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Zhou L, Zhang Z, Li H, Wang L. A latent profile analysis of psychosocial adjustment in patients with enterostomy after rectal cancer surgery. Eur J Oncol Nurs 2024; 71:102626. [PMID: 38878693 DOI: 10.1016/j.ejon.2024.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 07/22/2024]
Abstract
PURPOSE The aim of this study was to improve the level of psychosocial adjustment and quality of life of patients with enterostomy by analyzing the subgroups of psychosocial adjustment and its influencing factors. METHODS This was a multi-center cross-sectional study. On the basis of investigating the level of psychosocial adjustment of enterostomy patients, a profile model of psychosocial adjustment of patients with enterostomy was established by using latent profile analysis. Univariate analysis and multinomial logistical regression were used to analyze the factors affecting the different psychosocial adjustment subgroups of enterostomy patients. RESULTS Psychosocial adjustment of 3840 patients with enterostomy can be divided into three latent characteristics: Moderately high psychosocial adjustment level and high positive emotion in enterostomy patients (24.5%), Medium psychosocial but low social life adjustment (64.6%), low psychosocial adjustment level and high negative emotion (10.9%). Multinomial logistic regression showed that enterostomy self-care knowledge score, gender, medical payment method, educational background, carer, and self-care ability were affecting the subgroup classification of psychosocial adjustment of enterostomy patients. CONCLUSION The psychosocial adjustment level of enterostomy patients can be divided into three latent profiles, which have obvious classification characteristics. Future studies can provide individualized interventions for different subgroups of enterostomy patients to improve the psychosocial adjustment of enterostomy patients.
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Affiliation(s)
- Lu Zhou
- Department of Nursing, Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Zhengyang Zhang
- Department of Nursing, Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Hui Li
- Department of Nursing, Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Ling Wang
- Department of Nursing, Peking University People's Hospital, Beijing, China.
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He F, Tang C, Yang F, Chen D, Xiong J, Zou Y, Zhao D, Qian K. Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis. World J Surg Oncol 2024; 22:94. [PMID: 38610000 PMCID: PMC11010286 DOI: 10.1186/s12957-024-03363-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Temporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer. MATERIALS AND METHODS We conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer. RESULTS A total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure. CONCLUSION We identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.
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Affiliation(s)
- Fan He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chenglin Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Fuyu Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Defei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Junjie Xiong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yu Zou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dongqin Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Kun Qian
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Sun L, Zhou J, Ji L, Wang W, Zhang Q, Qian C, Zhao S, Li R, Wang D. Clinical application of the B-type sutured ileostomy in robotic-assisted low anterior resection for rectal cancer: a propensity score matching analysis. J Robot Surg 2024; 18:159. [PMID: 38578352 DOI: 10.1007/s11701-024-01924-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/24/2024] [Indexed: 04/06/2024]
Abstract
Currently, there is no consensus on the position and method for temporary ileostomy in robotic-assisted low anterior resection for rectal cancer. Herein, this study introduced the B-type sutured ileostomy, a new temporary ileostomy technique, and compared it to the traditional one to assess its efficacy and safety. Between September 2020 and December 2022 in our centre, B-type sutured ileostomy was performed on 124 patients undergoing robotic-assisted low anterior resection for rectal cancer. A retrospective review of a prospectively collected database identified patients who underwent robotic-assisted low anterior resection for rectal cancer with a temporary ileostomy between January 2018 and December 2022. Patients who underwent B-type sutured ileostomy (B group) were matched in a 1:1 ratio with patients who underwent traditional ileostomy (Control group) using a propensity score based on age, sex, BMI, Comorbidity, American Society of Anesthesiologists (ASA) score, and Prior abdominal surgery history. Surgical and postoperative outcomes, health status, and stoma closure data were analyzed for both groups. ClinicalTrials.gov Identifier:NCT05915052. The B group (n = 118) shows advantages compared to the Control group (n = 118) regarding total operation time (155.98 ± 21.63 min vs 168.92 ± 21.49 min, p = 0.001), postoperative body pain (81.92 ± 4.12 vs 78.41 ± 3.02, p = 0.001) and operation time of stoma closure (46.19 ± 11.30 min vs 57.88 ± 11.08 min, p = 0.025). The two groups had no other notable differences. The B-type sutured ileostomy is a safe and feasible option in robotic-assisted low anterior resection for rectal cancer. The B-type sutured ileostomy may offer advantages such as shorter overall surgical duration, lighter postoperative pain, and shorter second-stage ostomy incorporation surgery. However, attention should be directed towards the occurrence of stoma prolapse.
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Affiliation(s)
- Longhe Sun
- Clinical Medical College, Yangzhou University, Yangzhou, 225001, China
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Jiajie Zhou
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Lili Ji
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Wei Wang
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Qi Zhang
- Northern Jiangsu People's Hospital, Yangzhou, 225001, China
| | - Chunhua Qian
- The Forth People's Hospital of Taizhou, Taizhou, 225300, China
| | - Shuai Zhao
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Ruiqi Li
- Northern Jiangsu People's Hospital, Clinical Teaching Hospital of Medical School, Nanjing University, Yangzhou, 225001, China
| | - Daorong Wang
- Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, 225001, China.
- Northern Jiangsu People's Hospital, Yangzhou Institute of General Surgery, Yangzhou University, Yangzhou, 225001, China.
- Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Disease, Yangzhou, China.
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He F, Yang F, Tang C, Chen D, Zhao D, Xiong J, Zou Y, Huang G, Qian K. Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer. Can J Gastroenterol Hepatol 2024; 2024:2410643. [PMID: 38550348 PMCID: PMC10977340 DOI: 10.1155/2024/2410643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/10/2023] [Accepted: 01/02/2024] [Indexed: 04/02/2024] Open
Abstract
Background Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy. Method Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B). Results A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups. Conclusion Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.
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Affiliation(s)
- Fan He
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fuyu Yang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Chenglin Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Defei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dongqin Zhao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Junjie Xiong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yu Zou
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Guoquan Huang
- Hubei Provincial Key Lab of Selenium Resources and Bioapplications, No. 158 Wuyang Avenue, Enshi 445000, Hubei, China
| | - Kun Qian
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Patni S, Sharma N, Modi N, Bhatia A. Ghost Stoma Solving the Dilemma of Diversion After Anterior Resection: Surgical Technique Description and Experience from a Single Centre. Indian J Surg Oncol 2024; 15:53-58. [PMID: 38511029 PMCID: PMC10948707 DOI: 10.1007/s13193-023-01840-7] [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: 04/12/2023] [Accepted: 10/12/2023] [Indexed: 03/22/2024] Open
Abstract
Anastomotic leak is the most dreaded complication after anterior resection (AR). To do prophylactic diversion stoma or not is a matter of constant dilemma that most surgeons face. In such a situation, ghost stoma (GS) technique offers a middle path, wherein unnecessary prophylactic stomas can be avoided and at the same time ensuring that a diversion stoma can be created if need arises without the need of any major surgery or anaesthesia. Retrospective data of patients who underwent anterior resection with ghost stoma at our institute from January 2015 to December 2019 was analysed for clinical characteristics, operative outcomes and postoperative complications. Ghost stoma is fashioned by pulling up a loop of intestine up to parietal peritoneum layer of anterior abdominal wall with the help of silicone or plastic tube after anterior resection. During the study period, this technique was used in 68 patients of which 7 patients required creation of stoma under local anaesthesia for suspected or confirmed post-operative leak. One of these patients developed congestion of stoma for which the stoma was refashioned under regional anaesthesia. There were no major complications like bowel obstruction, strangulation or tube migration. However, two patients had prolonged ileus and were managed conservatively. Thus, unnecessary stoma was avoided in 89% patients of anterior resection. This is a simple, easy to learn, less time-consuming and oncologically safe procedure which can prevent patients from morbidity as well as psychological and financial burden associated with unnecessary stoma.
