Anterior Resection For Rectal Carcinoma Research Articles

A Multivariate Analysis of Anastomotic Stenosis After Anterior Resection for Rectal Carcinoma

A Multivariate Analysis of Anastomotic Stenosis After Anterior Resection for Rectal Carcinoma

Risk Factors for Anastomotic Leakage after Low Anterior Resection.

Low anterior resection (LAR) is a standard surgical procedure for distal rectal carcinoma that allows creation of a colorectal anastomosis, with anal sphincter preservation and permanent colostomy avoidance. Anastomotic leakage (AL) is a potential complication of LAR present in 3% to 20% of cases leading to a significant increase in postoperative morbidity. AL represents a communication between the intra luminal and extra luminal compartments caused by a violation of the integrity of the intestinal wall. The risk factors of this procedure have been discussed and still remain a controversial issue. Prevention is the best management. Patients with predisposing factors should be paid special attention. Our objective was to identify and analyze the risk factors of anastomotic leakage after low anterior resection of rectal carcinoma. This study included all patients who underwent low anterior resection for rectal cancer at the Department of Surgery of University Hospital Kaspela between 2011 and 2016. Low anterior resections were performed in 141 patients during the study period. Due to a positive air leak test on 16 patients, a protective ileostomy was created and these patients were eliminated from the study. The sex distribution of the remaining 125 patients was 69 men (55.2%) and 56 women (44.8%). The height of the anastomosis from the dentate line was 3.0 cm on an average (range 2.5 to 4 cm). Anastomotic leakage remains the most feared and serious complication after low anterior resection surgery. The evidence suggests that the main risk factors for anastomotic leakage at low anterior resection are the height of the anastomosis and the high ASA score.

A Retrospective Study of Risk Factors for Symptomatic Anastomotic Leakage after Laparoscopic Anterior Resection of the Rectal Cancer without a Diverting Stoma.

Background Anastomotic leakage (AL) is a common and devastating postoperative issue for patients who have undergone anterior resection of rectal carcinoma and can lead to increased short-term morbidity and mortality. Moreover, it might be associated with a worse oncological prognosis of tumors. This study is aimed at exploring the risk factors for symptomatic AL after laparoscopic anterior resection (LAR) for rectal tumors without a preventive diverting stoma. Materials and Methods This case control study retrospectively reviewed the data of 496 consecutive patients who underwent LAR of the rectum without a preventive diverting stoma at the Cancer Hospital, Chinese Academy of Medical Sciences between September 2016 and September 2017. All patients were divided into an AL group and a control group based on the occurrence of postoperative symptomatic AL. Factors regarding patient-related variables, operation-related variables, and tumor-related variables were collected and assessed between the two groups through univariate and multivariate logistic regression analyses to identify independent risk factors for AL. Results In total, 18 (3.6%) patients developed postoperative symptomatic AL. Univariate analysis showed that a synchronous primary malignancy of the left hemicolon (P = 0.047), intraoperative chemotherapy (P = 0.003), and level of anastomosis (P = 0.033) were significantly related with AL. Multivariate analysis was subsequently performed to adjust for confounding biases and confirmed that a synchronous primary malignancy of the left hemicolon (odds ratio (OR), 12.225; 95% confidence interval (CI), 1.764-84.702; P = 0.011), intraoperative chemotherapy (OR, 3.931; 95% CI, 1.334-11.583; P = 0.013), and level of anastomosis (OR, 3.224; 95% CI, 1.124-9.249; P = 0.030) were independent risk factors for symptomatic AL for patients who received LAR for rectal neoplasms without a preventive diverting stoma. Conclusions Synchronous primary malignancy of the left hemicolon, intraoperative chemotherapy, and a low anastomotic level can increase the risks of postoperative symptomatic AL after LAR of the rectum without a protective diverting stoma.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Intraoperative intraperitoneal chemotherapy increases the incidence of anastomotic leakage after anterior resection of rectal tumors.

