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Sharabiany S, Joosten JJ, Musters GD, Talboom K, Tanis PJ, Bemelman WA, Hompes R. Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre. Colorectal Dis 2024; 26:650-659. [PMID: 38418896 DOI: 10.1111/codi.16863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024]
Abstract
AIM Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre. METHOD Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome. RESULTS In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567). CONCLUSION High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.
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Affiliation(s)
- Sarah Sharabiany
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna J Joosten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JH. Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort. Ann Surg 2023; 278:772-780. [PMID: 37498208 PMCID: PMC10549897 DOI: 10.1097/sla.0000000000006043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL). BACKGROUND AL after RC resection often results in a permanent stoma. METHODS This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated. RESULTS This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76). CONCLUSIONS The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.
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Affiliation(s)
- Nynke G. Greijdanus
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - Francisco B. de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H. Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O. Perez
- Department of Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yves Panis
- Department of Colorectal Surgery, Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Department of Surgery, Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Pieter J. Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Johannes H.W. de Wilt
- Department of Surgery, Radboud university medical centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Talboom K, Greijdanus NG, Brinkman N, Blok RD, Roodbeen SX, Ponsioen CY, Tanis PJ, Bemelman WA, Cunningham C, de Lacy FB, Hompes R. Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series. Tech Coloproctol 2023; 27:1099-1108. [PMID: 37212927 PMCID: PMC10562258 DOI: 10.1007/s10151-023-02808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/15/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR. METHODS This retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up. RESULTS Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008). CONCLUSION Proactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N G Greijdanus
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N Brinkman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S X Roodbeen
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Y Ponsioen
- Department of Gastro-Enterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F B de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Talboom K, Borstlap WAA, Roodbeen SX, Bruns ERJ, Buskens CJ, Hompes R, Tytgat KMAJ, Tuynman JB, Consten ECJ, Heuff G, Kuiper T, van Geloven AAW, Veldhuis GJ, van der Hoeven JAB, Gerhards MF, Sietses C, Spinelli A, van de Ven AWH, van der Zaag ES, Westerterp M, van Westreenen HL, Dijkgraaf ML, Juffermans NP, Bemelman WA, Hess D, Swank HA, Scholten L, van der Bilt JDW, Jansen MA, van Duijvendijk P, Bezuur D, Carvello M, Foppa C, de Vos tot Nederveen Cappel WH, Geitenbeek RTJ, van Woensel L, De Castro SMM, Wientjes C, van Oostendorp S. Ferric carboxymaltose infusion versus oral iron supplementation for preoperative iron deficiency anaemia in patients with colorectal cancer (FIT): a multicentre, open-label, randomised, controlled trial. Lancet Haematol 2023; 10:e250-e260. [PMID: 36863386 DOI: 10.1016/s2352-3026(22)00402-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND A third of patients with colorectal cancer who are eligible for surgery in high-income countries have concomitant anaemia associated with adverse outcomes. We aimed to compare the efficacy of preoperative intravenous and oral iron supplementation in patients with colorectal cancer and iron deficiency anaemia. METHODS In the FIT multicentre, open-label, randomised, controlled trial, adult patients (aged 18 years or older) with M0 stage colorectal cancer scheduled for elective curative resection and iron deficiency anaemia (defined as haemoglobin level of less than 7·5 mmol/L (12 g/dL) for women and less than 8 mmol/L (13 g/dL) for men, and a transferrin saturation of less than 20%) were randomly assigned to either 1-2 g of ferric carboxymaltose intravenously or three tablets of 200 mg of oral ferrous fumarate daily. The primary endpoint was the proportion of patients with normalised haemoglobin levels before surgery (≥12 g/dL for women and ≥13 g/dL for men). An intention-to-treat analysis was done for the primary analysis. Safety was analysed in all patients who received treatment. The trial was registered at ClincalTrials.gov, NCT02243735, and has completed recruitment. FINDINGS Between Oct 31, 2014, and Feb 23, 2021, 202 patients were included and assigned to intravenous (n=96) or oral (n=106) iron treatment. Treatment began a median of 14 days (IQR 11-22) before surgery for intravenous iron and 19 days (IQR 13-27) for oral iron. Normalisation of haemoglobin at day of admission was reached in 14 (17%) of 84 patients treated intravenously and 15 (16%) of 97 patients treated orally (relative risk [RR] 1·08 [95% CI 0·55-2·10]; p=0·83), but the proportion of patients with normalised haemoglobin significantly increased for the intravenous treatment group at later timepoints (49 [60%] of 82 vs 18 [21%] of 88 at 30 days; RR 2·92 [95% CI 1·87-4·58]; p<0·0001). The most prevalent treatment-related adverse event was discoloured faeces (grade 1) after oral iron treatment (14 [13%] of 105), and no treatment-related serious adverse events or deaths were observed in either group. No differences in other safety outcomes were seen, and the most common serious adverse events were anastomotic leakage (11 [5%] of 202), aspiration pneumonia (5 [2%] of 202), and intra-abdominal abscess (5 [2%] 202). INTERPRETATION Normalisation of haemoglobin before surgery was infrequent with both treatment regimens, but significantly improved at all other timepoints following intravenous iron treatment. Restoration of iron stores was feasible only with intravenous iron. In selected patients, surgery might be delayed to augment the effect of intravenous iron on haemoglobin normalisation. FUNDING Vifor Pharma.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Sapho X Roodbeen