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Affiliation(s)
- Sanjeev Patni
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan India
| | - Nivedita Sharma
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan India
- Present address: Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan India
| | - Nishith Modi
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan India
| | - Anish Bhatia
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan India
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Sueda T, Tei M, Mori S, Nishida K, Yasuyama A, Nomura M, Yoshikawa Y, Tsujie M. Clinical Impact of Transanal Drainage Tube on Anastomosis Leakage Following Minimally Invasive Resection Without Diverting Stoma in Patients With Rectal Cancer: A Propensity Score-matched Analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:608-616. [PMID: 37852234 DOI: 10.1097/sle.0000000000001237] [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: 05/12/2023] [Accepted: 08/09/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES As one of the most serious complications of rectal cancer (RC) surgery, preventing anastomotic leakage (AL) is crucial. Several studies have suggested a positive role of the transanal drainage tube (TaDT) in AL prevention. However, whether TaDT is beneficial for AL in patients with RC remains controversial. The present study aimed to evaluate the clinical impact of TaDT on AL following minimally invasive resection without diverting stoma (DS) in patients with RC. MATERIALS AND METHODS We retrospectively analyzed 392 consecutive patients with RC who had undergone minimally invasive resection without DS between 2010 and 2021. Propensity score matching (PSM) was performed to reduce selection bias. AL was classified as grade A, B, or C. RESULTS A TaDT was used in 214 patients overall. After PSM, we enrolled 316 patients (n=158 in each group). Before PSM, significant group-dependent differences were observed in terms of age, American Society of Anesthesiologists physical status, and the use of antiplatelet/anticoagulant agents. The frequency of AL was 7.3% in the overall cohort and was significantly lower in the TaDT group (3.7%) than in the non-TaDT group (11.8%). The rate of grade B AL was significantly lower in the TaDT group than in the non-TaDT group (before PSM, P <0.01; after PSM, P =0.02). However, no significant differences between groups were found for grade C AL. Moreover, multivariate analysis identified the lack of a TaDT as an independent risk factor for AL in the overall and matched cohorts [before PSM, odds ratio, 3.64, P <0.01; after PSM, odds ratio, 2.91, P =0.02]. CONCLUSION These results indicated that TaDT may play a beneficial role in preventing AL, particularly of grade B, for patients with RC undergoing minimally invasive resection without DS. However, further randomized controlled trials, including patient-reported outcomes, are still needed to understand better the role of TaDT in preventing ALs in patients with RC undergoing minimally invasive resection without DS.
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Eklöv K, Bringman S, Löfgren J, Nygren J, Everhov ÅH. PHaLIR: prevent hernia after loop ileostomy reversal-a study protocol for a randomized controlled multicenter study. Trials 2023; 24:575. [PMID: 37684648 PMCID: PMC10486037 DOI: 10.1186/s13063-023-07430-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/05/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Rectal cancer is a common cancer worldwide. Surgery for rectal cancer with low anterior resection often includes the formation of a temporary protective loop ileostomy. The temporary ostomy is later reversed in a separate operation. One complication following stoma closure is the development of a hernia at the former stoma site, and this has been reported in 7-15% of patients. The best method to avoid hernia after stoma closure is unclear. The most common closure is by suturing only, but different forms of mesh have been tried. Biological mesh has in a randomized trial halved hernia incidence after stoma reversal. Biosynthetic mesh and retromuscular mesh are currently being evaluated in ongoing studies. METHODS The present multicenter, double-blinded, randomized, controlled study will compare standard suture closure of the abdominal wall in loop ileostomy reversal with retromuscular synthetic mesh at the stoma site. The study has been approved by the Regional Ethical Review board in Stockholm. Patients aged 18-90 years, operated on with low anterior resection and a protective loop ileostomy for rectal cancer and planned for ileostomy reversal, will be considered for inclusion in the study. Randomization will be 1:1 on the operation day with concealed envelopes. The estimated sample size is intended to evaluate the superiority of the experimental arm and to detect a reduction of hernia occurrence from 12 to 3%. The operation method is blinded to the patients and in the chart and for the observer at the 30-day follow-up. The main outcome is hernia occurrence at the stoma site within 3 years postoperatively, diagnosed through CT with strain. Secondary outcomes are operation time, length of hospital stay, pain, and 30-day complications. DISCUSSION This double-blinded randomized controlled superiority study will compare retromuscular synthetic mesh during the closure of loop ileostomy to standard care. If this study can show a lower frequency of hernia with the use of prophylactic mesh, it may lead to new surgical guidelines during stoma closure. TRIAL REGISTRATION ClinicalTrials.gov NCT03720262. Registered on October 25, 2018.
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Affiliation(s)
- Karolina Eklöv
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden.
| | - Sven Bringman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Södertälje Hospital, Södertälje, Sweden
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
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Bischofberger S, Adshead F, Moore K, Kocaman M, Casali G, Tong C, Roy S, Collins M, Brunner W. Assessing the environmental impact of an anastomotic leak care pathway. Surg Open Sci 2023; 14:81-86. [PMID: 37528919 PMCID: PMC10388196 DOI: 10.1016/j.sopen.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 08/03/2023] Open
Abstract
Background The healthcare sector faces increasing pressure to improve environmental sustainability whilst continuing to meet the needs of patients. One strategy is to lower the avoidable demand on healthcare services, by reducing the number of surgical complications, such as anastomotic leak (AL). The aim of this study was to assess the environmental impact associated with the care pathway of AL. Methods An environmental impact assessment was performed according to the Sustainable Healthcare Coalition (SHC) guidelines. A care pathway, describing the typical steps involved in the diagnosis and treatment of AL was developed. Activity and emission data for each stage of the care pathway were used to calculate the climate, water and waste impact of the treatment of AL patients. Results The environmental impact assessment shows that AL is associated with an average climate, water and waste impact per patient of 1303 kg CO2-eq, 1803 m3 of water and 123 kg waste, respectively. Grade C leaks are associated with the greatest environmental impact, contributing to 89.3 %, 79.4 % and 97.9 % of each impact, respectively. A breakdown of the environmental impact of each activity shows that stoma home management is the largest contributor to the total climate (46.6 %) and waste (47.3 %) impact of AL patients, whilst in-patient hospital stay contributes greatest to the total water impact (46.7 %). Conclusions The treatment of AL is associated with a substantial environmental impact. This study is, to our knowledge, the first to assess the environmental impact associated with the treatment of AL.
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Affiliation(s)
| | | | | | | | | | - Cindy Tong
- Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | - Sanjoy Roy
- Johnson & Johnson MedTech, New Brunswick, NJ, USA
| | | | - Walter Brunner
- Department of Surgery, Colorectal Unit, Kantonsspital St. Gallen, Switzerland
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International survey among surgeons on the perioperative management of rectal cancer. Surg Endosc 2023; 37:1901-1915. [PMID: 36258001 DOI: 10.1007/s00464-022-09702-z] [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: 05/25/2022] [Accepted: 10/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several pivotal studies and international guidelines on the perioperative management of rectal cancer have been published. However, little is known about the current state of perioperative management of rectal cancer patients in clinical practice worldwide. METHODS An online survey including 13 questions focusing on key topics related to the perioperative management of patients with rectal cancer was conducted among colorectal surgeons registered within the database of the Research Institute Against Digestive Cancer (IRCAD). RESULTS A total of 535 respondents from 89 countries participated in the survey. Most surgeons worked in the European region (40.9%). Two hundred and fifty-four respondents (47.5%) performed less than 25% of surgical procedures laparoscopically. The most commonly used definition of the upper limit of the rectum was a fixed distance from the anal verge (23.4%). Magnetic resonance imaging was used to define the upper limit of the rectum by 258 respondents (48.2%). During total mesorectal excision (TME), 301 respondents (56.3%) used a high-tie technique. The most commonly constructed anastomosis was an end-to-end anastomosis (68.2%) with the majority of surgeons performing a leak test intraoperatively (88.9%). A total of 355 respondents (66.4%) constructed a diverting ostomy, and the majority of these surgeons constructed an enterostomy (82%). A total of 208 respondents (39.3%) closed a stoma within 8 weeks. Lastly, 135 respondents (25.2%) introduced a solid diet on postoperative day 1. CONCLUSION There is considerable heterogeneity in the perioperative management of rectal cancer patients worldwide with several discrepancies between current international practice and recommendations from international guidelines. To achieve worldwide standardization in rectal cancer care, further research is needed to elucidate the cause of this heterogeneity and find ways of improved implementation of best practice recommendations.
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Shao S, Zhao Y, Lu Q, Liu L, Mu L, Qin J. Artificial intelligence assists surgeons' decision-making of temporary ileostomy in patients with rectal cancer who have received anterior resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:433-439. [PMID: 36244844 DOI: 10.1016/j.ejso.2022.09.020] [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: 06/23/2022] [Revised: 08/27/2022] [Accepted: 09/28/2022] [Indexed: 10/07/2022]
Abstract
BACKGROUND Due to the difficult evaluation of the risk of anastomotic leakage (AL) after rectal cancer resection, the decision to perform a temporary ileostomy is not easily distinguishable. The aim of the present study was to develop an artificial intelligence (AI) model for identifying the risk of AL to assist surgeons in the selective implementation of a temporary ileostomy. MATERIALS AND METHODS The data from 2240 patients with rectal cancer who received anterior resection were collected, and these patients were divided into one training and two test cohorts. Five AI algorithms, such as support vector machine (SVM), logistic regression (LR), Naive Bayes (NB), stochastic gradient descent (SGD) and random forest (RF) were employed to develop predictive models using clinical variables and were assessed using the two test cohorts. RESULTS The SVM model indicated good discernment of AL, and might have increased the implementation of temporary ileostomy in patients with AL in the training cohort (p < 0.001). Following the assessment of the two test cohorts, the SVM model could identify AL in a favorable manner, which performed with positive predictive values of 0.150 (0.091-0.234) and 0.151 (0.091-0.237), and negative predictive values of 0.977 (0.958-0.988) and 0.986 (0.969-0.994), respectively. It is important to note that the implementation of temporary ileostomy in patients without AL would have been significantly reduced (p < 0.001) and which would have been significantly increased in patients with AL (p < 0.05). CONCLUSION The model (https://alrisk.21cloudbox.com/) indicated good discernment of AL, which may be used to assist the surgeon's decision-making of performing temporary ileostomy.