BACKGROUNDIntraoperative intraperitoneal chemotherapy is an emerging treatment modality for locally advanced rectal neoplasms. However, its impacts on postoperative complications remain unknown. Anastomotic leakage (AL) is one of the most common and serious complications associated with the anterior resection of rectal tumors. Therefore, we designed this study to determine the effects of intraoperative intraperitoneal chemotherapy on AL.AIMTo investigate whether intraoperative intraperitoneal chemotherapy increases the incidence of AL after the anterior resection of rectal neoplasms.METHODSThis retrospective cohort study collected information from 477 consecutive patients who underwent an anterior resection of rectal carcinoma using the double stapling technique at our institution from September 2016 to September 2017. Based on the administration of intraoperative intraperitoneal chemotherapy or not, the patients were divided into a chemotherapy group (171 cases with intraperitoneal implantation of chemotherapy agents during the operation) or a control group (306 cases without intraoperative intraperitoneal chemotherapy). Clinicopathologic features, intraoperative treatment, and postoperative complications were recorded and analyzed to determine the effects of intraoperative intraperitoneal chemotherapy on the incidence of AL. The clinical outcomes of the two groups were also compared through survival analysis.RESULTSThe univariate analysis showed a significantly higher incidence of AL in the patients who received intraoperative intraperitoneal chemotherapy, with 13 (7.6%) cases in the chemotherapy group and 5 (1.6%) cases in the control group (P = 0.001). As for the severity of AL, the AL patients who underwent intraoperative intraperitoneal chemotherapy tended to be more severe cases, and 12 (92.3%) out of 13 AL patients in the chemotherapy group and 2 (40.0%) out of 5 AL patients in the control group required a secondary operation (P = 0.044). A multivariate analysis was subsequently performed to adjust for the confounding factors and also showed that intraoperative intraperitoneal chemotherapy increased the incidence of AL (odds ratio = 5.386; 95%CI: 1.808-16.042; P = 0.002). However, the survival analysis demonstrated that intraoperative intraperitoneal chemotherapy could also improve the disease-free survival rates for patients with locally advanced rectal cancer.CONCLUSIONIntraoperative intraperitoneal chemotherapy can improve the prognosis of patients with locally advanced rectal carcinoma, but it also increases the risk of AL following the anterior resection of rectal neoplasms.

Rectal carcinoma and multiple gastrointestinal stromal tumors (GIST) of the small intestine in a patient with neurofibromatosis type 1: a case report

BackgroundNeurofibromatosis type 1 (NF1) is an autosomally dominant inherited disorder characterized by multiple pigmented skin spots (café-au-lait spots) and neurofibroma. NF1 is associated with a wide variety of benign or malignant tumors. We report a NF1 patient who received surgical treatment for rectal carcinoma and multifocal small intestinal gastrointestinal stromal tumors (GISTs).Case presentationA 70-year-old female patient with NF1 was referred to our hospital after a positive fecal occult blood test. Locally advanced rectal carcinoma was detected in the upper rectum using colonoscopy. A submucosal tumor 20 mm in diameter was detected in the duodenal bulb during the upper gastrointestinal endoscopy. The biopsy specimen from the duodenum was GIST with positive immunostaining of KIT and CD34 microscopically. Laparoscopic low anterior resection for rectal carcinoma and local excision of the duodenal GIST were performed successfully. During the operation, five white small nodules were found on the serosa of the jejunum. One nodule was excised for histological examination. The resected rectal tumor was a well-differentiated adenocarcinoma with multiple lymph nodes metastases according to the histology. The duodenal tumor was found to be low-risk GIST. Moreover, the nodule from the jejunum was very low risk GIST. An excised skin wart was neurofibroma according to the histology.ConclusionsGIST or carcinomas have been reported to occasionally occur in the digestive tract of the patients with NF1. We present a rare case of a NF1 patient with GISTs and colorectal carcinoma.

Clinical control study of defunctioning and non-defuncioning stoma in low anterior resection for rectal cancer

