Anastomotic leakage and functional outcomes following total mesorectal excision with delayed and immediate colo-anal anastomosis for rectal cancer: Two single-arm phase II trials

BACKGROUND

Anastomotic leakage (AL) remains a major cause of morbidity following total mesorectal excision (TME). A diverting ileostomy reduces the risk of AL but impairs quality of life (QoL). Delayed colo-anal anastomosis (DCAA) may be an alternative to immediate colo-anal anastomosis (ICAA) without creation of a diverting ileostomy.

STUDY DESIGN

Patients with T3 or N+ rectal tumours were treated with neoadjuvant chemoradiation and TME. To evaluate DCAA or ICAA with diverting ileostomy, a two multicenter single-arm phase II trials was designed. The primary endpoint was the rate of AL requiring a diverting ileostomy up to 30 days postoperatively. Secondary endpoints were 30-day postoperative complications, 1- and 2-year disease-free survival; QoL at baseline, 6 months and anorectal function measured by the low anterior resection syndrome questionnaire and Wexner score at baseline, 6 months and a late assessment at median 8 years following surgery.

RESULTS

AL requiring diverting ileostomy occurred in one patient (2.1%; 95% confidence interval (CI) [0; 11.1]) in the DCAA group and in five patients (8.6%; 95%CI [3.2; 21.0]) in the ICAA group. Thirty-day postoperative complications occurred in 13 patients (27.1%) in the DCAA group and in 10 patients (19.2%) in the ICAA group. Short and long-term functional outcomes showed similar patterns.

CONCLUSION

These two single-arm phase II trials showed that DCAA has low rates of AL requiring a diverting ileostomy and acceptable long-term functional results. DCAA seems a good choice to restore bowel continuity.

Neorectal prolapse following proctectomy: a novel application of mesh sacral pexy

Neorectal prolapse following proctectomy for cancer has seldom been reported and treatment has mostly consisted in the resection of the prolapse via a perineal approach. Management of a patient with neorectal J-pouch prolapse using mesh sacral pexy via an abdominal approach is reported. By analogy with native rectal prolapse due to pelvic static disorders, laparoscopic mesh sacral pexy is likely to afford the same advantages of low morbidity and durability when applied to neorectal prolapse following rectal cancer surgery.

Second redo surgery after two consecutive failures of a colorectal or coloanal anastomosis: is it reasonable?

PURPOSE

Colorectal redo surgery is well known to be a difficult procedure, associated with a high risk of failure. The aim of this study was to look into patients presenting two consecutive failed colorectal (CRA) or coloanal (CAA) anastomosis who underwent a second redo surgery (i.e., third anastomosis).

METHODS

A retrospective study based on a prospective database of second redo surgeries of CRA or CAA, in an expert center. Sixteen patients between 2005 and 2020 were analyzed.

RESULTS

After a mean follow-up of 28 ± 26 months, success of surgery (defined as no stoma at the end of follow-up) was reported in 10/16 patients (63%). One patient with chronic anastomotic leakage and another with early colonic ischemia had no defunctioning stoma reversal. In the remaining four patients with a failed second redo surgery, a definitive stoma was ultimately created for fistula recurrence (n = 1), poor functional results (n = 2), or local cancer recurrence (n = 1). Two risk factors for failure of this second redo surgery were significantly found in a univariate analysis: (1) nature of the primary anastomosis: 3/13 s redo surgeries failed (23%) if a CRA was first made and 3/3 (100%) if it was a CAA (p = 0.036); (2) age: patients with a failed second redo surgery were older (p = 0.04).

CONCLUSION

A 63% rate of success of second redo surgery was observed after two failed CRA or CAA. Although a demanding procedure, it can be proposed to carefully selected and motivated patients.

Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer

Despite advances in coloanal anastomosis techniques, satisfactory procedures completed without complications remain lacking. We investigated the effectiveness of our recently developed ‘Short stump and High anastomosis Pull-through’ (SHiP) procedure for delayed coloanal anastomosis without a stoma. In this retrospective study, we analysed functional outcomes, morbidity, and mortality rates and local recurrence of 37 patients treated using SHiP procedure, out of the 282 patients affected by rectal cancer treated in our institution between 2012 and 2020. The inclusion criterion was that the rectal cancer be located within 4 cm from the anal margin. One patient died of local and pulmonary recurrence after 6 years, one developed lung and liver metastases after 2 years, and one experienced local recurrence 2.5 years after surgery. No major leak, retraction, or ischaemia of the colonic stump occurred; the perioperative mortality rate was zero. Five patients (13.51%) had early complications. Stenosis of the anastomosis, which occurred in nine patients (24.3%), was the only long-term complication; only three (8.1%) were symptomatic and were treated with endoscopic dilation. The mean Wexner scores at 24 and 36 months were 8.3 and 8.1 points, respectively. At the 36-month check-up, six patients (24%) had major LARS, ten (40%) had minor LARS, and nine (36%) had no LARS. The functional results in terms of LARS were similar to those previously reported after immediate coloanal anastomosis with protective stoma. The SHiP procedure resulted in a drastic reduction in major complications, and none of the patients had a stoma.