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Affiliation(s)
- Shengli Shao
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Yufeng Zhao
- Department of Vascular Surgery, First Hospital of Lanzhou University, 730030, Lanzhou, China
| | - Qiyi Lu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Lu Liu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Lei Mu
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Jichao Qin
- Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China; Molecular Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Gaidarski III AA, Ferrara M. The Colorectal Anastomosis: A Timeless Challenge. Clin Colon Rectal Surg 2022; 36:11-28. [PMID: 36619283 PMCID: PMC9815911 DOI: 10.1055/s-0042-1756510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.
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Affiliation(s)
| | - Marco Ferrara
- Colon and Rectal Clinic of Orlando, Orlando, Florida,Address for correspondence Marco Ferrara, MD Colon and Rectal Clinic of Orlando110 West Underwood ST, Suite A, Orlando, FL 32806
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12
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Yu XN, Xu LM, Bin YW, Yuan Y, Tian SB, Cai B, Tao KX, Wang L, Wang GB, Wang Z. Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients. Curr Med Sci 2022; 42:1256-1266. [PMID: 36544033 DOI: 10.1007/s11596-022-2616-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 01/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients. METHODS A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019. RESULTS The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001). CONCLUSION The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.
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Affiliation(s)
- Xiang-Nan Yu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Lu-Ming Xu
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ya-Wen Bin
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ye Yuan
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shao-Bo Tian
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Bo Cai
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kai-Xiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Lin Wang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Guo-Bin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Zheng Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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13
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A diversion stoma after anterior resection for rectal cancer. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract108920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This review covers the problem of forming a diverting stoma during resections of the rectum with primary anastomosis. The incidence of rectal cancer tends to increase, and surgical resection remains the main method of treatment. Anastomotic leakage significantly increases the postoperative mortality. The most effective way to prevent severe complications is the formation of a diverting stoma. However, the indications, the choice of a specific technique and the timing of the stoma elimination are not clearly defined. This review discusses the state of the problem, special attention is paid to the choice of the level of stoma formation (ileostomy or transversostomy).
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14
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SEGURA GIMÉNEZ MJ, RODRÍGUEZ CARRILLO R, AZORÍN SAMPER MDC, ALARCÓN IRANZO M, RUIZ CARMONA MD, LOZOYA TRUJILLO R, SOLANA BUENO A, ALÓS COMPANY R. Impact of defunctioning loop ileostomy on renal function and hydroelectrolyte balance in rectal cancer patients. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Pai SST, Lin HH, Cheng HH, Huang SC, Lin CC, Lan YT, Wang HS, Yang SH, Jiang JK, Chen WS, Lin JK, Chang SC. Clinical outcome of local treatment and radical resection for pT1 rectal cancer. Int J Colorectal Dis 2022; 37:1845-1851. [PMID: 35852585 DOI: 10.1007/s00384-022-04220-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectal cancer is mainly cured by radical resection with neoadjuvant chemoradiation or adjuvant chemotherapy. Pathological T1 lesions can be managed by local treatment and radiotherapy thereafter. Lower morbidity is the key benefit of these local treatments. Since nodal metastasis is important for staging, radical resection (RR) is suggested. Rectal cancer has higher surgical morbidity than colon cancer; local treatment has been the preferred choice by patients. METHODS We retrospectively enrolled data of 244 patients with pT1 rectal adenocarcinoma. A total of 202 patients (82.8%) underwent RR, including low anterior resection (LAR) and abdomino-perineal resection (APR), and 42 patients (17.2%) underwent LT, including transanal excision and colonoscopic polypectomy. RESULTS In our study, seven patients (16.7%) had loco-regional recurrence and distant metastasis from the LT group while eight patients (4.0%) had distant metastasis without loco-regional recurrence from the RR group. The lymph node metastasis rate in RR group was 8.4%. Forty-seven patients (24.2%) underwent LAR with temporary stoma, and its reversal rate was 100%. In the RR group, postoperative complication rate was 10.4% with a mortality rate of 0.5%. Recurrence-free survival (RFS) was 95.7% for RR and 80.2% for LT (P = 0.001), and overall survival (OS) was 93.7% for RR and 70.0% for LT (P = 0.001). CONCLUSION This study found that RFS and OS in patients of pT1 rectal adenocarcinoma that had received RR were better than receiving LT. Further adjuvant chemotherapy was possible for some RR patients. A higher recurrence rate after LT must be balanced against the morbidity and mortality associated with RR.
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Affiliation(s)
- Summer Sheue-Tsuey Pai
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-Hsin Lin
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Hou-Hsuan Cheng
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Chieh Huang
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuan-Tzu Lan
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huann-Sheng Wang
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shung-Haur Yang
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Colon & Rectal Surgery, Department of Surgery, National Yang Ming Chiao Tung University Hospital, Yilan, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jeng-Kai Jiang
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Shone Chen
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ching Chang
- Division of Colon & Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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16
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Waqas A, Mykoniatis I, Sidiqi N, Ahmed A, Stefan S, Naqvi S, Harper M, Khan J. Early Experience of Undertaking Robotic Assisted Total Mesorectal Excision in Rectal Resections, Avoiding a Diverting Stoma: Key eHancement of the Anastomosis for No Stoma Technique - A Case Series. Surg Innov 2022:15533506221108833. [PMID: 35855510 DOI: 10.1177/15533506221108833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.
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Affiliation(s)
- Ahmad Waqas
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Ioanis Mykoniatis
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Najaf Sidiqi
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Anwar Ahmed
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Samuel Stefan
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Syed Naqvi
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Mick Harper
- Faculty of Science, 66971University of Portsmouth, Portsmouth, UK
| | - Jim Khan
- Portsmouth Hospitals University NHS Trust, Queen Alexandra Hospital, Portsmouth, UK.,2369Anglia Ruskin University Chelmsford, Chelmsford, UK
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17
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Comprehensive literature review of the outcome, modifications, and alternatives to double-stapled low pelvic colorectal anastomosis. Surgery 2022; 172:512-521. [DOI: 10.1016/j.surg.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/16/2022] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
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18
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Madbouly KM, Hany Emile S, Gamal AA. Transanal total mesorectal excision (TaTME) with delayed coloanal anastomosis versus TaTME with immediate coloanal anastomosis and temporary diversion in middle and low rectal cancer. J Surg Oncol 2022; 125:865-871. [PMID: 35032329 DOI: 10.1002/jso.26795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) avoids the difficulty of laparoscopic dissection of the lower part of the rectum. The need for stoma is associated with many stoma-related complications. The objective was to compare TaTME with immediate coloanal anastomosis and protective ileostomy (TaTME-IA) versus Turnbull-Cutait delayed coloanal anastomosis (TaTME-TC). METHODS A retrospective cohort study included patients with low rectal cancer at least 1 cm above the top of the anal sphincter. Patients had either TaTME-IA or TaTME-TC. Primary outcome measures were anastomotic and stoma-related complications. Secondary outcomes included rate of permanent stomas, local recurrence, continence, and quality of life (QOL). RESULTS TaTME-IA was done in 25 patients versus 20 who had TaTME-TC. TaTME-IA had significantly longer mean operative time (p = 0.04) and shorter length of stay (LOS) (4.5 vs. 11.4 days; p = 0.0001) compared to TaTME-TC. Anastomotic leak was reported in two patients of TaTME-IA versus one patient of TaTME-TC (p = 0.77). Anastomotic stenosis was reported in one patient in each group. No significant difference between groups as regard continence, local recurrence, and QOL. CONCLUSION TaTME-TC is a safe option that can be offered for patients with low rectal cancer who refuse or are not amenable to a temporary stoma. Anastomotic complications were similar in both groups. LOS was much longer in TaTME-TC, however, it avoids stoma complications. Both groups had similar functional oncologic outcomes and QOL.