Objective To compare the clinical data and postoperative complications between defunctioning stoma and non-defunctioning stoma in laparoscopic low anterior resection for rectal carcinoma, and study the clinical significance of non-defunctioning stoma. Methods The clinical data of 70 cases who accepted laparoscopic low anterior resection was collected. According to the operative methods, all patients were divided into two groups, defu ctioning stoma group included 42 cases and non-defunctioning stoma group induded 28 cases. The situation of postoper rative complications of patients boh two groups were compared by SPSS 19.0. Results The operation time, bleeding volume, eating time in defunctioning stoma groups and non-defunctioning stoma groups were no statistical significant.The time staying in hospital in defunctioning stoma groups was longer than that of non-defunctioning stoma groups(P<0.05). defunctioning stoma groups, anastomotic leakages happened in 2 case, anastomotic hemorrhage in 1 case, incision complications in 2 cases, anastomotic strictures in 8 cases, stoma complications in 1 case. The total morbidity was 28.5%.In non-defunctioning stoma group anastomotic leakages happened in 1 case, anastomotic hemorrhage happened in 1 case, incision complications happened in 1 case, internal complications happened in 1 case.The postoperative morbidity was 17.8%. The total complications had significant difference in the two groups(P<0.05). The anastomotic leakage and hemorrhage in two groups had no difference significantly. Conclusion Defunctioning stoma with no indication can not decrease the complication in laparoscopic low anterior resection for rectal cancer case. Key words: Rectal neoplasms; Laparoscopes; Ostomy; Postoperative complications; Low anterior resection

Long-term outcomes of laparoscopic low anterior resection of rectal carcinoma with preservation of the left colic artery

To investigate the long-term outcomes of laparoscopic low anterior resection of rectal carcinoma with preservation of the left colic artery(LCA). Clinicopathological and follow-up data of 322 cases with rectal carcinoma undergoing laparoscopic low anterior resection in Department of General Surgery, Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2007 to December 2011 were retrospectively analyzed. According to the different surgical methods of inferior mesenteric artery (IMA), cases were divided into the trial group (LCA preservation plus lymph nodes around IMA root dissection, 168 cases) and the control group(origin of IMA ligation, 154 cases). The 5-year rates of disease-free survival(DFS) and overall survival(OS) were compared between two groups. There were no statistically significant differences in the baseline data between the two groups. The follow-up rate was 91.1%(153/168) during 5-60 months in the trial group, and 90.3%(139/154) during 6-60 months in the control group. The number of patients who developed death, local recurrence and metastasis were 49(32.0%), 9(5.9%) and 62(40.5%) in the trial group, and 44(31.7%), 9(6.5%) and 52(37.4%) in the control group, respectively, without significant differences(all P>0.05). The 5-year DFS and OS rates were 57.2% and 69.5% in the trial group, and 59.7% and 70.1% in the control group, and the differences were not significant between the two groups(all P>0.05). After stratification by TNM stage, the 5-year DFS rates of I( stage, II( stage and III( stage were 80.4%, 62.5% and 45.1% in the trial group, and 82.6%, 66.0% and 48.8% in the control group; the 5-year OS rates of I( stage, II( stage and III( stage were 90.2%, 76.2% and 56.7% in the trial group, and 94.4%, 74.3% and 60.5% in the control group, respectively, and the differences were not significant as well (all P>0.05). The long-term outcomes after laparoscopic low anterior resection of rectal carcinoma with preservation of LCA and dissection of lymph nodes around root of IMA are comparable with ligation at origin of IMA.

直腸癌術後に生じた直腸膣瘻に対し，膣剤を併用した洗浄により保存的に治癒し得た1例

直腸癌術後に生じた直腸膣瘻に対し，膣剤を併用した洗浄により保存的に治癒し得た1例

Full-thickness endoscopic resection of local residual neoplasia in the hepatic flexure – video case report

Summary: We present a case of a 56-year-old patient after low anterior resection for rectal carcinoma and with local residual neoplasia after endoscopic mucosal resection in the hepatic flexure. The lesion was resected by endoscopic full-thickness resection technique (FTR). Histological examination confirmed completely resected tubular adenoma with HGIN. Patient was dismissed after two days without any complications.

Complications of Diverting Ileostomy after Low Anterior Resection for Rectal Carcinoma

There have been few studies directly comparing the postoperative complications in patients with a diverting ileostomy to patients who were not diverted after low anterior resection (LAR) for rectal carcinoma. This study is a retrospective chart review of all rectal carcinoma patients (99) who underwent a LAR from January 2009 to December 2014 at Loma Linda University Medical Center and Veterans Affairs Loma Linda Healthcare System. A majority of patients were diverted (58% vs 42%). The diverted patients were more likely to have a low tumor location (P < 0.01), preoperative chemoradiation (P < 0.01), and more intraoperative blood loss (P < 0.01). Our study shows a statistically significant higher overall complication rate among patients receiving a diverting ileostomy in the six months after LAR (61% vs 38%, P = 0.02). The difference is due to a higher rate of readmission (27% vs 14%) and acute kidney injury (14% vs 5%) in patients with a diverting ileostomy. It also shows that there is a higher rate of unplanned reoperation (11% vs 6%) due to anastomotic leak (17% vs 5%) in nondiverted patients. Further studies are needed to refine the specific indications to maximize the benefit of diverting ileostomy after LAR for rectal carcinoma.

