a systematic search in the PubMed, Embase, Cochrane Library, Sinomed, Web of Science, Wanfang, VIP, and CNKI databases for randomized controlled trials (RCTs) and nonrandomized studies up to June 2023. We performed a meta-analysis to evaluate the efficacy of anastomotic reinforcement sutures after rectal cancer surgery. The primary outcome measures were AL, anastomotic bleeding, and infection rates.

RESULTS

Eleven articles (1921 subjects) were analyzed, with 912 and 1009 cases in the reinforced and unreinforced suture groups, respectively. The reinforced suture group showed a lower AL incidence (odds ratio [OR]=0.25, 95% CI 0.17-0.37, P< 0.00001), lower infection rate (OR=0.41, 95%CI 0.19-0.89, P<0.05), shorter hospital stay (mean difference [MD]=-0.57, 95%CI -1.15-0.00, P≤0.05), and earlier anal exhaust (MD=-0.12, 95%CI -0.23-0.00, P<0.05). However, the operative time (MD=18.25, 95% CI 12.20-24.30, P<0.00001) was longer for reinforced sutures than for unreinforced sutures. There were no significant differences between the suture techniques in intraoperative blood loss MD=2.74, 95% CI -4.50-9.97, P>0.05), incidence of anastomotic bleeding (OR=0.49, 95%CI 0.12-1.97, P>0.05), and incidence of intestinal obstruction (OR=0.65, 95%CI 0.27-1.61, P>0.05).

CONCLUSION

Existing articles indicate that anastomotic reinforcement sutures can significantly reduce AL incidence. However, this conclusion still requires confirmation based on multicentre, high-quality RCTs with large sample sizes.

Effect of intraoperative anastomotic reinforcement suture on the prevention of anastomotic leakage of double-stapling anastomosis for laparoscopic rectal cancer: a systematic review and meta-analysis

BACKGROUND AND AIMS

The use of sutures to strengthen the anastomosis after rectal cancer surgery to reduce the possibility of anastomotic leakage has been debated. The aim of this systematic review and meta-analysis was to investigate the influence of intraoperative anastomotic reinforcing sutures on anastomotic leakage of double-stapling anastomosis for laparoscopic rectal cancer surgery.

METHODS

A systematic search of PubMed, Embase, Web of Science, and Cochrane databases was performed to identify literature examining anastomotic leak as the primary outcome to compare studies of laparoscopic surgery for rectal cancer using the double-stapling anastomosis technique with or without intraoperative anastomotic reinforcement with sutures.

RESULTS

A total of 1122 rectal cancer patients from 5 nonrandomized studies were included in the research. In the combined trial, intraoperative anastomotic reinforcement sutures significantly reduced the incidence of anastomotic leakage in patients who underwent laparoscopic rectal cancer surgery (OR, 0.32; 95% CI, 0.19-0.55; p < 0.0001). With or without intraoperative anastomotic reinforcing sutures, the incidence of postoperative reoperation for anastomotic leak did not differ substantially (OR, 0.32; 95% CI, 0.08-1.21, p = 0.09). Moreover, the surgery was prolonged due to anastomotic reinforcement with sutures (OR, 6.64; 95% CI, - 6.18 to 19.47, p = 0.31).

CONCLUSIONS

Intraoperative anastomotic reinforcement with sutures may be associated with a lower incidence of anastomotic leakage. The amount of research evidence is limited because most of the studies analyzed did not include patients with factors such as neoadjuvant therapy or prophylactic stomas. Therefore, additional multicenter randomized controlled studies with larger size samples are needed to support the validity of the approach.

Effect of reinforcement suture on anastomotic healing in rectal and sigmoid tumor resections, single-center experience: a retrospective case-controlled study

PURPOSE

Healing of colorectal anastomosis is burdened with a number of risk factors and the development of leak carries with it higher morbidity and mortality associated not only with worse quality of life but also worse oncological outcomes. The purpose of the study was an evaluation of the effect of reinforcement suture in the healing of stapler rectal anastomosis and risk factors for anastomotic leakage in mid, upper rectal and sigmoid tumors.

METHODS

A total of 357 patients who underwent curative resection for rectal or sigmoid tumor over 5 years were analyzed. Risk factors, baseline demographic and clinical data, and presence of leak were recorded. All statistical analyses were carried out at a significance level of P<0.05.