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Emma R J Bruns
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, Netherlands
| | - Gijsbert Heuff
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, Netherlands
| | - Teaco Kuiper
- Department of Gastroenterology, Amstelland Hospital, Amstelveen, Netherlands
| | | | - Gerrit J Veldhuis
- Department of Internal Medicine, Antonius Hospital, Sneek, Netherlands
| | | | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | | | | | - Marcel L Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam, Netherlands; Amsterdam Public Health Methodology, Amsterdam, Netherlands
| | - Nicole P Juffermans
- Department of Internal Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands; IBD Unit, Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita Salute San Raffaele, Milan, Italy.
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Talboom K, Greijdanus NG, Ponsioen CY, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum-assisted surgical closure (EVASC) of anastomotic defects after low anterior resection for rectal cancer; lessons learned. Surg Endosc 2022; 36:8280-8289. [PMID: 35534735 PMCID: PMC9613741 DOI: 10.1007/s00464-022-09274-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic vacuum-assisted surgical closure (EVASC) is an emerging treatment for AL, and early initiation of treatment seems to be crucial. The objective of this study was to report on the efficacy of EVASC for anastomotic leakage (AL) after rectal cancer resection and determine factors for success. METHODS This retrospective cohort study included all rectal cancer patients treated with EVASC for a leaking primary anastomosis after LAR at a tertiary referral centre (July 2012-April 2020). Early initiation (≤ 21 days) or late initiation of the EVASC protocol was compared. Primary outcomes were healed and functional anastomosis at end of follow-up. RESULTS Sixty-two patients were included, of whom 38 were referred. Median follow-up was 25 months (IQR 14-38). Early initiation of EVASC (≤ 21 days) resulted in a higher rate of healed anastomosis (87% vs 59%, OR 4.43 [1.25-15.9]) and functional anastomosis (80% vs 56%, OR 3.11 [1.00-9.71]) if compared to late initiation. Median interval from AL diagnosis to initiation of EVASC was significantly shorter in the early group (11 days (IQR 6-15) vs 70 days (IQR 39-322), p < 0.001). A permanent end-colostomy was created in 7% and 28%, respectively (OR 0.18 [0.04-0.93]). In 17 patients with a non-defunctioned anastomosis, and AL diagnosis within 2 weeks, EVASC resulted in 100% healed and functional anastomosis. CONCLUSION Early initiation of EVASC for anastomotic leakage after rectal cancer resection yields high rates of healed and functional anastomosis. EVASC showed to be progressively more successful with the implementation of highly selective diversion and early diagnosis of the leak.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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7
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Talboom K, Greijdanus NG, van Workum F, Ubels S, Rosman C, Hompes R, de Wilt JHW, Tanis PJ. International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study. Int J Colorectal Dis 2022; 37:2049-2059. [PMID: 36002748 PMCID: PMC9436864 DOI: 10.1007/s00384-022-04240-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Little is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide. METHODS In this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases). RESULTS In total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy. CONCLUSION This TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
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8
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Talboom K, van Helsdingen CPM, Abdelrahman S, Derikx JPM, Tanis PJ, Hompes R. Usefulness of CT scan as part of an institutional protocol for proactive leakage management after low anterior resection for rectal cancer. Langenbecks Arch Surg 2022; 407:3567-3575. [PMID: 36002771 DOI: 10.1007/s00423-022-02652-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Highly selective fecal diversion after low anterior resection (LAR) for rectal cancer requires a strict postoperative protocol for early detection of anastomotic leakage (AL). The purpose of this study was to evaluate C-reactive protein (CRP)-based CT imaging in diagnosis and subsequent management of AL. METHODS All patients that underwent a CT scan for suspicion of AL after transanal total mesorectal excision for rectal cancer in a university center (2015-2020) were included. Outcome parameters were diagnostic yield of CT and timing of CT and subsequent intervention. RESULTS Forty-four out of 125 patients underwent CT (35%) with an overall median interval of 5 h (IQR 3-6) from CRP measurement. The anastomosis was diverted in 7/44 (16%). CT was conclusive or highly suspicious for AL in 23, with confirmed AL in all those patients (yield 52%), and was false-negative in one patient (sensitivity 96%). CT initiated subsequent intervention after median 6 h (IQR 3-25). There was no or minor suspicion of AL on imaging in all 20 patients without definitive diagnosis of AL. After CT imaging on day 2, AL was confirmed in 0/1, and these proportions were 6/6 for day 3, 7/10 for day 4, 2/4 for day 5, and 9/23 beyond day 5. CONCLUSION In the setting of an institutional policy of highly selective fecal diversion and pro-active leakage management, the yield of selective CT imaging using predefined CRP cut-off values was 52% with a sensitivity of 96%, enabling timely and tailored intervention after a median of 6 h from imaging.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C P M van Helsdingen