Carcinoma microsatellite instability status as a predictor of benefit from fluorouracil-based adjuvant chemotherapy for stage II rectal cancer.

Rectal cancers with high microsatellite-instable have clinical and pathological features that differentiate them from microsatellite-stable or low- frequency carcinomas, which was studied rarely in stage II rectal cancer, promoting the present investigation of the usefulness of microsatellite-instability status as a predictor of the benefit of adjuvant chemotherapy with fluorouracil in stage II rectal cancer. Data of 460 patients who underwent primary anterior resection with a double stapling technique for rectal carcinoma at a single institution from 2008 to 2012 were retrospectively collected. All patients experienced a total mesorectal excision (TME) operation. Survival analysis were analyzed using the Cox regression method. Five-year rate of disease-free survival (DFS) was noted in 390 (84.8%) of 460 patients with stage II rectal cancer. Of 460 tissue specimens, 97 (21.1%) exhibited high-frequency microsatellite instability. Median age of the patients was 65 (50-71) and 185 (40.2%) were male. After univariate and multivariate analysis, microsatellite instability (p= 0.001), female sex (p< 0.05) and fluorouracil-based adjuvant chemotherapy (p< 0.001), the 3 factors were attributed to a favorable survival status independently. Among 201 patients who did not receive adjuvant chemotherapy, those cancers displaying high-frequency microsatellite instability had a better 5-year rate of DFS than tumors exhibiting microsatellite stability or low-frequency instability (HR, 13.61 [95% CI, 1.88 to 99.28]; p= 0.010), while in 259 patients who received adjuvant chemotherapy, there was no DFS difference between the two groups (p= 0.145). Furthermore, patients exhibiting microsatellite stability or low-frequency instability who received adjuvant chemotherapy had a better 5-year rate of DFS than patients did not (HR, 5.16 [95% CI, 2.90 to 9.18]; p< 0.001), while patients exhibiting high-frequency microsatellite instability were not connected with increased DFS (p= 0.696). It was implied that female patients had better survival than male. Survival status after anterior resection of rectal carcinoma is related to the microsatellite instability status, adjuvant chemotherapy and gender. Fluorouracil-based adjuvant chemotherapy benefits patients of stage II rectal cancer with microsatellite-stable or low microsatellite-instable, but not those with high microsatellite- instable. Additionally, free of adjuvant chemotherapy, carcinomas with high microsatellite-instable have a better 5-year rate of DFS than those with microsatellite-stable or low microsatellite-instable, and female patients have a better survival as well.

Incidence and Mortality of Anastomotic Dehiscence Requiring Reoperation After Rectal Carcinoma Resection

Anastomotic dehiscence (AD) requiring reoperation is the most severe complication following anterior rectal resection. We performed a systematic review on studies that describe AD requiring reoperation and its subsequent mortality after anterior resection for rectal carcinoma. A systematic search was performed on published literature. Data on the definition and rate of AD, the number of ADs requiring reoperation, the mortality caused by AD, and the overall postoperative mortality were pooled and analyzed. A total of 39 studies with 24,232 patients were analyzed. The studies varied in incidence and definition of AD. Systematic review of the data showed that the overall rate of AD was 8.6%, and the rate of AD requiring reoperation was 5.4%. The postoperative mortality caused by AD was 0.4%, and the overall postoperative mortality was 1.3%. We found considerable risk and mortality for AD requiring reoperation, which largely contributed to the overall postoperative mortality.