RESULTS

One hundred fifty-one patients met the inclusion criteria for the study. The overall incidence of leak was 2.8% in the group with reinforcement suture and 6.3% in the group without reinforcement suture. Because of the low incidence of leak the results were not statistically significant. Further results also show that none of the monitored parameters (age, weight, body mass index, tumor distance, preoperative radiotherapy, tumor stage, type of surgery) were significant predictors of anastomotic leakage.

CONCLUSION

Although the reinforcement suture is a safe and simple option for anastomosis protection after rectal or sigmoid resections, its statistical significance was not demonstrated in our study.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND

Multiple linear stapler firings during double stapling technique (DST) after laparoscopic low anterior resection (LAR) are associated with an increased risk of anastomotic leakage (AL). However, it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.

AIM

To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging (MRI).

METHODS

We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis, which were randomly divided into a training set (n = 260) and testing set (n = 68). Binary logistic regression was adopted to create a clinical model using six factors. The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed. Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks. Sensitivity, specificity, accuracy, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) was calculated for each model.

RESULTS

The prevalence of ≥ 3 linear stapler cartridges was 17.7% (58/328). The prevalence of AL was statistically significantly higher in patients with ≥ 3 cartridges compared to those with ≤ 2 cartridges (25.0% vs 11.8%, P = 0.018). Preoperative carcinoembryonic antigen level > 5 ng/mL (OR = 2.11, 95%CI 1.08-4.12, P = 0.028) and tumor size ≥ 5 cm (OR = 3.57, 95%CI 1.61-7.89, P = 0.002) were recognized as independent risk factors for use of ≥ 3 linear stapler cartridges. Diagnostic performance was better with the integrated model (accuracy = 94.1%, PPV = 87.5%, and AUC = 0.88) compared with the clinical model (accuracy = 86.7%, PPV = 38.9%, and AUC = 0.72) and the image model (accuracy = 91.2%, PPV = 83.3%, and AUC = 0.81).

CONCLUSION

MRI-based deep learning model can predict the use of ≥ 3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery. This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for ≥ 3 linear stapler cartridges.

Intracorporeal reinforcement with barbed suture is associated with low anastomotic leakage rates after laparoscopic low anterior resection for rectal cancer: a retrospective study

Background

Anastomotic leakage (AL) is one of most severe postoperative complications following low anterior resection (LAR) for rectal cancer, and has an adverse impact on postoperative recovery. The occurence of AL is associated with several factors, while few studies explored the role of intracorporeal barbed suture reinforcement in it.

Methods

Consecutive cases underwent laparoscopic LAR for rectal cancer from Mar. 2018 to Feb. 2021 in our center were retrospectively collected. Cases were classified into the intracorporeal barbed suture reinforcement group and the control group according to whether performing intracorporeal reinforcement with barbed suture, and AL incidences were compared between two groups. Propensity score matching (PSM) was then performed based on identified risk factors to reduce biases from covariates between two groups. AL incidences in the matched cohort were compared.

Results

A total of 292 cases entered into the study, and AL incidences were significantly lower in the intracorporeal barbed suture reinforcement group compared with the control group (10.00% vs 2.82%, P = 0.024). Sex, BMI, preoperative adjuvant chemoradiotherapy and anastomotic level were chose for PSM analyses based on previous studies. In the matched cohort, the AL incidences were still significantly lower in the intracorporeal barbed suture reinforcement group (10.57% vs 2.44%, SD = 0.334).

Conclusions

Intracorporeal barbed suture reinforcement is associated with low AL incidences after laparoscopic LAR for rectal cancer, which is a potential procedure for reducing AL and worthy of application clinically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01782-x.

Efficacy of staple line reinforcement by barbed suture for preventing anastomotic leakage in laparoscopic rectal cancer surgery

BACKGROUND

Anastomotic leakage (AL) is a severe complication in rectal cancer surgery. Various methods, including intracorporeal reinforcing suturing, have been used to reduce the incidence of AL. However, little is known about the efficacy of staple-line reinforcement by barbed suture for preventing AL.

AIM

To evaluate the efficacy of staple-line reinforcement using barbed suture for preventing AL in laparoscopic surgery for rectal cancer.