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Affiliation(s)
- Khaled M Madbouly
- Department of Surgery, Section of Colon & Rectal Surgery, University of Alexandria, Alexandria, Egypt
| | - Sameh Hany Emile
- Department of Surgery, Colorectal Surgery Unit, Mansoura University, Mansoura, Egypt
| | - Abd Allah Gamal
- Department of Surgery, Section of Colon & Rectal Surgery, University of Alexandria, Alexandria, Egypt
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19
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Kuk JC, Lim DR, Shin EJ. Effect of transanal drainage tube of anastomotic leakage following low anterior resection without a defunctioning stoma for rectal cancer. Asian J Surg 2021; 45:2639-2644. [PMID: 34953640 DOI: 10.1016/j.asjsur.2021.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/08/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Anastomotic leakage (AL) is one of the most serious complications of rectal cancer surgery. The aim of this study was to analyze the effectiveness and safety of transanal drainage tube (TDT) placement to prevent AL after low anterior resection (LAR) for rectal cancer. MATERIAL AND METHOD In this retrospective study, the data of 556 patients with rectal cancer who underwent LAR using the double stapling technique between January 2001 and April 2016 were analyzed. The patients were divided two groups: the non-transanal drainage tube (NTDT) group comprised patients without a TDT (n = 341) and the transanal drainage tube (TDT) group, patients with a TDT (n = 215). RESULTS The overall rate of AL was 4.1% (n = 23). The AL rate was significantly lower in the TDT group. The AL rate was 5.6% (n = 19) in the NTDT group and 1.9% (n = 4) in the TDT group (p = 0.032). The mean time of AL postoperatively was 6.0 days. Among AL patients, the re-operation rate for AL was 84.2% (16/19) for the NTDT group and 75.0% (3/4) for the TDT group. Sex, age, BMI, neoadjuvant chemoradiation therapy, tumor location, and double stapler diameter were not analysized to be risk factors for AL after LAR. Non-use of a TDT (odds ratio, 0.106; 95% confidence interval, 0.013-0.843; p = 0.034) was established as a risk factor for AL in the logistic analysis. CONCLUSION Based on the present data, TDT placement can reduce the rate of AL following LAR using the double stapling technique for rectal cancer.
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Affiliation(s)
- Jung Cheol Kuk
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Dae Ro Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea.
| | - Eung Jin Shin
- Division of Colon and Rectal Surgery, Department of Surgery, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
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20
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Favuzza J. Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains. Clin Colon Rectal Surg 2021; 34:366-370. [PMID: 34853556 DOI: 10.1055/s-0041-1735266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.
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Affiliation(s)
- Joanne Favuzza
- Division of Colon and Rectal Surgery, Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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21
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Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients. J Gastrointest Surg 2021; 25:2000-2010. [PMID: 32869144 PMCID: PMC7970451 DOI: 10.1007/s11605-020-04781-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice. METHODS Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge. RESULTS Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar. CONCLUSIONS Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.
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22
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Zhuang ZX, Wei MT, Yang XY, Zhang Y, Zhuang W, Wang ZQ. Long-term outcome of indwelling colon observed seven years after radical resection for rectosigmoid cancer: A case report. World J Clin Cases 2021; 9:5252-5258. [PMID: 34307575 PMCID: PMC8283588 DOI: 10.12998/wjcc.v9.i19.5252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/28/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Indwelling colon is characterized by an excluded segment of the colon after surgical diversion of the fecal stream with colostomy so that contents are unable to pass through this part of the colon. We report a rare case of purulent colonic necrosis that occurred 7 years after surgical colonic exclusion.
CASE SUMMARY A 73-year-old male had undergone extended radical resection for rectosigmoid cancer. The invaded ileocecal area and sigmoid colon were removed during the procedure, and the ileum was anastomosed side-to-side with the rectum. The excluded ascending, transverse, and descending colon were sealed at both ends and left in the abdomen. After 7 years, the patient developed persistent abdominal pain and distension. Work-up indicated intestinal obstruction. The patient underwent ultrasound-guided catheter drainage of the descending colon and a large amount of viscous liquid was drained, but the symptoms persisted; therefore, surgery was planned. Intraoperatively, extensive adhesions were found in the abdominal cavity, and the small intestine and the indwelling colon were widely dilated. The dilated colon was 56 cm long, 5 cm wide (diameter), and contained about 1500 mL of viscous liquid. The indwelling colon was surgically removed and its histopathological examination revealed colonic congestion and necrosis with hyperplasia of granulation tissue. The bacterial culture of the secretions was negative. The patient recovered after the operation.
CONCLUSION Although colonic exclusion is routinely performed, this report aimed to increase awareness regarding the possible long-term complications of indwelling colon.
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Affiliation(s)
- Zi-Xuan Zhuang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ming-Tian Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xu-Yang Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yang Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wen Zhuang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Qiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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23
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Borucki JP, Schlaeger S, Crane J, Hernon JM, Stearns AT. Risk and consequences of dehydration following colorectal cancer resection with diverting ileostomy. A systematic review and meta-analysis. Colorectal Dis 2021; 23:1721-1732. [PMID: 33783976 DOI: 10.1111/codi.15654] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
AIM This systematic review aims to assess dehydration prevalence and dehydration-related morbidity from diverting ileostomy compared to resections without ileostomy formation in adults undergoing colorectal resection for cancer. METHOD MEDLINE, Embase, CENTRAL and ClinicalTrials.gov were searched for studies of any design that reported dehydration, renal function and dehydration-related morbidity in adult colorectal cancer patients with diverting ileostomy (last search 12 August 2020). Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias in randomized trials and the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS Of 1927 screened papers, 22 studies were included (21 cohort studies and one randomized trial) with a total of 19 485 patients (12 209 with ileostomy). The prevalence of dehydration was 9.00% (95% CI 5.31-13.45, P < 0.001). The relative risk of dehydration following diverting ileostomy was 3.37 (95% CI 2.30-4.95, P < 0.001). Three studies assessing long-term trends in renal function demonstrated progressive renal impairment persisting beyond the initial insult. Consequences identified included unplanned readmission, delay or non-commencement of adjuvant chemotherapy, and development of chronic kidney disease. DISCUSSION Significant dehydration is common following diverting ileostomy; it is linked to acute kidney injury and has a long-term impact on renal function. This study suggests that ileostomy confers significant morbidity particularly related to dehydration and renal impairment.
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Affiliation(s)
- Joseph P Borucki
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Jasmine Crane
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - James M Hernon
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Adam T Stearns
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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24
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Ye H, Huang S, Yu J, Zhou Q, Xi C, Cao L, Wang P, Shen J, Gong Z. Comparison of the clinical outcomes of skin bridge loop ileostomy and traditional loop ileostomy in patients with low rectal cancer. Sci Rep 2021; 11:9101. [PMID: 33907300 PMCID: PMC8079674 DOI: 10.1038/s41598-021-88674-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 04/14/2021] [Indexed: 01/18/2023] Open
Abstract
To compare the clinical results of patients with low rectal cancer who underwent skin bridge loop ileostomy and traditional loop ileostomy, and provide clinical evidence for choosing a better ostomy method. We retrospectively collected data of 118 patients with rectal cancer who underwent low anterior resection and loop ileostomy. To investigate the patients characteristics, postoperative stoma-related complications and the frequency of exchanged ostomy bags. The differences of these indicators between the two groups of patients who underwent skin bridge loop ileostomy and traditional loop ileostomy were compared. The Visual Analog Scale (VAS) score of the skin bridge loop ileostomy group was lower than that of the traditional ileostomy loop group (P < 0.05). The skin bridge group had a lower Discoloration, Erosion, Tissue overgrowth (DET) score and incidence of mucocutaneous separation than the traditional group at the 1st and 2nd weeks after operation (P < 0.05). The average number of weekly exchanged ostomy bags was significantly less in the skin bridge group than in the traditional group within 4 weeks after surgery (P < 0.05). Our experience demonstrates that the skin bridge loop ileostomy may significantly reduce early postoperative stoma-related complications, the frequency of exchanged ostomy bags and patients' medical costs after discharge.
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Affiliation(s)
- Hui Ye
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Shujuan Huang
- Department of Respiratory and Critical Care Medicine, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434020, Hubei Province, China
| | - Jie Yu
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Qichang Zhou
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Changlei Xi
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Longlei Cao
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Peiyun Wang
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Jie Shen
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China
| | - Zhilin Gong
- Department of Colorectal Anal Surgery, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, No. 60 Jingzhong Road, Jingzhou, 434020, Hubei Province, China.
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Yang K, Zhao J, Chu L, Hu M, Zhou W, Li Y, Ye X, Huang R, Wang H, Wang H. Temporary impairment of renal function in patients with rectal cancer treated with diverting ileostomy. J Gastrointest Oncol 2021; 12:620-629. [PMID: 34012654 DOI: 10.21037/jgo-21-118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Fluid and electrolyte disturbance, which impairs renal function, has been reported in patients with temporary ileostomy. However, the dynamic changes in serum electrolytes and renal function in rectal cancer patients with ileostomy have not been well described. In the present study, we aimed to evaluate alterations in serum electrolytes and renal function in rectal cancer patients undergoing ileostomy creation and closure. Methods The levels of serum potassium, serum sodium, serum blood urea nitrogen, serum creatinine and estimated glomerular filtration rate (eGFR) were analyzed in 320 patients with rectal cancer including 156 patients with an ileostomy (the ileostomy group) and 164 patients without an ileostomy (the control group). Results After index surgery, the levels of serum potassium and serum creatinine in the ileostomy group were significantly higher than those in the control group (P<0.05). In contrast, the levels of serum sodium and the eGFR showed decreases in the ileostomy group compared to the control group after index surgery (P<0.05). At 3 months after ileostomy creation, the ileostomy group had a significantly increased rate of eGFR <60 mL/min/1.73 m2 compared to the control group (5.8% vs. 1.2%, P=0.032). In line with the results of univariate analysis, multivariable analysis identified ileostomy and diabetes as independent risk factors for a decreased eGFR (P=0.005 and P=0.022, respectively). Furthermore, a significantly rebound of eGFR was observed in patients after ileostomy closure (P=0.013). Conclusions Ileostomy can cause temporary electrolyte disturbance and renal function impairment in patients with rectal cancer. Diabetes is an independent risk factor for renal function damage in patients with rectal cancer who receive a temporary ileostomy.
