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Qiu W, Liu J, He K, Hu G, Mei S, Guan X, Wang X, Tian J, Tang J. Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study. Surg Endosc 2024:10.1007/s00464-024-11085-2. [PMID: 39090199 DOI: 10.1007/s00464-024-11085-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated. AIM Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR. MATERIAL AND METHODS A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL). RESULTS After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029). CONCLUSIONS Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.
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Affiliation(s)
- Wenlong Qiu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Junguang Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Kunshan He
- Key Laboratory of Molecular Imaging Chinese Academy of Sciences, Beijing Key Laboratory of Molecular Imaging. Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, Beijing, 100000, China
| | - Gang Hu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China
| | - Jie Tian
- Key Laboratory of Molecular Imaging Chinese Academy of Sciences, Beijing Key Laboratory of Molecular Imaging. Key Laboratory of Big Data-Based Precision Medicine, Ministry of Industry and Information Technology, Beijing, 100000, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100000, China.
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Bolshinsky V, Sweet DE, Vitello DJ, Jia X, Holubar SD, Church J, Herts BR, Steele SR. Using CT-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery. Dis Colon Rectum 2024; 67:929-939. [PMID: 38517090 DOI: 10.1097/dcr.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND A complete total mesorectal excision is the criterion standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively the difficulty of proctectomy is largely unexplored. OBJECTIVE To determine pelvic structural factors associated with incomplete total mesorectal excision after curative proctectomy and build a predictive model for total mesorectal excision quality. DESIGN Retrospective cohort study. SETTING A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). PATIENTS Curative-intent proctectomy for rectal adenocarcinoma. INTERVENTIONS All radiological measurements were obtained from preoperative CT images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. MAIN OUTCOME MEASURES Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. RESULTS Of the 410 cases meeting inclusion criteria, 362 underwent a complete total mesorectal excision (88%). Multivariable regression identified a deeper sacral curve (per 100 mm 2 [OR: 1.14; 95% CI, 1.06-1.23; p < 0.001]) and a greater transverse distance of the pelvic outlet (per 10 mm [OR:1.41, 95% CI, 1.08-1.84; p = 0.012]) to be independently associated with incomplete total mesorectal excision. An increased area of the pelvic inlet (per 10 cm 2 [OR: 0.85; 95% CI, 0.75-0.97; p = 0.02) was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs <0.4) between BMI (<30 vs ≥30) and sex was identified. A model was built to predict mesorectal quality using the following variables: depth of sacral curve, area of pelvic inlet, and transverse distance of the pelvic outlet. LIMITATIONS Retrospective analysis is not controlled for the choice of surgical approach. CONCLUSIONS Pelvimetry predicts total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in the comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract . USO DE MEDICIONES DE PELVIMETRA Y OBESIDAD VISCERAL BASADAS EN TC PARA PREDECIR LA CALIDAD DE TME EN PACIENTES SOMETIDOS A CIRUGA DE CNCER DE RECTO ANTECEDENTES:Una escisión mesorrectal total y completa es el estándar de oro en la cirugía curativa del cáncer de recto. Garantizar la calidad es un desafío en una pelvis estrecha y la obesidad amplifica las dificultades técnicas. La pelvimetría es la medición de las dimensiones pélvicas, pero su papel para medir la dificultad preoperatoria de la proctectomía está en gran medida inexplorado.OBJETIVO:Determinar los factores estructurales pélvicos asociados con la escisión mesorrectal total incompleta después de una proctectomía curativa y construir un modelo predictivo para la calidad de la escisión mesorrectal total.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Base de datos de un centro de referencia cuaternario de pacientes diagnosticados con adenocarcinoma de recto (2009-2017).PACIENTES:Proctectomía con intención curativa para adenocarcinoma de recto.INTERVENCIONES:Todas las mediciones radiológicas se obtuvieron a partir de imágenes de TC preoperatorias utilizando herramientas de software de procesamiento de imágenes validadas. La integridad de la escisión mesorrectal total se obtuvo a partir de informes histológicos.PRINCIPALES MEDIDAS DE VALORACIÓN:Capacidad de la pelvimetría radiológica y las mediciones de obesidad para predecir la calidad total de la escisión mesorrectal.RESULTADOS:De los 410 casos que cumplieron los criterios de inclusión, 362 tuvieron una escisión mesorrectal total completa (88%). Una regresión multivariable identificó una curva sacra más profunda (por 100 mm2); OR:1,14,[IC95%:1,06-1,23,p<0,001], y mayor distancia transversal de salida pélvica (por 10mm); OR:1,41, [IC 95%:1,08-1,84,p=0,012] como asociación independiente con escisión mesorrectal total incompleta. Un área aumentada de entrada pélvica (por 10 cm2); OR:0,85, [IC95%:0,75-0,97,p=0,02] se asoció con una mayor tasa de escisión mesorrectal completa. No se identificaron diferencias en la proporción de obesidad visceral y la obesidad visceral (proporción>0,4 vs.<0,4) entre el índice de masa corporal (<30 vs.>=30) o el sexo. Se construyó un modelo para predecir la calidad mesorrectal utilizando variables: profundidad de la curva sacra, área de la entrada pélvica y distancia transversal de la salida pélvica.LIMITACIONES:Análisis retrospectivo no controlado por la elección del abordaje quirúrgico.CONCLUSIONES:La pelvimetría predice la calidad de la escisión mesorrectal total en la cirugía del cáncer de recto y puede alertar a los cirujanos preoperatoriamente sobre casos de dificultad inusual. Este modelo predictivo puede contribuir a la estrategia de tratamiento y ayudar en la comparación de resultados entre técnicas tradicionales y novedosas de escisión mesorrectal total. (Traducción- Dr. Ingrid Melo).