METHODS

We retrospectively reviewed the clinical datum of 319 patients undergoing laparoscopic low anterior resection combined with double stapling technique between May 1, 2017 and January 31, 2021. All surgeries were performed by the same surgical team specializing in colorectal surgery. Patients were divided into two groups depending on whether they received reinforcing sutures. Patients’ baseline characteristics did not show any significant difference between the two groups. We analyzed patient-, tumor-, as well as surgery-related variables using univariate and multivariate logistic analyses.

RESULTS

There were 168 patients in the reinforcing suture group and 151 patients in the non-reinforcing suture group. AL occurred in 25 cases (7.8%). Its incidence was significantly higher in the non-reinforcing suture group than in the reinforcing suture group (4.8% vs 11.3%, P = 0.031). The multivariate analyses demonstrated that the tumor site, tumor size and presence of staple-line reinforcement were independent risk factors for AL. We divided these patients into two risk groups based on the combination of tumor site and tumor size. Patients without any risk factor were assigned to the low-risk group (n = 177), whereas those having one or two risk factors were assigned to the high-risk group (n = 142). In the high-risk group, the AL incidence considerably decreased in the reinforcing suture group compared with that in the non-reinforcing suture group (P = 0.038). Nonetheless, no significant difference was found in the low-risk group between the two groups.

CONCLUSION

Staple-line reinforcement by barbed suture may decrease the incidence of AL. A large-scale prospective randomized controlled trial is needed for evaluating the efficacy of staple-line reinforcement for preventing AL.

Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer

Objectives

This paper introduces the surgical procedure of "terminal ileum suspension" in the radical resection for low rectal cancer patients and evaluates the possibility of its clinical application.

Methods

This paper retrospectively analyzed the data of patients with low rectal cancer who underwent "terminal ileum suspension" during radical resection of rectal cancer (Dixon) in our hospital, and introduces the specific surgical procedures and key points of "terminal ileum suspension". Observe the relevant conditions of patients during the operation, postoperative recovery and postoperative complications, and analyze the safety and feasibility of this operation ("terminal ileum suspension").

Results

The operation of all 8 patients went smoothly, and no anastomotic leakage, intestinal obstruction, and open diversion of suspended terminal ileum were found. The application of "terminal ileum suspension" in the operation of low rectal cancer has achieved ideal clinical effect, without increasing the rate of anastomotic leakage and rehospitalization, reducing the proportion of the secondary return operation, and reducing the pain of the patients.

Conclusion

"Terminal ileum suspension" is a safe, effective and feasible surgical method for laparoscopic radical resection of low rectal cancer, which can be applied in clinical practice.

Feasibility of endoscopic hand suturing on rectal anastomoses in ex vivo porcine models

Prevention of postoperative anastomotic leakage in rectal surgery is still required. This study investigated the feasibility of endoscopic hand suturing (EHS) on rectal anastomosis ex vivo. By using isolated porcine colon, we prepared ten anastomoses 6–10 cm from the virtual anus. Then, we sutured anastomoses intraluminally by EHS, which involved a continuous suturing method in 5 cases and a nodule suturing method with extra corporeal ligation in 5 cases. Completeness of suturing, number of stitches, procedure time and presence of stenosis were investigated. Furthermore, the degree of stenosis was compared between the two suturing methods. In all cases, EHS were successfully completed. The median number of stitches and procedure time was 8 and 5.8 min, respectively. Stenosis was created in all continuous suturing cases whereas none was seen in nodule suturing cases. The shortening rate was significantly greater in the continuous suturing method than in the nodule suturing method. Intraluminal reinforcement of rectal anastomosis by EHS using nodule suturing with extra corporeal ligation is feasible without stenosis, which may be helpful as a countermeasure against possible postoperative anastomotic leakage in rectal surgery.