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Affiliation(s)
- Keli Yang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Zhao
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lili Chu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Minhui Hu
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenbin Zhou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yang Li
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinmei Ye
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rongkang Huang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huaiming Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database. World J Surg 2021; 45:1630-1641. [PMID: 33733700 PMCID: PMC8093169 DOI: 10.1007/s00268-021-06054-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 01/16/2023]
Abstract
Background Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR). Methods All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated. Results Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016–2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations. Conclusion Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.
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Brind'Amour A, Pravong V, Sidéris L, Dubé P, De Guerke L, Fortin S, Auclair MH, Trilling B, Tremblay JF. Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy? Eur J Surg Oncol 2021; 47:2346-2351. [PMID: 33637373 DOI: 10.1016/j.ejso.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Literature on rectal anastomosis and diverting ileostomy in patients treated with hyperthermic intraperitoneal chemotherapy (HIPEC) is limited. This study assesses the safety of rectal anastomoses during cytoreductive surgery (CRS) and HIPEC, with and without fecal diversion, and its morbidity when performed. MATERIALS AND METHODS From January 2012 to January 2020, patients with peritoneal metastases who underwent CRS and HIPEC that required a rectal anastomosis were included in this single-hospital retrospective chart review. RESULTS 84 patients were included, of which 29 had a diverting loop ileostomy. The rectal anastomotic leak (AL) rate for the series was 8.3%. Factors associated with AL were male gender (p = 0.031) and increased BMI (p < 0.0005). Diverting loop ileostomy was associated with a significant decrease of clinically significant rectal AL (0% vs 12.7%, p = 0.045). However, the 90-day readmission rate was higher in this group (37.9% vs 10.9%, p = 0.003). Stoma reversal surgery was performed for all patients, but 3 patients experienced AL (10.7%). CONCLUSIONS This study suggests that creation of a diverting loop ileostomy may be an effective strategy to prevent symptomatic rectal AL following CRS with HIPEC. However, it is also associated with an increased readmission rate and increased risk of AL following reversal surgery.
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Affiliation(s)
| | - Vera Pravong
- Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lucas Sidéris
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Pierre Dubé
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lara De Guerke
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Suzanne Fortin
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Marie-Hélène Auclair
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Bertrand Trilling
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Jean-François Tremblay
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada.
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Quality of Life and Bowel Function Following Early Closure of a Temporary Ileostomy in Patients with Rectal Cancer: A Report from a Single-Center Randomized Controlled Trial. J Clin Med 2021; 10:jcm10040768. [PMID: 33671925 PMCID: PMC7919002 DOI: 10.3390/jcm10040768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess quality of life and bowel function in patients undergoing early vs. standard ileostomy closure. We retrospectively assessed patients from our previous randomized controlled trial. Patients with a temporary ileostomy who underwent rectal cancer surgery and did not have anastomotic leakage or other. Early closure (EC; 30 days after creation) and standard closure (SC; 90 days after creation) of ileostomy were compared. Thirty-six months (17–97) after stoma closure, we contacted patients by phone and filled in two questionnaires—The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and low anterior resection syndrome (LARS) score. This index trial was not powered to assess the difference in bowel function between the two groups. All the patients in the SC group had anastomosis <6 cm from the anal verge compared to 42 of 43 (97.7%) in the EC group. There were no statistically significant differences between EC (26 patients) and SC (25 patients) groups in the EORTC QLQ-C30 and LARS questionnaires. Global quality of life was 37.2 (0–91.7; ±24.9) in the EC group vs. 34.3 (0–100; ±16.2) in the SC (p = 0.630). Low anterior resection syndrome was present in 46% of patients in the EC and 56% in the SC group (p = 0.858). Major LARS was found more often in younger patients. However, no statistical significance was found (p = 0.364). The same was found with quality of life (p = 0.219). Age, gender, ileostomy closure timing, neoadjuvant treatment, complications had no effect of worse bowel function or quality of life. There was no difference in quality of life or bowel function in the late postoperative period after the early vs. late closure of ileostomy based on two questionnaires and small sample size. None of our assessed risk factors had a negative effect on bowel function o quality of life.
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Rintala JM, Tahvonen PR, Vuolio ST, Typpö IT, Suokanerva KA, Huhta HI. The Effect of Laparoscopic Technique on the Surgical Outcome of Colorectal Cancer in a Small-Volume Rural Finnish Lapland Central Hospital. Gastrointest Tumors 2020; 8:16-24. [PMID: 33728292 DOI: 10.1159/000511104] [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: 06/22/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Laparoscopic colorectal surgery has become widely used in treating colorectal cancer. Multicenter studies have shown that laparoscopy decreases postoperative complications and provides equivalent long-term oncological results compared to open surgery. Previous studies were conducted in high-volume institutions, with selected patients, which may influence the reported outcome of laparoscopy. Methods All patients with colorectal cancer that underwent surgery for a primary tumor between 2005 and 2015 in the Lapland Central Hospital were retrospectively collected. We retrieved data on the primary surgical outcome and complications within the first 30 days after surgery from patient records. We surveyed the national patient registry to determine long-term oncological results and patient survival. Results We identified 349 patients treated for colorectal cancer during 2005-2015. Of these, 219 patients (median age 71 years) underwent laparoscopy and 130 (median age 72 years) underwent open surgery. The 5-year disease-specific survival rates for stages I-III colon cancer were 83.3 and 87.7%, respectively. The 3-year disease-specific survival rates for stages I-III rectal cancer were 86.1 and 65.0%, respectively. Conclusion Our results showed that the introduction of laparoscopic colorectal surgery for treating cancer in a rural, small-volume hospital provided short- and long-term results comparable to findings from previous studies conducted in high-volume centers. Therefore, laparoscopy should be considered the treatment of choice for colorectal cancer in small, rural clinics.
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Affiliation(s)
- Jukka M Rintala
- Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland, Oulu, Finland.,Department of Surgery Oulu University Hospital Oulu Finland, Oulu, Finland
| | - Pirita R Tahvonen
- Department of Radiology Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Saija T Vuolio
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Ilpo T Typpö
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Kai A Suokanerva
- Department of Surgery Lapland Central Hospital Rovaniemi, Rovaniemi, Finland
| | - Heikki I Huhta
- Cancer and Translational Medicine Research Unit, Medical Research Centre Oulu University of Oulu Oulu Finland, Oulu, Finland.,Department of Surgery Oulu University Hospital Oulu Finland, Oulu, Finland
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Low preoperative maximum squeezing pressure evaluated by anorectal manometry is a risk factor for non-reversal of diverting stoma. Langenbecks Arch Surg 2020; 406:131-139. [PMID: 33074347 DOI: 10.1007/s00423-020-02011-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE A diverting stoma is created to prevent anastomotic leakage and related complications impairing sphincteric function in rectal surgery. However, diverting stoma may be left unclosed. This study is aimed to analyze preoperative factors including anorectal manometric data associated with diverting stoma non-reversal before rectal surgery. We also addressed complications related to diverting stoma in patients undergoing surgery for rectal malignant tumor. METHODS A total of 203 patients with rectal malignant tumor who underwent sphincter-preserving surgery with diverting stoma were retrospectively evaluated. The risk factors for non-reversal of diverting stoma were identified by univariate and multivariate analyses. For these analyses, anorectal manometric data were measured before rectal surgery. The association between stoma-related complications and other clinicopathological features was also analyzed. RESULTS During the median follow-up of 46.4 months, 24% (49 patients) did not undergo stoma reversal. Among parameters that were available before rectal surgery, age ≥ 75 years, albumin < 3.5 g/dl, tumor size ≥ 30 mm, tumor distance from the anal verge < 4 cm, and maximum squeezing pressure (MSP) < 130 mmHg measured by anorectal manometry (ARM) were independent factors associated with stoma non-reversal. The most common stoma-related complication was peristomal skin irritation (25%). Ileostomy was the only factor associated with peristomal skin irritation. CONCLUSION The current study demonstrated that low preoperative MSP evaluated by ARM, old age, hypoalbuminemia, and a large tumor close to the anus were predictive of diverting stoma non-reversal. Stoma site should be well deliberated when patients have the aforementioned risk factors for diverting stoma non-reversal.