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Affiliation(s)
| | - David E Sweet
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominic J Vitello
- Department of General Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xue Jia
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - James Church
- Department of Colorectal Surgery, Columbia University Medical Center, Herbert Irving Pavilion, New York, New York
| | - Brian R Herts
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Du Q, Yang W, Zhang J, Qiu S, Liu X, Wang Y, Yang L, Zhou Z. Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:2338-2348. [PMID: 36928167 PMCID: PMC11020000 DOI: 10.1097/js9.0000000000000205] [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: 06/12/2022] [Accepted: 11/20/2022] [Indexed: 03/18/2023]
Abstract
BACKGROUND The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis. MATERIALS AND METHODS A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated. RESULTS A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR. CONCLUSIONS Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
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Affiliation(s)
- Qiang Du
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Wenming Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Jianhao Zhang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Siyuan Qiu
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Xueting Liu
- Department of Evidence-Based Medicine and Clinical Epidemiology
| | - Yong Wang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Lie Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zongguang Zhou
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Xu X, Zhong H, You J, Ren M, Fingerhut A, Zheng M, Li J, Yang X, Song H, Zhang S, Ding C, Abuduaini N, Yu M, Liu J, Zhang Y, Kang L, Cai Z, Feng B. Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study. Int J Surg 2024; 110:709-720. [PMID: 38016136 PMCID: PMC10871607 DOI: 10.1097/js9.0000000000000945] [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: 07/20/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer. MATERIAL AND METHODS Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation. RESULTS The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer. CONCLUSION taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation.
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Affiliation(s)
- Ximo Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hao Zhong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun You
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen
| | - Mingyang Ren
- Department of Gastrointestinal Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz, Austria
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianwen Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiqin Song
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sen Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengsheng Ding
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Naijipu Abuduaini
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengqin Yu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Liu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Kang
- Department of General Surgery (Colorectal Surgery)
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Wang Z, Guo Y, Li S, He L, Zhao Y, Wang Q. What affects the selection of diverting ileostomy in rectal cancer surgery: a single-center retrospective study. BMC Surg 2024; 24:30. [PMID: 38263089 PMCID: PMC10804464 DOI: 10.1186/s12893-024-02316-3] [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: 06/16/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The selection of diverting ileostomy (DI) is controversial. This study aimed to explore the factors affecting the selection of diverting ileostomy (DI) following laparoscopic low anterior resection for rectal cancer. METHODS This retrospective, case-control study included patients who underwent laparoscopic-assisted sphincter-saving surgery for mid-low rectal cancer from January 2019 to June 2021. Univariate and multivariate analyses were performed on the patient's clinicopathological characteristics and pelvic dimensions measured by abdominopelvic electron beam computed tomography. RESULTS A total of 382 patients were included in the analysis, of which 182 patients (47.6%) did not undergo DI, and 200 patients (52.4%) underwent DI. The univariate analysis suggested that male sex (p = 0.003), preoperative radiotherapy (p < 0.001), patients with an anastomosis below the levator ani plane (p < 0.001), the intertuberous distance (p < 0.001), the sacrococcygeal distance (p = 0.025), the mid pelvis anteroposterior diameter (p = 0.009), and the interspinous distance (p < 0.001) were associated with performing DI. Multivariate analysis confirmed that preoperative radiotherapy (p = 0.037, odds ratio [OR] = 2.98, 95% confidence interval [CI] = 1.07-8.30), anastomosis below the levator ani plane (p < 0.001, OR = 7.09, 95% CI = 4.13-12.18), and the interspinous distance (p = 0.047, OR = 0.97, 95% CI = 0.93-1.00) were independently associated with performing DI. CONCLUSION Pelvic parameters also influence the choice of DI. According to this single-center experience, patients with a shorter interspinous distance, particularly narrow pelvic with an interspinous distance of < 94.8 mm, preoperative radiotherapy, and anastomosis below the levator ani plane, prefer to have a DI and should be adequately prepared by the physician.
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Affiliation(s)
- Zhen Wang
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yuchen Guo
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Shuang Li
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Liang He
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yinquan Zhao
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Quan Wang
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China.