Biomaterial-Assisted Anastomotic Healing: Serosal Adhesion of Pectin Films

Anastomotic leakage is a frequent complication of intestinal surgery and a major source of surgical morbidity. The timing of anastomotic failures suggests that leaks are the result of inadequate mechanical support during the vulnerable phase of wound healing. To identify a biomaterial with physical and mechanical properties appropriate for assisted anastomotic healing, we studied the adhesive properties of the plant-derived structural heteropolysaccharide called pectin. Specifically, we examined high methoxyl citrus pectin films at water contents between 17-24% for their adhesivity to ex vivo porcine small bowel serosa. In assays of tensile adhesion strength, pectin demonstrated significantly greater adhesivity to the serosa than either nanocellulose fiber (NCF) films or pressure sensitive adhesives (PSA) (p < 0.001). Similarly, in assays of shear resistance, pectin demonstrated significantly greater adhesivity to the serosa than either NCF films or PSA (p < 0.001). Finally, the pectin films were capable of effectively sealing linear enterotomies in a bowel simulacrum as well as an ex vivo bowel segment. We conclude that pectin is a biomaterial with physical and adhesive properties capable of facilitating anastomotic healing after intestinal surgery.

[Prevention of colorectal anastomotic leakage using its reinforcement (results of the randomized study)]

OBJECTIVE

To reduce the incidence of postoperative complications via reinforcement of colorectal anastomosis.

MATERIAL AND METHODS

A randomized prospective study included 115 patients. In the main group (n=60), anterior resections were followed by reinforcement of colorectal anastomosis via suturing the muscular and serous layers at 2, 4, 6, 8, 10, 12 o'clock. In case of low anterior resection, all layers of intestinal wall were transanally sutured at the above-mentioned points. Reinforcement was not performed in the control group (n=55).

RESULTS

In the main group, overall incidence of anastomotic leakage was 8.3% (5/60), in the control group - 25.5% (14/55) (p=0.01). We also analyzed the subgroups of anastomoses with high and low risk of leakage. In case of transabdominal reinforcement, incidence of anastomotic leakage was 11% (2/18) in the main group and 0% (0/14) in the control group (p=0.6). Transanal reinforcement was followed by anastomotic leakage in 7% (3/42) of patients in the main group and 34% (14/41) of patients in the control group (p=0.005).

CONCLUSION

Reinforcement of colorectal instrumental anastomosis by additional sutures reduces the incidence of postoperative complications associated with anastomotic leakage.

Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial

AIM

The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy.

METHODS

This is a prospective, multicentre, parallel-arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1-3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group).

RESULTS

Twenty-nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra-operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of -1.20% (90% CI -17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI -7.74 to 38.17).

CONCLUSION

Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1-3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771).

Mucosa plication reinforced colorectal anastomosis and trans-anal vacuum drainage: a pilot study with preliminary results

Dehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019–October 2020. The mean age of patients was 61 years (lower–upper quartiles 54–69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower–upper quartiles 3.00–4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien–Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation.

Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.

The safety and efficacy of laparoscopic surgery versus laparoscopic NOSE for sigmoid and rectal cancer

BACKGROUND

Laparoscopic surgery with natural orifice specimen extraction (La-NOSE) is being performed more frequently for the minimally invasive management of sigmoid and rectal cancer. The objective of this meta-analysis was to compare the clinical and oncological safety and efficacy of La-NOSE versus conventional laparoscopy (CL).

METHODS

A search of the PubMed, Web of Science, and Cochrane databases was performed for studies that compared clinical or oncological outcomes of conventional laparoscopic resection using NOSE with conventional laparoscopic resection for sigmoid and rectal cancer.

RESULTS

Compared with CL group, the length of hospital stay and the pain score on the first day were shorter in the La-Nose group. The La-NOSE group had a lower incidence of total perioperative complications (OR 0.46; 95% CI [0.32 to 0.66]; I² = 0%; P < 0.0001) and a lower incidence of surgical site infections (SSIs) (OR 0.11; 95% CI [0.04 to 0.29]; I² = 0%; P < 0.0001) than the CL group, while the anastomotic leakage showed no significant difference between the La-Nose group and the CL group (P = 0.19). 5-year disease-free survival (DFS) and 5-year overall survival (OS) were no significant difference between the La-Nose group and the CL group (P = 0.43, P = 0.40, respectively).

CONCLUSIONS

La-NOSE can achieve oncological and surgical safety comparable to that of CL for patients with sigmoid and rectal cancer. La-NOSE in patients was associated with a shorter hospital stay, shorter time to first flatus or defecation, less postoperative pain, and fewer surgical site infections (SSIs) and total perioperative complications. In general, the operative time in La-NOSE was longer than that in CL. The long-term oncological efficacy of La-NOSE seems to be equivalent to that of CL.