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Marquardt C, Kalev G, Schiedeck T. Intraoperative fluorescence angiography with indocyanine green: retrospective evaluation and detailed analysis of our single-center 5-year experience focused on colorectal surgery. Innov Surg Sci 2020; 5:35-42. [PMID: 33506092 PMCID: PMC7798305 DOI: 10.1515/iss-2020-0009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/10/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives Assessing bowel perfusion with indocyanine green fluorescence angiography (ICG-FA) shows positive effects on anastomotic healing in colorectal surgery. Methods A retrospective evaluation of 296 colorectal resections where we performed ICG-FA was undertaken from January 2014 until December 2018. Perfusion of the bowel ends measured with ICG-FA was compared to the visual assessment before and after performing the anastomosis. According to the observations, the operative strategy was confirmed or changed. Sixty-seven low anterior rectal resections (LARs) and 76 right hemicolectomies were evaluated statistically, as ICG-FA was logistically not available for every patient in our service and thus a control group for comparison resulted. Results The operative strategy based on the ICG-FA results was changed in 48 patients (16.2%), from which only one developed an anastomotic leakage (AL) (2.1%). The overall AL rate was calculated as 5.4%. Within the 67 patients with LAR, the strategy was changed in 11 patients (16.4%). No leakage was seen in those. In total three AL happened (4.5%), which was three times lower than the AL rate of 13.6% in the control group but statistically not significant. From the 76 right hemicolectomies a strategy change was undertaken in 10 patients (13.2%), from which only one developed an AL. This was the only AL reported in the whole group (1.3%), which was six times lower than the leakage rate of the control group (8.1%). This difference was statistically significant (p=0.032). Conclusions Based on the positive impact by ICG-FA on the AL rate, we established the ICG-FA into our clinical routine. Although randomized studies are still missing, ICG-FA can raise patient safety, with only about 10 min longer operating time and almost no additional risk for the patients.
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Affiliation(s)
- Christoph Marquardt
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Baden-Wuerttemberg, Germany
| | - Georgi Kalev
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Baden-Wuerttemberg, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Baden-Wuerttemberg, Germany
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63:1191-1222. [PMID: 33216491 DOI: 10.1097/dcr.0000000000001762] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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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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Kryzauskas M, Bausys A, Degutyte AE, Abeciunas V, Poskus E, Bausys R, Dulskas A, Strupas K, Poskus T. Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery. World J Surg Oncol 2020; 18:205. [PMID: 32795348 PMCID: PMC7427291 DOI: 10.1186/s12957-020-01968-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/23/2020] [Indexed: 02/03/2023] Open
Abstract
Background Anastomotic leakage (AL) significantly impairs short-term outcomes. The impact on the long-term outcomes remains unclear. This study aimed to identify the risk factors for AL and the impact on long-term survival in patients with left-sided colorectal cancer. Methods Nine-hundred patients with left-sided colorectal carcinoma who underwent sigmoid or rectal resection were enrolled in the study. Risk factors for AL after sigmoid or rectal resection were identified, and long-term outcomes of patients with and without AL were compared. Results AL rates following sigmoid and rectal resection were 5.1% and 10.7%, respectively. Higher ASA score (III–IV; OR = 10.54, p = 0.007) was associated with AL in patients undergoing sigmoid surgery on multivariable analysis. Male sex (OR = 2.40, p = 0.004), CCI score > 5 (OR = 1.72, p = 0.025), and T3/T4 stage tumors (OR = 2.25, p = 0.017) were risk factors for AL after rectal resection on multivariable analysis. AL impaired disease-free and overall survival in patients undergoing sigmoid (p = 0.009 and p = 0.001) and rectal (p = 0.003 and p = 0.014) surgery. Conclusion ASA score of III–IV is an independent risk factor for AL after sigmoid surgery, and male sex, higher CCI score, and advanced T stage are risk factors for AL after rectal surgery. AL impairs the long-term survival in patients undergoing left-sided colorectal surgery.
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Affiliation(s)
- Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Augustinas Bausys
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Vilius Abeciunas
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania.
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rimantas Bausys
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania
| | - Audrius Dulskas
- Faculty of Medicine, Vilnius University, Ciurlionio str. 21, 03101, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Chaouch MA, Kellil T, Jeddi C, Saidani A, Chebbi F, Zouari K. How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review. Ann Coloproctol 2020; 36:213-222. [PMID: 32919437 PMCID: PMC7508486 DOI: 10.3393/ac.2020.05.14.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023] Open
Abstract
Anastomosis leakage (AL) after colorectal surgery is an embarrassing problem. It is associated with poor consequence. This review aims to summarize published evidence on prevention of AL after colorectal surgery and provide recommendations according to the Oxford Centre for Evidence-Based Medicine. We conducted bibliographic research on January 15, 2020, of PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. We retained meta-analysis, reviews, and randomized clinical trials. We concluded that mechanical bowel preparation did not reduce AL. It seems that oral antibiotic or oral antibiotic with mechanical bowel preparation could reduce the risk of AL. The surgical approach did not affect the AL rate. The low ligation of the inferior mesenteric artery could reduce the AL rate. The mechanical anastomosis is superior to handsewn anastomosis only in case of right colectomies, with similar results in rectal surgery between the 2 anastomosis techniques. In the case of right colectomies, this anastomosis could be performed intracorporeally or extracorporeally with similar outcomes. The air leak test did not reduce AL. There is no interest of external drainage in colonic surgery but drains reduced the rate of AL and rate of reoperation after low anterior resection. The transanal tube reduced the rate of AL.
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Affiliation(s)
- Mohamed Ali Chaouch
- Department of Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Tarek Kellil
- Department of Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Camillia Jeddi
- Department of Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
| | - Ahmed Saidani
- Department of Digestive Surgery, Mahmoud Matri Hospital, University of Tunis Manar, Tunis, Tunisia
| | - Faouzi Chebbi
- Department of Digestive Surgery, Mahmoud Matri Hospital, University of Tunis Manar, Tunis, Tunisia
| | - Khadija Zouari
- Department of Digestive Surgery, Fattouma Bourguiba Hospital, University of Monastir, Monastir, Tunisia
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36
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Fielding A, Woods R, Moosvi SR, Wharton RQ, Speakman CTM, Kapur S, Shaikh I, Hernon JM, Lines SW, Stearns AT. Renal impairment after ileostomy formation: a frequent event with long-term consequences. Colorectal Dis 2020; 22:269-278. [PMID: 31562789 DOI: 10.1111/codi.14866] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/02/2019] [Indexed: 02/06/2023]
Abstract
AIM High stoma output and dehydration is common following ileostomy formation. However, the impact of this on renal function, both in the short term and after ileostomy reversal, remains poorly defined. We aimed to assess the independent impact on kidney function of an ileostomy after rectal cancer surgery and subsequent reversibility after ileostomy closure. METHODS This retrospective single-site cohort study identified patients undergoing rectal cancer resection from 2003 to 2017, with or without a diverting ileostomy. Renal function was calculated preoperatively, before ileostomy closure, and 6 months after ileostomy reversal (or matched times for patients without ileostomy). Demographics, oncological treatments and nephrotoxic drug prescriptions were assessed. Outcome measures were deterioration from baseline renal function and development of moderate/severe chronic kidney disease (CKD ≥ 3). Multivariate analysis was performed to assess independent risk factors for postoperative renal impairment. RESULTS Five hundred and eighty-three of 1213 patients had an ileostomy. Postoperative renal impairment occurred more frequently in ileostomates (9.5% absolute increase in rate of CKD ≥ 3; P < 0.0001) vs no change in patients without an ileostomy (P = 0.757). Multivariate analysis identified ileostomy formation, age, anastomotic leak and renin-angiotensin system inhibitors as independently associated with postoperative renal decline. Despite stoma closure, ileostomates remained at increased risk of progression to new or worse CKD [74/438 (16.9%)] compared to patients without an ileostomy [36/437 (8.2%), P = 0.0001, OR 2.264 (1.49-3.46)]. CONCLUSIONS Ileostomy formation is independently associated with kidney injury, with an increased risk persisting after stoma closure. Strategies to protect against kidney injury may be important in higher risk patients (elderly, receiving renin-angiotensin system antihypertensives, or following anastomotic leakage).
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Affiliation(s)
- A Fielding
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK
| | - R Woods
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK
| | - S R Moosvi
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - R Q Wharton
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - C T M Speakman
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - S Kapur
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK
| | - I Shaikh
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - J M Hernon
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - S W Lines
- Department of Nephrology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Department of Nephrology, St Bernard's Hospital, Gibraltar, Gibraltar
| | - A T Stearns
- Department of Colorectal Surgery, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.,Norwich Surgical Training and Research Academy, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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Jutesten H, Lydrup ML, Landberg A, Risberg D, Ekberg O, Zackrisson S, Buchwald P. Radiological findings in anastomotic leakage after anterior resection may predict a permanent stoma. Acta Radiol Open 2020; 9:2058460119897358. [PMID: 31934352 PMCID: PMC6945454 DOI: 10.1177/2058460119897358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/28/2019] [Indexed: 12/22/2022] Open
Abstract
Background Permanent stoma (PS) is common following treatment of anastomotic leakage (AL) after anterior resection (AR) and ways of predicting successful treatment outcome are missing. Purpose To explore radiological variables in rectal contrast studies in their relation to end-result of PS following treatment for AL after AR. Material and Methods The Swedish Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the region of Skåne from 1 January 2001 to 31 December 2011. Among identified AL cases, patients subjected to radiological imaging consistent with AL were evaluated according to a predetermined set of radiological variables. Information of PS as the end-result after AL treatment were retrieved from medical records. Results Thirty-two patients had radiological imaging available for analysis confirming AL after AR; PS rate after a median follow-up of 87 months (range = 21-165) after AR was 62%. Radiological findings compatible with abscess (P = 0.023) and a leak size ≤6 mm (P = 0.049) were significantly associated with PS. Conclusion In this limited explorative study, our findings suggest that abscess status and leak size could correspond to outcome of PS in treatment for AL after AR. Additional studies are warranted to further explore this subject.