- Department of Paediatric Surgery, Emma Childrens Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - S Abdelrahman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J P M Derikx
- Department of Paediatric Surgery, Emma Childrens Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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9
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de Lacy FB, Talboom K, Roodbeen SX, Blok R, Curell A, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates. Br J Surg 2022; 109:822-831. [PMID: 35640282 PMCID: PMC10364759 DOI: 10.1093/bjs/znac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/10/2022] [Accepted: 04/21/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. METHODS A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. RESULTS Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. CONCLUSION EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.
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Affiliation(s)
- F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Robin Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Anna Curell
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Oncological and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Roel Hompes
- Correspondence to: Roel Hompes, Department of Surgery, Amsterdam UMC, University of Amsterdam, Location AMC, J1A-216, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (e-mail: )
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10
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Talboom K, Tanis PJ, Bemelman WA, Hompes R. Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How? Clin Colon Rectal Surg 2022; 35:155-164. [PMID: 35237112 PMCID: PMC8885159 DOI: 10.1055/s-0041-1742117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.
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Affiliation(s)
- K. Talboom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands,Address for correspondence P. J. Tanis, MD, PhD Department of Surgery, Amsterdam UMCDe Boelelaan 1117, 1081 HV AmsterdamThe Netherlands
| | - W. A. Bemelman
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - R. Hompes
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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11
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Keller DS, Talboom K, van Helsdingen CPM, Hompes R. Treatment Modalities for Anastomotic Leakage in Rectal Cancer Surgery. Clin Colon Rectal Surg 2021; 34:431-438. [PMID: 34853566 DOI: 10.1055/s-0041-1736465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University of California at Davis Medical Center, Sacramento, California
| | - K Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - C P M van Helsdingen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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12
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An Y, Roodbeen SX, Talboom K, Tanis PJ, Bemelman WA, Hompes R. A systematic review and meta-analysis on complications of transanal total mesorectal excision. Colorectal Dis 2021; 23:2527-2538. [PMID: 34174138 DOI: 10.1111/codi.15792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/13/2022]
Abstract
AIM Transanal total mesorectal excision (TaTME) is a surgical approach for treating mid to low rectal cancer as well as other colorectal diseases. Since the procedure is difficult to master, perioperative complications of TaTME should be examined precisely, especially during the early implementation phase of this procedure. The primary aim of this review was to determine a pooled morbidity and anastomotic leakage (AL) rate after TaTME surgery, and the secondary aim was to show the completeness of reporting of complications among the included studies, as well as the correlation between completeness and reported incidence of complications. METHOD A systematic review of literature was conducted using Medline, Embase and Cochrane databases, searching for observational studies reporting on complications after TaTME. Studies published between 1 January 2010 and 15 October 2019 were included. Meta-analysis on the proportion of morbidity, AL and intraoperative complications was performed. RESULTS Forty-one studies (2446 TaTME cases), consisting of 27 noncomparative studies and 14 comparative studies, were included, after screening 1711 possible studies. The pooled rates of overall morbidity and AL were 30.0% (95% CI 26.4%-34.0%) and 6.8% (95% CI 5.2%-8.9%), respectively. Subgroup analysis showed that the morbidity rate in studies that reported 30-day results (35.5%; 95% CI 31.8%-39.4%) was significantly higher than the rate in studies that did not define the follow-up length for complications (23.4%; 95% CI 17.8%-30.1%; p = 0.003). The rates of intraoperative urethral injury, rectal injury, vaginal injury and bladder injury were 0.3% (95% CI 0.1%-1.7%), 0.4% (95% CI 0.1%-2.2%), 0.3% (95% CI 0.1%-0.8%) and 0.3% (95% CI 0.1%-1.7%), respectively. CONCLUSION This meta-analysis shows that pooled perioperative complication rates were within acceptable ranges. However, the significant difference in overall morbidity rate between the studies with 30-day results and the studies without a specified follow-up time, indicates a large under-reporting of complications in many studies.