Effectiveness of a Transanal Drainage Tube for the Prevention of Anastomotic Leakage after Laparoscopic Low Anterior Resection for Rectal Cancer

BACKGROUND AND OBJECTIVE

Anastomotic leakage is one of the most serious complications after laparoscopic low anterior resection Low Anterior Resection (LAR) for rectal cancers. The purpose of this study was to evaluate the effectiveness of a transanal drainage tube placed for the prevention of anastomotic leakage after laparoscopic LAR.

METHODS

The clinical data of 220 patients with rectal cancer who underwent laparoscopic LAR using the double stapling technique Double Stapling Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Technique (DST) from Jun 2017 to Dec 2018 were analyzed retrospectively at our institution. A transanal drainage tube was placed after anastomosis in 120 patients (TDT group). Another 100 patients were operated on without a transanal drainage tube (NTDT group). Clinicopathological and surgical factors, the frequencies of anastomotic leakage and re-operation after leakage were compared between the two groups.

RESULTS

Patient age, gender, body mass index, American Society of Anesthesiologists (ASA) score, previous abdominal surgery, intraoperative blood loss, tumor size, tumor stage, specimen length, distance of tumor from the anal verge, and operative time were comparable between the two groups. Overall rate of leakage was 4.5% (10/220). The frequency of leakage was 3.3% (4/120) in TDT group and was 6.0% (6/100) in NTDT group. The rate of leakage was significantly lower in TDT group (p<0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 50.0% (2/4) in TDT group, while in contrast it was 83.3% (5/6) in NTDT group. The rate of re-operation was lower in TDT group than NTDT group (p<0.05).

CONCLUSIONS

The use of a transanal drainage tube in laparoscopic LAR for rectal cancer is a simple and effective method for prevention of anastomotic leakage and decreases the rate of re-operation after symptomatic leakage.

[Reinforcement of staple line of colorectal anastomosis for leakage prevention: a systematic review and metaanalysis]

OBJECTIVE

To evaluate the influence of reinforcement of staple line of colorectal anastomosis on the incidence of leakage.

MATERIAL AND METHODS

A systematic review was performed in accordance with the PRISMA recommendations. Statistical analysis was carried out in the Review Manager 5.3 software.

RESULTS

This trial included four original articles published in 2011-2018. There were 493 patients. Reinforcement of anastomosis was made in 232 (47%) cases, colorectal anastomosis was not reinforced in 261 (53%) patients. Anastomotic leakage rate was 5.6 and 11.1% in both groups, respectively (OR 0.55, CI 0.13-2.33; p=0.42). Transabdominal reinforcement reduced leakage rate by 10.2% (OR 0.18, CI 0.06-0.55; p=0.002) while transanal reinforcement was ineffective (OR 1.66, CI 0.38-7.19; p=0,5). Incidence of preventive stoma was similar (OR 0.3, CI 0.07-1.22; p=0.09), but it was possible to abandon preventive stoma in 18% of cases after anastomotic reinforcement.

CONCLUSION

A small number of studies dedicated to anastomosis reinforcement resulted controversial data.

Short-term efficacy of natural orifice specimen extraction surgery for low rectal cancer

BACKGROUND

This case-control study compared the short-term clinical efficacy of natural orifice specimen extraction surgery (NOSES) using a prolapsing technique and the conventional laparoscopic-assisted approach for low rectal cancer.

AIM

To further explore the application value of the transanal placement of the anvil and to evaluate the short-term efficacy of NOSES for resecting specimens of low rectal cancer, as well as to provide a theoretical basis for its extensive clinical application.

METHODS

From June 2015 to June 2018, 108 consecutive laparoscopic-assisted low rectal cancer resections were performed at our center. Among them, 26 specimens were resected transanally using a prolapsing technique (NOSES), and 82 specimens were resected through a conventional abdominal wall small incision (LAP). A propensity score matching method was used to select 26 pairs of matched patients, and their perioperative data were analyzed.