Oncologic outcomes for low rectal adenocarcinoma following low anterior resection with coloanal anastomosis versus abdominoperineal resection: a National Cancer Database propensity matched analysis

PURPOSE

Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR).

METHODS

The National Cancer Database (2004-2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins.

RESULTS

Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62-0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65-0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67-0.85], p < 0.001).

CONCLUSIONS

Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation.

Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

Protocol for a randomized controlled trial (Turnbull-BCN)

PURPOSE

The aim of this study was to determine whether patients that underwent ultra-low rectal resection for cancer can benefit from the recently reintroduced two-stage Turnbull-Cutait abdominoperineal pull-through procedure.

METHODS

Patients with low rectal tumors undergoing radical sphincter-sparing resection are eligible for inclusion in a randomized multicenter study. Whether two-stage Turnbull-Cutait coloanal anastomosis provides significant benefits over hand-sewn coloanal anastomosis and associated lateral ileostomy in terms of postoperative morbidity is the primary endpoint. In addition, the study aims to assess secondary endpoints such as quality of life, fecal incontinence, and locoregional recurrence of the neoplasm. Patients with adenocarcinoma of the lower rectum diagnosed by rigid proctoscopy, with histological confirmation of malignancy, and who are candidates of rectal removal and coloanal anastomosis will be included in a randomized controlled and multicenter trial. Postoperative morbidity is defined as complications that occur within 30 days of the data of the second surgical procedure of the last patient included in the trial. Patients will be followed for a minimum period of 3 years.

CONCLUSIONS

The two-stage Turnbull-Cutait coloanal anastomosis may constitute an effective surgical alternative in the current approach to the treatment of low rectal cancer without the need of a temporary loop colostomy, preventing the wide range of complications related to stoma surgery.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov (trial number: NCT01766661). This trial is registered in January 10, 2013.

[Turnbull-cutait technique in low rectal cancer: Case report]

BACKGROUND

The surgical treatment for low rectal cancer involves an ultra-low anterior resection with complete mesorectal resection and coloanal anastomosis. Two-stage coloanal anastomosis such as the Turnbull-Cutait technique represents an option for patients with low rectal cancer.

CLINICAL CASE

A 69 year-old female patient with a diagnosis of adenocarcinoma (T2N1), located 4 cm from the anal margin. She received neoadjuvant radiotherapy. An ultra-low anterior resection and total resection of the mesorectum were performed. The intestinal transit was reconstructed by coloanal anastomosis using the Turnbull-Cutait technique.

CONCLUSION

Coloanal anastomosis with the Turnbull-Cutait technique represents a primary option for patients with low rectal cancer, avoiding a loop ileostomy, its economic impact and on their quality of life.

Management of failed low colorectal and coloanal anastomosis

The most serious early complication after rectal resection with low anastomosis is anastomotic leakage (AL). AL may compromise the long-term conservation of the anastomosis and also worsen oncological results. The aim of this review was to identify those factors that contribute to the prevention of AL and to delineate the various treatment options (endoscopic, perineal surgical approach, abdominal surgical approach) for chronic AL or anastomotic stricture. Treatments for AL or anastomotic stricture should be protected by proximal diversion of fecal flow, ideally by a diverting stoma created at the time of the initial proctectomy. Local approaches to surgical treatment should include perineal examination under general anesthesia by the surgeon and drainage of the fistula. Trans-abdominal interventions should be reserved for high AL and for failure of perineal procedures. Although they have only limited indications for the treatment of AL, endoscopic treatments can be used in a complementary manner to surgical treatment. Balloon dilation is the first-line treatment for anastomotic strictures.

Efficacy of imatinib mesylate neoadjuvant treatment for a locally advanced rectal gastrointestinal stromal tumor

Surgery is the standard treatment for a primary gastrointestinal stromal tumor (GIST); however, surgical resection is often not curative, particularly for large GISTs. In the past decade, with imatinib mesylate (IM), management strategies for GISTs have evolved significantly, and now IM is the standard care for patients with locally advanced, recurrent or metastatic GISTs. Adjuvant therapy with imatinib was recently approved for use, and preoperative imatinib is an emerging treatment option for patients who require cytoreductive therapy. IM neoadjuvant therapy for primary GISTs has been reported, but there is no consensus on the dose of the drug, the duration of treatment and the optimal time of surgery. These are critical because drug resistance or tumor progression can develop with a prolonged treatment. This report describes two cases of large rectal malignant GISTs, for which a abdominoperineal resection was initially anticipated. The two patients received IM preoperative treatment; we followed-up with CT or magnetic resonance imaging to access the response. After 9 months of treatment, a multi-disciplinary consensus that maximal benefit from imatinib had been achieved was reached. We determined the best time for surgical intervention and successfully performed sphincter-preserving surgery before resistance to imatinib or tumor progression occurred. We believe that a multidisciplinary team approach, considerating the optimal duration of therapy and the timing of surgery, is required to optimize treatment outcome.

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA.

METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales].

RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales.

CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.