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Liu F, Zhang B, Xiang J, Zhuo G, Zhao Y, Zhou Y, Ding J. Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study. Langenbecks Arch Surg 2023; 408:394. [PMID: 37816844 DOI: 10.1007/s00423-023-03131-9] [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: 05/18/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes. METHODS Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results. RESULTS Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks. CONCLUSION AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised. TRIAL REGISTRATION Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.
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Affiliation(s)
- Feifan Liu
- Postgraduate Training Base of Jinzhou Medical University, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Bin Zhang
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Jianbin Xiang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Guangzuan Zhuo
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yujuan Zhao
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yiming Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianhua Ding
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China.
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Zhang T, Wang G, Fang G, Qiu L, Lu F, Yin K, Miao Y. Clinical efficacy of anastomotic reinforcement suture in preventing anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:322. [PMID: 37594605 DOI: 10.1007/s00423-023-03058-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, with an incidence of about 10%, and the efficacy of reinforced sutures for preventing AL remains contentious. This study investigated the safety and effectiveness of reinforcement sutures for preventing AL after rectal cancer surgery. METHODS The present authors conducted a systematic search in the PubMed, Embase, Cochrane Library, Sinomed, Web of Science, Wanfang, VIP, and CNKI databases for randomized controlled trials (RCTs) and nonrandomized studies up to June 2023. We performed a meta-analysis to evaluate the efficacy of anastomotic reinforcement sutures after rectal cancer surgery. The primary outcome measures were AL, anastomotic bleeding, and infection rates. RESULTS Eleven articles (1921 subjects) were analyzed, with 912 and 1009 cases in the reinforced and unreinforced suture groups, respectively. The reinforced suture group showed a lower AL incidence (odds ratio [OR]=0.25, 95% CI 0.17-0.37, P< 0.00001), lower infection rate (OR=0.41, 95%CI 0.19-0.89, P<0.05), shorter hospital stay (mean difference [MD]=-0.57, 95%CI -1.15-0.00, P≤0.05), and earlier anal exhaust (MD=-0.12, 95%CI -0.23-0.00, P<0.05). However, the operative time (MD=18.25, 95% CI 12.20-24.30, P<0.00001) was longer for reinforced sutures than for unreinforced sutures. There were no significant differences between the suture techniques in intraoperative blood loss MD=2.74, 95% CI -4.50-9.97, P>0.05), incidence of anastomotic bleeding (OR=0.49, 95%CI 0.12-1.97, P>0.05), and incidence of intestinal obstruction (OR=0.65, 95%CI 0.27-1.61, P>0.05). CONCLUSION Existing articles indicate that anastomotic reinforcement sutures can significantly reduce AL incidence. However, this conclusion still requires confirmation based on multicentre, high-quality RCTs with large sample sizes.
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Affiliation(s)
- Tao Zhang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Gang Wang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Guida Fang
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Lei Qiu
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Feng Lu
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Kaihong Yin
- Department of Digestive Medicine, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China
| | - Yongchang Miao
- Department of Gastrointestinal Surgery, Bengbu Medical College Lianyungang Clinical College, The Second People's Hospital of Lianyungang, Lianyungang, 222003, Jiangsu Province, China.
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Yi X, Liao W, Feng X, Li H, Chen Z, Wang J, Lu X, Wan J, Lin J, Hong X, Diao D. An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area. Updates Surg 2022; 74:1645-1656. [PMID: 35596113 DOI: 10.1007/s13304-022-01282-w] [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: 12/14/2021] [Accepted: 03/20/2022] [Indexed: 12/24/2022]
Abstract
Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.
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Affiliation(s)
- Xiaojiang Yi
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Weilin Liao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaochuang Feng
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Hongming Li
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Zhaoyu Chen
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiahao Wang
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xinquan Lu
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jin Wan
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Jiaxin Lin
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China
| | - Xiaoyan Hong
- Department of Anesthesiology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Dechang Diao
- Department of Colorectal (Tumor) Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, 14 floor, West area, No.111, Dade Road, Guangzhou, 510120, China.
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Oshio H, Oshima Y, Yunome G, Okazaki S, Kawamura I, Ashitomi Y, Musha H, Kawai M, Motoi F. Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study. Ann Med Surg (Lond) 2021; 70:102902. [PMID: 34691436 PMCID: PMC8519803 DOI: 10.1016/j.amsu.2021.102902] [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: 09/08/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer. Materials and methods We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed. Results Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis. Conclusion Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer. No studies to date have focused on treatment of locally advanced rectal cancer in men using intersphincteric resection hybrid technology involving transabdominal robotic surgery with conventional transanal total mesorectal excision. We found that hybrid surgery is feasible and may improve the quality of total mesorectal excision and the rate of radical resection for advanced rectal cancer. Hybrid surgery may improve urinary and sexual function. This technique has many potential benefits and would be an alternative approach for rectal cancer.
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Affiliation(s)
- Hiroshi Oshio
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan.,Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Yukiko Oshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Gen Yunome
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Shinji Okazaki
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Ichiro Kawamura
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Yuya Ashitomi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Hiroaki Musha
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Masaaki Kawai
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Fuyuhiko Motoi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
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