Outcomes Based on Risk Assessment of Anastomotic Leakage after Rectal Cancer Surgery

Anastomotic leakage (AL) is associated with high morbidity and mortality, high reoperation rates, and increased hospital length of stay. Here we investigated the risk factors for AL after anterior resection for rectal cancer with a double stapling technique. Data for 460 patients who underwent primary anterior resection with a double stapling technique for rectal carcinoma at a single institution from 2003 to 2007 were prospectively collected. All patients experienced a total mesorectal excision (TME) operation. Clinical AL was defined as the presence of leakage signs and confirmed by diagnostic work-up according to ICD-9 codes 997.4, 567.22 (abdominopelvic abscess), and 569.81 (fistula of the intestine). Univariate and logistic regression analyses of 20 variables were undertaken to determine risk factors for AL. Survival was analysed using the Cox regression method. AL was noted in 35 (7.6%) of 460 patients with rectal cancer. Median age of the patients was 65 (50-74) and 161 (35%) were male. The diagnosis of AL was made between the 6th and 12th postoperative day (POD; mean 8th POD). After univariate and multivariate analysis, age (p=0.004), gender (p=0.007), tumor site (p<0.001), preoperative body mass index (BMI) (p<0.001), the reduction of TSGF on 5th POD less than 10U/ml (p=0.044) and the pH value of pelvic dranage less than or equal to 6.978 on 3rd POD (p<0.001) were selected as 6 independent risk factors for AL. It was shown that significant differences in survival of the patients were AL-related (p<0.001), high ASA score related (p=0.036), high-level BMI related (p=0.007) and advanced TNM stage related (p<0.001). AL after anterior resection for rectal carcinoma is related to advanced age, low tumor site, male sex, high preoperative BMI, low pH value of pelvic drainage on POD 3 and a significant reduction of TSGF on POD 5. In addition to their high risk of immediate postoperative morbidity and mortality, AL, worse physical status, severe obesity and advanced TNM stage have similarly negative impact on survival.

Risk Assessment on Anastomotic Leakage after Rectal Cancer Surgery: An Analysis of 753 Patients

To investigate the risk factors for anastomotic leakage (AL) after anterior resection for rectal cancer with a double stapling technique. Between January 2004 and December 2011, 753 consecutive patients in Jiangsu Cancer Hospital and Research Institute diagnosed with rectal cancer and undergoing anterior resection with a double stapling technique were recruited. All patients experienced a total mesorectal excision (TME) operation. Additionally, decrease of postoperative tumor supplied group of factors (TSGF), which have not been reported before, was proposed as a new indicator for AL. Univariate and multivariate analysis were performed to determine risk factors for AL. AL was detected in 57 (7.6%) of 753 patients with rectal cancer. The diagnosis of anastomotic leakage was confirmed between the 6th and 12th postoperative day (POD; mean 8th POD). After univariate analysis and multivariate analysis, age (p<0.001), gender (p=0.002), level of anastomosis (p <0.001), preoperative body mass index (BMI) (p = 0.001) and reduction of TSGF in 5th POD was less than 10 μ/ml (p <0.001) were selected as 5 independent risk factors for AL. It was also indicated that a temporary defunctioning transverse ileostomy (p = 0.04) would decrease the occurrence of AL. AL after anterior resection for rectal carcinoma is related to elderly status, low level site of the tumor (below the peritoneal reflection), being male, preoperative BMI and the decrease of TSGF in 5th POD is less than 10 m/ml. Preventive ileostomy is advisable after TME for low rectal tumors to prevent AL.

Treatment of chronic presacral sinus after low anterior resection

The aim of this retrospective study was to determine patient and treatment characteristics with corresponding clinical outcome of symptomatic chronic presacral sinus after low anterior resection. Twenty-two patients were treated for a presacral sinus persisting for at least 12 months after low anterior resection for rectal carcinoma between January 2005 and March 2012. Patient charts were reviewed and analysed using descriptive statistics. Fistula formation was the most frequently observed secondary complication in 55% of patients. A median of 6 (1-44) surgical, endoscopic or radiological interventions related to the presacral sinus were performed. Overall, the chronic presacral sinus healed after multimodality treatment in nine (41%) patients at a median interval from primary surgery of 45 (24-93) months. If basic treatment principles were followed (anastomotic reconstruction or completion proctectomy with filling of the cavity), healing rate of the sinus was higher than where these principles were not adhered to (62% vs 11%). Successful treatment of a chronic presacral sinus after low anterior resection appears to be achieved by salvage surgery with anastomotic reconstruction in highly selected patients or intersphincteric completion proctectomy and omentoplasty.