RESULTS

The baseline data were comparable between the two matched groups. All 52 patients underwent the surgery successfully. The operative time, blood loss, number of harvested lymph nodes, postoperative complication rate, circumferential margin involvement, postoperative follow-up data, and postoperative anal function were not statistically significant. The NOSES group had shorter time to gastrointestinal function recovery (2.6 ± 1.0 d vs 3.4 ± 0.9 d, P = 0.006), shorter postoperative hospital stay (7.1 ± 1.7 d vs 8.3 ± 1.1 d, P = 0.003), lower pain score (day 1: 2.7 ± 1.8 vs 4.6 ± 1.9, day 3: 2.0 ± 1.1 vs 4.1 ± 1.2, day 5: 1.7 ± 0.9 vs 3.3 ± 1.0, P < 0.001), a lower rate of additional analgesic use (11.5% vs 61.5%, P = 0.001), and a higher satisfaction rate in terms of the aesthetic appearance of the abdominal wall after surgery (100% vs 23.1%, P < 0.001).

CONCLUSION

NOSES for low rectal cancer can achieve satisfactory short-term efficacy and has advantages in reducing postoperative pain, shortening the length of postoperative hospital stay, and improving patients’ satisfaction in terms of a more aesthetic appearance of the abdominal wall.

[Prevention of colorectal anastomotic leakage in patients with rectal cancer]

OBJECTIVE

To develop a technique of anastomosis sutures protection using the Foley catheter in rectal cancer surgery.

MATERIAL AND METHODS

There were 42 patients with rectal cancer T1-3N0-2M0 (the 7^th TNM edition) who underwent radical sphincter-sparing surgery with neoadjuvant chemoradiotherapy for the period from November 2016 to June 2018. All procedures were performed at the Regional Clinical Oncology Center. All operations were completed with formation of colorectal anastomosis in 'end-to-side' fashion. Patients were divided into 2 groups (main and control) depending on used technique. In the main group (n=20), Foley catheter #30 in accordance with original method was used to protect the anastomosis. Preventive colostomy was applied in 15 patients. The control group consisted of 22 patients. None of these patients underwent prevention of anastomosis leakage. Preventive colostomy was performed in 14 patients.

RESULTS

There were no early postoperative complications in the main group. The catheter was removed after 7-9 days. In the control group, 5 patients had symptoms of anastomotic leakage (22.5%; p<0.05). Medication was effective in 4 cases. Re-laparotomy were required in 1 patient.

CONCLUSION

Thus, anastomosis sutures protection using the Foley catheter is quite reliable and technically simple procedure with favorable outcomes.

Rectal tube drainage reduces major anastomotic leakage after minimally invasive rectal cancer surgery

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.

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Impact of anal decompression on anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis

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.

The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.

Efficacy of transanal tube for prevention of anastomotic leakage following laparoscopic low anterior resection for rectal cancers: a retrospective cohort study in a single institution

BACKGROUND

Anastomotic leakage is one of the most serious complications following laparoscopic low anterior resection (LAR) for rectal cancers. The purpose of this study was to investigate whether transanal tube placement can reduce anastomotic leakage following laparoscopic LAR.

METHODS

Retrospective assessment was performed on 205 patients with rectal cancers who underwent laparoscopic LAR. A transanal tube was placed after anastomosis in 96 patients (group A). Another 109 patients were operated on without a transanal tube (group B). Clinicopathological and operative variables, the frequencies of anastomotic leakage and re-operation after leakage were investigated.

RESULTS

Patient age, gender, body mass index, tumor size, Dukes' stage, intra-operative blood loss, and the rate of left colic artery preservation were comparable between the two groups. Tumor location was lower and operative time was significantly longer in group A than group B (p < 0.001). Overall rate of leakage was 9.3 % (19/205). The frequency of leakage was 4.2 % (4/96) in group A and was 13.8 % (15/109) in group B. The rate of leakage was significantly lower in group A (p < 0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 0 % (0/4) in group A, while in contrast it was 73.3 % (10/15) in group B. The rate of re-operation was lower in group A than group B (p < 0.05) and all cases with symptomatic leakage in group A were cured by conservative treatment.

CONCLUSIONS

Transanal tube placement was effective for prevention of anastomotic leakage following laparoscopic LAR and avoiding re-operation after symptomatic leakage.