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Slooter MD, Talboom K, Sharabiany S, van Helsdingen CPM, van Dieren S, Ponsioen CY, Nio CY, Consten ECJ, Wijsman JH, Boermeester MA, Derikx JPM, Musters GD, Bemelman WA, Tanis PJ, Hompes R. IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol. BMC Surg 2020; 20:240. [PMID: 33059647 PMCID: PMC7565357 DOI: 10.1186/s12893-020-00890-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023] Open
Abstract
Background Anastomotic leakage (AL) is still a common and feared complication after low anterior resection (LAR) for rectal cancer. The multifactorial pathophysiology of AL and lack of standardised treatment options requires a multi-modal approach to improve long-term anastomotic integrity. The objective of the IMARI-trial is to determine whether the one-year anastomotic integrity rate in patients undergoing LAR for rectal cancer can be improved using a multi-interventional program. Methods IMARI is a multicentre prospective clinical effectiveness trial, whereby current local practice (control cohort) will be evaluated, and subsequently compared to results after implementation of the multi-interventional program (intervention cohort). Patients undergoing LAR for rectal cancer will be included. The multi-interventional program includes three preventive interventions (mechanical bowel preparation with oral antibiotics, tailored full splenic flexure mobilization and intraoperative fluorescence angiography using indocyanine green) combined with a standardised pathway for early detection and active management of AL. The primary outcome is anastomotic integrity, confirmed by CT-scan at one year postoperatively. Secondary outcomes include incidence of AL, protocol compliance and association with AL, temporary and permanent stoma rate, reintervention rate, quality of life and functional outcome. Microbiome analysis will be conducted to investigate the role of the rectal microbiome in AL. In a Dutch nationwide study, the AL rate was 20%, with anastomotic integrity of 90% after one year. Based on an expected reduction of AL due to the preventive approaches of 50%, and increase of anastomotic integrity by a standardised pathway for early detection and active management of AL, we hypothesised that the anastomotic integrity rate will increase from 90 to 97% at one year. An improvement of 7% in anastomotic integrity at one year was considered clinically relevant. A total number of 488 patients (244 per cohort) are needed to detect this difference, with 80% statistical power. Discussion The IMARI-trial is designed to evaluate whether a multi-interventional program can improve long-term anastomotic integrity after rectal cancer surgery. The uniqueness of IMARI lies in the multi-modal design that addresses the multifactorial pathophysiology for prevention, and a standardised pathway for early detection and active treatment of AL. Trial registration Trialregister.nl (NL8261), January 2020.
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Affiliation(s)
- M D Slooter
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
| | - S Sharabiany
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | | | - S van Dieren
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - C Y Ponsioen
- Department of Gastroenterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - C Y Nio
- Department of Radiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - J H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - J P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - G D Musters
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
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Pallisera-Lloveras A, Planelles-Soler P, Hannaoui N, Mora-López L, Muñoz-Rodriguez J, Serra-Pla S, Dominguez-Garcia A, Prats-López J, Navarro-Soto S, Serra-Aracil X. Dissection of the inferior mesenteric vein versus of the inferior mesenteric artery for the genitourinary function after laparoscopic approach of rectal cancer surgery: a randomized controlled trial. BMC Urol 2019; 19:75. [PMID: 31382934 PMCID: PMC6683580 DOI: 10.1186/s12894-019-0501-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/18/2019] [Indexed: 01/29/2023] Open
Abstract
Background Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA. Methods Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group. Discussion The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery. Trial registration Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088) (Date of registration 04/03/2018).
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Affiliation(s)
- Anna Pallisera-Lloveras
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain.
| | - Paula Planelles-Soler
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Naim Hannaoui
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Laura Mora-López
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Jesús Muñoz-Rodriguez
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Sheila Serra-Pla
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Arturo Dominguez-Garcia
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Joan Prats-López
- Urology Department, Parc Taulí University Hospital, Sabadell, Universitat Autònoma de Barcelona, Parc Taulí s/n 08208, Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
| | - Xavier Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell, UniversitatAutònoma de Barcelona, Parc Taulí s/n. 08208 Sabadell, Barcelona, Spain
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