Gastrointestinal: Gingival metastasis from rectal carcinoma

A 77-year-old woman had undergone low anterior resection for rectal carcinoma 4 years ago. She developed multiple pulmonary metastases 2 years ago, which did not respond to palliative chemotherapy with FOLFOX (fluorouracil, leucovorin, and oxaliplatin) followed by FOLFIRI (fluorouracil, leucovorin, and irinotecan). She presented with an upper right premolar buccal gingival mass, which was progressively enlarging for 2 months (Fig. 1). The mass was associated with pain and bleeding, and as a result she had great difficulty in chewing and oral feeding. Incisional biopsy of the mass confirmed the diagnosis of metastatic adenocarcinoma from colorectal primary (based on the immunohistochemical staining pattern of strong and diffuse positivity for CDX-2, weak and focal positivity for cytokeratin 20, and negativity for cytokeratin 7) (Fig. 2). Palliative radiotherapy was given to control the local symptoms of pain and bleeding, and her oral feeding improved afterwards. However, she developed progressive bony metastases and finally died 4 months after the diagnosis of gingival metastasis. Metastatic tumors to the oral cavity are uncommon, accounting for 1% of all malignant neoplasms in this region. The jawbones are usually involved in most of the cases, while less than one third of oral metastases are located in the soft oral tissues, such as the gingiva. Most oral metastatic tumors present in patients who have also developed metastases at other sites, but in up to one third of patients they are the first clinical sign of an underlying malignant process. The most common primary tumors are lung in men and breast in women; oral metastases from colorectal primary are exceedingly rare. In fact, gingival metastasis is a very rare and late presentation of colorectal carcinoma, and the consequent survival is just a few weeks or months. The gross appearance of gingival metastasis may be indistinguishable from other benign buccal lesions, such as pyogenic granuloma and giant cell granuloma. Histological examination with immunohistochemical techniques is thus essential to confirm the diagnosis. Gingival metastasis can cause progressive discomfort, such as pain or bleeding, as illustrated in our case. Therefore, even in cases with advanced or disseminated disease, palliative treatment such as radiotherapy is necessary to improve the quality of life of patients. In selected cases with solitary oral metastasis, surgical resection can be considered. Contributed by

Can Transanal Tube Placement after Anterior Resection for Rectal Carcinoma Reduce Anastomotic Leakage Rate? A Single‐institution Prospective Randomized Study

Anastomotic leakage is the most significant complication after low anterior resection (LAR) for rectal carcinoma, and it is the major cause of postoperative mortality and morbidity. The objective of the present study was to investigate whether the use of a transanal tube as an alternative endoluminal diversion technique for rectal carcinoma can reduce the 30-day leakage rate after LAR. From June 2003 to December 2009, a total of 398 patients were randomized to a transanal tube or not after LAR. Inclusion criteria for randomization were biopsy-proven carcinoma of the rectum located ≤15 cm above the anal verge, measured with a rigid rectoscope; age≥18 years; informed consent; ability to understand the study information; estimated survival of >6 months; anterior resection for the lesion; final negative air leakage test; intact anastomotic stapler rings; and the absence of major intraoperative adverse events. Patient demographics, tumor size and location, Duke's stage, preoperative co-morbidity, and operative details were comparable between the two groups in general analysis and subgroup analysis (double-staple technique and handsewn technique). The overall rate of symptomatic leakage was 6.78% (27 of 398 patients). Patients randomized to a transanal tube (n=200) had leakage in 4.0% (8 of 200 patients) and those without a tube (n=198) in 9.6% (19 of 198 patients) (p=0.026). With regard to the double-staple technique subgroup, 3.7% (7 of 188) patients with a tube presented with a symptomatic anastomotic leakage, compared with 9.3% (17 of 182) of those without a tube (p=0.028). Of the patients with anastomotic leakage in the double-staple technique subgroup, the need for urgent abdominal reoperation was 28.6% (two of seven patients) in those randomized to a transanal tube and 82.4% (14 of 17) in those without (p=0.021). The 30-day mortality after LAR was nil. In the double-staple technique subgroup, a quicker resumption of gastrointestinal motility manifested by a smaller ratio of patients with flatus>postoperative day (POD) 3 (p=0.019) and a smaller ratio of poor gastrointestinal electromyogram on POD 3 (p<0.001) was associated with use of a transanal tube. Additionally, patients with a tube appeared to have a lower rectal resting pressure by POD 3 (4.0±2.2 vs. 5.0±2.2 kPa; p<0.001) or POD 5 (4.3±2.3 vs. 5.6±2.3 kPa; p<0.001), compared to the resting pressures patients without the device, respectively. A shorter length of hospital stay was associated with use of a transanal tube both in the double-staple technique subgroup (p<0.001) and the handsewn technique subgroup (p=0.011). Multivariate logistic regression analysis revealed that body mass index>25 kg/m2 and a poor gastrointestinal electromyogram on POD 3 were found to be independent risk factors for anastomotic leakage in the low anastomosis subgroup. The presence of a transanal tube is effective and safe in decreasing the rate of clinically significant anastomotic leaks and in mitigating the clinical consequences of leakage after anterior resection for rectal cancer with the technique of total mesorectal excision and double-staple anastomosis. The potential benefits of transanal tube placement are multifactorial, including drainage, reduction of endoluminal pressure, and promotion of gastrointestinal motility. Obesity and poor gastrointestinal electromyogram on POD 3 are independent risk factors for anastomotic leakage in patients with low anastomosis.