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Affiliation(s)
- Henrik Jutesten
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Axel Landberg
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Daniel Risberg
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Sophia Zackrisson
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Pamela Buchwald
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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Morales-Conde S, Alarcón I, Yang T, Licardie E, Balla A. A Decalogue to Avoid Routine Ileostomy in Selected Patients With Border Line Risk to Develop Anastomotic Leakage After Minimally Invasive Low-Anterior Resection: A Pilot Study. Surg Innov 2019; 27:44-53. [PMID: 31789117 DOI: 10.1177/1553350619890720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose. Protective ileostomy (PI) during anterior resection (AR) for rectal cancer decreases the incidence of anastomotic leakage (AL) and its subsequent complications, but it may itself be the cause of morbidity. The aim is to report our protocol in the management of selected patients with borderline risk to develop AL after laparoscopic AR and ghost ileostomy (GI) creation. Methods. Patients who underwent AR were stratified based on the risk to develop AL. Steps to avoid PI were splenic flexure mobilization, reduced pelvic bleeding, to employ different stapler charge if neoadjuvant chemo-radiotherapy is performed, to perform a horizontal section of the rectum, to evaluate the anastomotic vascularization with a fluorescence angiography, to perform a side-to-end anastomosis, intraoperative methylene blue test, pelvic and transanal drainage tubes placement, and the GI creation. After surgery, inflammatory blood markers were monitored to detect potential leakages. Results. Twelve patients were included. In one case, the specimen proximal section was changed after fluorescence angiography. There were no conversions in this group of patients. One postoperative AL occurred and was treated with radiological drainage placement, not being necessary to convert the GI. PI was avoided in 100% of cases. Conclusions. Patients' characteristics cannot be changed, but several steps were used to avoid routine PI creation. The present protocol could be a valuable option to avoid PI in selected patients. Further studies with a wider sample size, and defined criteria to stratify the patients based on the risk to develop AL, are required.
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Affiliation(s)
| | - Isaias Alarcón
- University Hospital "Virgen del Rocio," University of Sevilla, Sevilla, Spain
| | - Tao Yang
- University Hospital "Virgen del Rocio," University of Sevilla, Sevilla, Spain
| | - Eugenio Licardie
- University Hospital "Virgen del Rocio," University of Sevilla, Sevilla, Spain
| | - Andrea Balla
- University Hospital "Virgen del Rocio," University of Sevilla, Sevilla, Spain.,University of Rome, Rome, Italy
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Meyer J, Naiken S, Christou N, Liot E, Toso C, Buchs NC, Ris F. Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges. World J Gastroenterol 2019; 25:5017-5025. [PMID: 31558854 PMCID: PMC6747296 DOI: 10.3748/wjg.v25.i34.5017] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.
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Affiliation(s)
- Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Surennaidoo Naiken
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Niki Christou
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
| | | | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, Genève 1211, Switzerland
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40
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Effectiveness of endosponge therapy for the management of presacral abscesses following rectal surgery. Tech Coloproctol 2019; 23:551-557. [PMID: 31338710 DOI: 10.1007/s10151-019-02007-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/13/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Anastomotic leak after rectal surgery is reported in 9% (range 3-28%) of patients. The aim of our study was to evaluate the effectiveness of endosponge therapy for anastomotic. Endpoints were the rate of restored continuity and the functional bowel outcome after anastomotic leakage. METHODS This was a multicenter retrospective observational cohort study. All patients with symptomatic anastomotic leakage after rectal surgery who had endosponge therapy between January 2012 and August 2017 were included. Functional bowel outcome was measured using the low anterior resection syndrome (LARS) score system. RESULTS Twenty patients were included. Eighteen patients had low anterior resection (90%) for rectal cancer. A diverting ileostomy was performed at primary surgical intervention in 14 patients (70%). Fourteen patients (70%) were treated with neoadjuvant (chemo-)radiotherapy. The median time between primary surgical intervention and first endosponge placement was 21 (5-537) days. The median number of endosponge changes was 9 (2-28). The success rate of the endosponge treatment was 88% and the restored gastrointestinal continuity rate was 73%. A chronic sinus occurred in three patients (15%). All patients developed LARS, of which 77% reported major LARS. CONCLUSIONS Endosponge therapy is an effective treatment for the closure of presacral cavities with high success rate and leading to restored gastrointestinal continuity in 73%. However, despite endosponge therapy many patients develop major LARS.
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41
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Keane C, Park J, Öberg S, Wedin A, Bock D, O'Grady G, Bissett I, Rosenberg J, Angenete E. Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer. Br J Surg 2019; 106:645-652. [PMID: 30706439 PMCID: PMC6590150 DOI: 10.1002/bjs.11092] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/07/2018] [Accepted: 11/17/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer. METHODS Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI). RESULTS Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054). CONCLUSION Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.
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Affiliation(s)
- C. Keane
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - J. Park
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - S. Öberg
- Centre for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of CopenhagenCopenhagenDenmark
| | - A. Wedin
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - D. Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
| | - G. O'Grady
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - I. Bissett
- Department of Surgery, Faculty of Medicine and Health Sciences, University of AucklandNew Zealand
| | - J. Rosenberg
- Centre for Perioperative Optimization, Department of Surgery, Herlev and Gentofte Hospital, University of CopenhagenCopenhagenDenmark
| | - E. Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital ÖstraGothenburgSweden
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Jutesten H, Draus J, Frey J, Neovius G, Lindmark G, Buchwald P, Lydrup ML. High risk of permanent stoma after anastomotic leakage in anterior resection for rectal cancer. Colorectal Dis 2019; 21:174-182. [PMID: 30411471 DOI: 10.1111/codi.14469] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023]
Abstract
AIM This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma. METHOD The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records. RESULTS Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow-up of 87 months (range 21-165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re-laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re-laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively). CONCLUSION Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long-term follow-up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection.
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Affiliation(s)
- H Jutesten
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - J Draus
- Department of Surgery, Hallands Hospital, Halmstad, Sweden
| | - J Frey
- Department of Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - G Neovius
- Department of Surgery, Central Hospital, Kristianstad, Sweden
| | - G Lindmark
- Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - P Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - M L Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Wei D. Progress in prevention and treatment of anastomotic leakage after surgery for rectal cancer. Shijie Huaren Xiaohua Zazhi 2018; 26:1849-1856. [DOI: 10.11569/wcjd.v26.i32.1849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common malignant tumors in the world, and its morbidity and mortality both rank third among all malignant tumors in China. Rectal cancer accounts for 60%-70% of cases of CRC. With the in-depth study of the pathogenesis of CRC and the mechanism of tumor metastasis, and the improvement of surgical techniques and methods, anal sphincter surgery for middle and low rectal cancer is increasing gradually. Although the quality of life of the patients improves significantly after anal sphincter preservation for rectal cancer, anastomotic leakage is still one of the most common and serious complications. Studies show that the incidence of anastomotic leakage after surgery for low rectal cancer is 3%-21%, and the death rate is up to 3%. Therefore, a comprehensive assessment of patients and analysis of risk factors before operation is of great significant for reducing the potential risk of anastomotic leakage and choosing surgical approach and appropriate preventive measures to prevent and reduce the occurrence of anastomotic leakage. In this paper, we summarize the recent research on anastomotic leakage after rectal cancer surgery in order to help other clinicians reduce the incidence of anastomotic leakage in clinical practice.
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Affiliation(s)
- Dong Wei
- Institute of Anal-colorectal Surgery, the 150th Central Hospital of Chinese PLA, Luoyang 471031, He'nan Province, China
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44
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Sujatha-Bhaskar S, Whealon M, Inaba CS, Koh CY, Jafari MD, Mills S, Pigazzi A, Stamos MJ, Carmichael JC. Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost. Surg Endosc 2018; 33:644-650. [PMID: 30361967 DOI: 10.1007/s00464-018-6518-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal. METHODS A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes. RESULTS Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00). CONCLUSION Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.
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Affiliation(s)
- Sarath Sujatha-Bhaskar
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Matthew Whealon
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Colette S Inaba
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Christina Y Koh
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Mehraneh D Jafari
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Steven Mills
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Alessio Pigazzi
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Michael J Stamos
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Joseph C Carmichael
- Department of Surgery, University of California Irvine School of Medicine, Irvine, CA, USA.