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Affiliation(s)
- Yongbo An
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC (AMC), University of Amsterdam, Amsterdam, The Netherlands
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13
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van Workum F, Talboom K, Hannink G, Wolthuis A, de Lacy BF, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rosman C, Hompes R, Tanis PJ, de Wilt JHW. Treatment of anastomotic leakage after rectal cancer resection: The TENTACLE-Rectum study. Colorectal Dis 2021; 23:982-988. [PMID: 33169512 PMCID: PMC8246753 DOI: 10.1111/codi.15435] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/25/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
AIM Anastomotic leakage is a severe complication after low anterior resection (LAR) for rectal cancer and occurs in up to 20% of patients. Most research focuses on reducing its incidence and finding predictive factors for anastomotic leakage. There are no robust data on severity and treatment strategies with associated outcomes. The aims of this work were (1) to investigate the factors that contribute to severity of anastomotic leakage and to compose an anastomotic leakage severity score and (2) to evaluate the effects of different treatment approaches on prespecified outcome parameters, stratified for severity score and other leakage characteristics. METHOD TENTACLE-Rectum is an international multicentre retrospective cohort study. Patients with anastomotic leakage after LAR for primary rectal cancer between 1 January 2014 and 31 December 2018 will be included by each centre. We aim to include 1246 patients in this study. The primary outcome is 1-year stoma-free survival (i.e. patients alive at 1 year without a stoma). Secondary outcomes include number of reinterventions and unplanned readmissions within 1 year, total length of hospital stay, total time with a stoma, the type of stoma present at 1 year (defunctioning, permanent), complications related to secondary leakage and mortality. For aim (1) regression models will be used to create an anastomotic leakage severity score. For aim (2) the effectiveness of different treatment strategies for leakage will be tested after correction for severity score and leakage characteristics, in addition to other potential related confounders. CONCLUSION TENTACLE-Rectum will be an important step towards drawing up evidence-based recommendations and improving outcomes for patients who experience severe treatment-related morbidity.
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Affiliation(s)
- Frans van Workum
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands,Department of Surgery and cancerImperial CollegeLondonUK
| | - Kevin Talboom
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Gerjon Hannink
- Department of Operating RoomsRadboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Jeremie H. Lefevre
- Department of Digestive SurgerySorbonne Université, AP‐HPHôpital Saint AntoineParisFrance
| | - Michael Solomon
- Department of SurgeryUniversity of Sydney Central Clinical SchoolCamperdownNew South WalesAustralia
| | - Matteo Frasson
- Department of SurgeryValencia University Hospital La FeValenciaSpain
| | | | - Quentin Denost
- Department of SurgeryBordeaux University HospitalBordeauxFrance
| | | | - Tsuyoshi Konishi
- Department of Gastroenterological SurgeryCancer Institute Hospital of the Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yves Panis
- Colorectal DepartmentBeaujon Hospital, Clichy, and University of ParisClichyFrance
| | - Camiel Rosman
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
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14
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Talboom K, Vogel I, Blok RD, Roodbeen SX, Ponsioen CY, Bemelman WA, Hompes R, Tanis PJ. Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer. Br J Surg 2021; 108:609-612. [PMID: 33793724 DOI: 10.1093/bjs/znab018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/20/2020] [Indexed: 11/12/2022]
Abstract
Abstract
In this single center case series with nine percent primary diversion, 86 of 94 patients alive and with complete follow-up at one year had a functioning anastomosis. Seventy-five of the initial 99 patients never had a stoma. Meaning: Highly selective fecal diversion in combination with proactive leakage management, low anastomoses can be preserved safely, and the majority of patients will be spared all disadvantages of a diverting stoma.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - I Vogel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - S X Roodbeen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - C Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam, the Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
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15
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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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16
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Talboom K, van Kesteren J, Sonneveld DJA, Tanis PJ, Bemelman WA, Hompes R. Early transanal closure after vacuum-assisted drainage for anastomotic leakage in rectal cancer surgery - a video vignette. Colorectal Dis 2020; 22:973-974. [PMID: 32150763 DOI: 10.1111/codi.15032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022]
Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J van Kesteren
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - D J A Sonneveld
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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