Anterior resection for rectal carcinoma - risk factors for anastomotic leaks and strictures

To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection (AR) and its subsequent management. Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection (LAR) to identify the various preoperative, operative, and post operative factors that might have influence on anastomotic leaks and strictures. There were 68 males and 40 females with an average of 47 years (range 21-75 years). The median distance of the tumor from the anal verge was 8 cm (range 3-15 cm). Sixty (55.6%) patients underwent handsewn anastomosis and 48 (44.4%) were stapled. The median operating time was 3.5 h (range 2.0-7.5 h). Sixteen (14.6%) patients had an anastomotic leak. Among these, 11 patients required re-exploration and five were managed expectantly. The anastomotic leak rate was similar in patients with and without diverting stoma (8/60, 13.4% with stoma and 8/48; 16.7% without stoma). In 15 (13.9%) patients, resection margins were positive for malignancy. Nineteen (17.6%) patients developed anastomotic strictures at a median duration of 8 mo (range 3-20 mo). Among these, 15 patients were successfully managed with per-anal dilatation. On multivariate analysis, advance age (> 60 years) was the only risk factor for anastomotic leak (P = 0.004). On the other hand, anastomotic leak (P = 0.00), mucin positive tumor (P = 0.021), and lower rectal growth (P = 0.011) were found as risk factors for the development of an anastomotic stricture. Advance age is a risk factor for an anastomotic leak. An anastomotic leak, a mucin-secreting tumor, and lower rectal growth predispose patients to develop anastomotic strictures.

Laparoscopic low anterior resection for rectal carcinoma: Complications and management in 132 consecutive patients

To analyze the clinical manifestations and risk factors of complications in laparoscopic low anterior resection (LAR) for rectal cancer patients. A series of 132 consecutive patients who received laparoscopic LAR for rectal cancer in our center were included. The etiology, diagnosis, treatment and prevention of rectal cancer were studied among the patients with surgery-related complications using both univariate and multivariate regression analysis. No conversion to open surgery was observed and 5 cases converted to hand-assisted laparoscopic operation. The overall morbidity rate was 20.5%. Complications occurred during the operation in 7 patients (5.3%), within 30 postoperative days in 24 patients (18.2%), and within 3 mo in 2 patients (1.5%). The most significant complications were anastomotic leakage (9.1%) and anastomotic hemorrhage (5.3%). Size and location of tumor, pathological staging and preoperative nutrition were significant factors associated with LAR complications, while gender, age and pathological type showed no relevance. Binary logistics regression showed that the size and location of tumor, and pathological staging were independent factors of laparoscopic LAR. All the complications were treated during their onset of clinical manifestations by interventional or conservative therapy. Anastomotic leakage is a major complication in laparoscopic LAR. The complications may be associated with tumor size and site, and pathological stage. Interventional therapies are of value in the management of laparoscopic LAR complications.