- Department of Surgery, University of California, Irvine, 333 City Blvd. W. Ste. 850, Orange, CA, 92868, USA.
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Implications of Stoma Formation as Part of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. World J Surg 2018; 42:2036-2042. [PMID: 29302727 DOI: 10.1007/s00268-017-4450-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Formation of protective stoma as part of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) may be an effective tool in reducing anastomotic leak incidence. Our aim was to evaluate the incidence and implications of stoma formation during CRS-HIPEC and to examine whether a creation of protective stoma reduces the postoperative morbidity. METHODS A cohort retrospective analysis of all CRS-HIPEC procedures performed between 2004 and 2016 was conducted. Predicting factors for stoma formation were assessed by comparing all patients who underwent stoma formation to those who did not; both groups were then restricted to cases with ≥2 bowel anastomoses and compared in terms of perioperative outcomes in order to determine whether protective stoma confers a morbidity benefit. RESULTS One hundred and ninety-nine CRS-HIPEC procedures were performed on 186 patients. Thirty-four patients (17%) underwent stoma formation, 24 of them as protective stoma. Formation of a stoma was correlated with higher peritoneal carcinomatosis index score (13.6 ± 8 vs. 9.5 ± 7.7, p = 0.007), larger number of organs resected (p < 0.001), greater number of anastomoses (p < 0.001), prolonged operative time (8.1 ± 2.7 vs. 6.6 ± 2.2 h, p = 0.002), and prolonged hospital stay (12 vs. 8.5 days, p = 0.001). In procedures requiring ≥2 anastomoses, formation of protective stoma reduced the anastomotic leak rate (6 vs. 37%, p = 0.025), the morbidity rate (6 vs. 41%, p = 0.017), and reoperation rate (0 vs. 28%, p = 0.03). Overall, 15 patients (44%) underwent stoma reversal, 3 of whom had a complication treated non-operatively. CONCLUSIONS Protective stoma should be considered in extensive CRS-HIPEC procedures requiring two or more bowel anastomoses in order to reduce the postoperative morbidity rate.
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Shelygin YA, Nagudov MA, Ponomarenko AA, Alekseev MV, Rybakov EG, Tarasov MA, Achkasov SI. [Meta-analysis of management of colorectal anastomotic leakage]. Khirurgiia (Mosk) 2018:30-41. [PMID: 30199049 DOI: 10.17116/hirurgia201808230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.
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Affiliation(s)
- Yu A Shelygin
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Nagudov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - A A Ponomarenko
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M V Alekseev
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - E G Rybakov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Tarasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - S I Achkasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
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Loriau J, Petit E, Mephon A, Angliviel B, Sauvanet E. [Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29525185 DOI: 10.1016/j.gofs.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.
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Affiliation(s)
- J Loriau
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France.
| | - E Petit
- Service d'imagerie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - A Mephon
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - B Angliviel
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - E Sauvanet
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
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Westerduin E, Borstlap WAA, Musters GD, Westerterp M, van Geloven AAW, Tanis PJ, Wolthuis AM, Bemelman WA, D'Hoore A. Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases. Colorectal Dis 2018; 20:35-43. [PMID: 28795776 DOI: 10.1111/codi.13844] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/26/2017] [Indexed: 12/12/2022]
Abstract
AIM The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA. METHOD This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up. RESULTS A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8-27]. The median duration of follow-up was 27 months (IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004-0.122). CONCLUSION Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.
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Affiliation(s)
- E Westerduin
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands
| | - W A A Borstlap
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - G D Musters
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - M Westerterp
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | | | - P J Tanis
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A M Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
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Krenzien F, Benzing C, Harders F, Junghans T, Rasim G, Bothe C, Pratschke J, Zorron R. THE VULKAN TECHNIQUE: A NOVEL OSTOMY-CLOSURE TECHNIQUE THAT REDUCES COMPLICATIONS AND OPERATIVE TIMES. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 30:139-142. [PMID: 29257851 PMCID: PMC5543794 DOI: 10.1590/0102-6720201700020013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/11/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ostomy reversals remain at high risk for surgical complications. Indeed, surgical-side infections due to bacterial contamination of the stoma lead to revision surgery and prolonged hospital stay. AIM To describe the novel vulkan technique of ostomy reversal that aims to reduce operative times, surgical complications, and readmission rates. METHODS Ostomy closure was performed using the vulkan technique in all patients. This technique consists of external intestinal closure, circular skin incision and adhesiolysis, re-anastomosis, and closure of the subcutaneous tissue in three layers, while leaving a small secondary wound through which exudative fluid can be drained. The medical records of enterostomy patients were retrospectively reviewed from our hospital database. RESULTS The vulkan technique was successfully performed in 35 patients mainly by resident surgeons with <5 years of experience (n=22; 62.8%). The ileostomy and colostomy closure times were 53 min (interquartile range [IQR], 41-68 min; n=22) and 136 min (IQR: 88-188 min; n=13; p<0.001), respectively. The median hospital stay was seven days (IQR: 5-14.5 days); the length of hospital stay did not differ between ileostomy and colostomy groups. Major surgical complications occurred only in patients who underwent colostomy closure following the Hartmann procedure (n=2); grade≥IIIb according Clavien-Dindo classification. CONCLUSION The vulkan technique was successfully applied in all patients with very low rates of surgical-site infections. Off note, residents with limited surgical experience mainly performed the procedure while operating time was less than one hour.
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Affiliation(s)
- Felix Krenzien
- Center of Innovative Surgery (ZIC), Department of Surgery, Campus Virchow Klinikum and Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institut of Health (BIH), Berlin, Germany
| | - Christian Benzing
- Center of Innovative Surgery (ZIC), Department of Surgery, Campus Virchow Klinikum and Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Harders
- Department of General, Visceral, Thorax and Vascular Surgery, Clinic Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Tido Junghans
- Department of General, Visceral, Thorax and Vascular Surgery, Clinic Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Gyurdhan Rasim
- Department of General, Visceral, Thorax and Vascular Surgery, Clinic Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Claudia Bothe
- Department of General, Visceral, Thorax and Vascular Surgery, Clinic Bremerhaven Reinkenheide, Bremerhaven, Germany
| | - Johann Pratschke
- Center of Innovative Surgery (ZIC), Department of Surgery, Campus Virchow Klinikum and Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ricardo Zorron
- Center of Innovative Surgery (ZIC), Department of Surgery, Campus Virchow Klinikum and Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of General, Visceral, Thorax and Vascular Surgery, Clinic Bremerhaven Reinkenheide, Bremerhaven, Germany
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50
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Soriani P, Tontini GE, Neumann H, de Nucci G, De Toma D, Bruni B, Vavassori S, Pastorelli L, Vecchi M, Lagoussis P. Endoscopic full-thickness resection for T1 early rectal cancer: a case series and video report. Endosc Int Open 2017; 5:E1081-E1086. [PMID: 29250584 PMCID: PMC5659870 DOI: 10.1055/s-0043-118657] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/14/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic treatment of malignant colorectal polyps is often challenging, especially for early rectal cancer (ERC) localized close to the dentate line. Conversely, the surgical approach may result in temporary or definitive stoma and in frequent post-surgical complications. The Full-Thickness Resection Device (FTRD ® ) System (Ovesco Endoscopy, Tübingen, Germany) is a novel system that, besides having other indications, appears to be promising for wall-thickness excision of intestinal T1 carcinoma following incomplete endoscopic resection. However, follow-up data on patients treated with this device are scarce, particularly for ERC. PATIENTS AND METHODS Six consecutive patients with incomplete endoscopic resection of T1-ERC were treated with the FTRD and their long-term outcomes were evaluated based on a detailed clinical and instrumental assessment. RESULTS The endoscopic en bloc full-thickness resection was technically feasible in all patients. The histopathologic analysis showed a complete endoscopic resection in all cases, and a full-thickness excision in four. Neither complications, nor disease recurrence were observed during the 1-year follow-up period. CONCLUSIONS The FTRD System is a promising tool for treating ERC featuring a residual risk of disease recurrence after incomplete endoscopic mucosal resection in patients unfit for surgery or refusing a surgical approach.
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Affiliation(s)
- Paola Soriani
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy,Corresponding author Gian Eugenio Tontini, MD PhD Gastroenterology and Digestive Endoscopy UnitIRCCS Policlinico San DonatoVia Morandi 3020097 San Donato MilaneseMilanItaly+39-2-52774655
| | - Helmut Neumann
- First Medical Department, University Medical Center Mainz, Mainz, Germany
| | - Germana de Nucci
- Gastroenterology and Digestive Endoscopy Unit, A.O. Salvini, Garbagnate Milanese, Milan, Italy
| | - Domenico De Toma
- Division of Oncology I, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Barbara Bruni
- Pathology and Cytodiagnostic Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Sara Vavassori
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Luca Pastorelli
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Pavlos Lagoussis
- Division of General Surgery I, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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