Complication Of Rectal Surgery Research Articles

Predictors of anastomotic leak after anterior rectal resections for localized malignant neoplasms

Background:. Anastomotic leak (AL) is the most serious complication in rectal surgery. Predicting and preventing AL remains an urgent task. The purpose of the study is to analyze the 17-year experience of the Federal State Budgetary Institution Federal Research Center FMBA of Russia in performing anterior resection of the rectum in patients with cancer of the rectum and rectosigmoid junction and to establish risk factors for the development of AL. Methods. The results of treatment of 492 patients who were treated in 2006-2022 were studied. anterior resection of the rectum was performed. 21 patients developed AL. A retrospective comparison of the characteristics of two groups of patients was carried out: those with a smooth course of the postoperative period and those with the development of AL. Results. Reliable risk factors for the development of AL were identified and, based on statistical analysis, a prognostic scoring model was proposed: smoking (1 point), type 2 diabetes mellitus (1 point), preoperative chemotherapy (1 point), blood loss over 50 ml (2 points), preoperative radiation therapy (3 points), and the location of the colorectal anastomosis at a distance of up to 5 cm from the anus (4 points). The sensitivity of the model on the training set with 8 points or more was 85.6%, with a specificity above 97.4%. Conclusion. The following tactics are proposed: if there are 4 points and above, we form a preventive intestinal stoma; if there are 1-3 points, we install a transanal drainage. Complete abandonment of these two preventive measures is possible only if the patient does not have any of the listed risk factors for the development of anastomotic leak.

Tandem Mass Tag-Based Proteomic Profiling Identifies Biomarkers in Drainage Fluid for Early Detection of Anastomotic Leakage after Rectal Cancer Resection.

Anastomotic leakage (AL), one of the most severe complications in rectal surgery, is often diagnosed late because of the low specificity of the clinical symptoms and limitations of current clinical investigations. Identification of patients with early AL remains challenging. Here, we explored the protein expression profiles of AL patients to provide potential biomarkers to identify AL in patients who undergo surgery for rectal cancer. We screened differentially expressed proteins (DEPs) in drainage fluid from AL and non-AL patients using a tandem mass tag method. A total of 248 DEPs, including 98 upregulated and 150 downregulated proteins, were identified between AL and non-AL groups. Gene ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses suggested that DEPs were enriched in neutrophil degranulation, bacterial infection, proteolysis, hemostasis, and complement and coagulation cascades. The results of enzyme-linked immunosorbent assay validated that the expression of the top three upregulated DEPs, AMY2A, RETN, and CELA3A, was significantly increased in the drainage fluid of AL patients, compared with that of non-AL patients (AMY2A, P = 0.001; RETN, P < 0.0001; and CELA3A, P = 0.023). Thus, our findings provide several potential biomarkers for the early diagnosis of AL after rectal cancer resection.

Altered mRNA Expression Due to Rectal Perforation in a Porcine Model - A Pilot Study.

Anastomotic leakage is the most serious and unwelcome complication in rectal surgery. It has a great impact on postoperative morbidity and mortality. In this pilot study, changes of mRNA expression in blood were analyzed in an animal model designed to imitate anastomotic leakage. Twelve pigs were randomized into two groups: A sham-operated control group and an experimental group in which iatrogenic rectal perforation was performed. The changes in the mRNA expression at 4 hours after creating the perforation were studied. Microarray analysis was performed using Gene Chip whole porcine genome array. mRNA expression of 19,124 genes was investigated. Significantly increased levels of genes with a fold change greater than 2 were found, including 276 coding for unknown proteins and 48 coding for known proteins. Eleven of those which coded for known proteins were up-regulated with a fold change >4. Eleven known genes were highly up-regulated after rectal perforation. These genes were mainly involved in inflammatory response, intracellular signaling and cell membrane regulation. Their corresponding proteins might potentially be clinical biomarkers of anastomotic leakage and should be evaluated in further clinical studies.

The role of CRP in the diagnosis of postoperative complications in rectal surgery.

Postoperative complications of rectal resections classified as grade III or higher according to Clavien-Dindo system, which also include anastomotic leaks, are usually life-threatening conditions. Delayed diagnosis may account for almost 18% of deaths. Due to nonspecific clinical signs in the early postoperative period, diagnosing these complications may truly be a challenge for clinicians. Nowadays, with the implementation of the ERAS protocol (enhanced recovery after surgery) and efforts concentrated on quickly delivered treatment to patients suffering from the above-mentioned complications, an appropriate marker with high specificity is required. Postoperative levels of C-reactive protein in blood serum seem promising in this aspect. The presented study aimed to determine the cut-off level of serum C-reactive protein as a possible predictive factor for early diagnosis of serious postoperative complications associated with rectal resections. This could also lead clinicians to the diagnosis of anastomotic leak after other possible options are ruled out. This study is a retrospective observational analysis of patients who underwent open resection of rectal cancer during a one-year period. Collected data included risk factors (age, gender, BMI, bowel preparation), record of complications and C Reactive Protein (CRP) serum levels. The study included 162 patients. Uncomplicated postoperative course was observed in 58 patients (35.8%). Complications were present in 104 cases (64.2%), including surgical site infections (16.7%) and anastomotic leak (9.9%). The mortality rate was 2.5%. Serum CRP threshold predicting relevant complications reached a sensitivity of 83.3% and specificity of 82.7% on POD 4, with a 175.4 mg/L cut-off value, burdened with a 95.7% negative predictive value. Postoperative serum C-reactive protein may be used as a good predictor of infectious complications, including anastomotic leaks. Measuring CRP levels in the early postoperative period may facilitate identification oflow-risk patients ensure early and safe discharges from hospital after rectal resections.

Sarcopenia is a strong predictive factor of clinical and oncological outcomes following curative colorectal cancer resection.

Skeletal muscle depletion and subsequent functional loss is common in gastrointestinal malignancy. Usual markers of nutritional status may not be part of routine workup. The predictive value of sarcopenia was assessed and compared with clinically utilized factors. The aim of this was to assess the association between computed tomography assessed sarcopenia with outcomes in colorectal cancer resection. A total of 228 consecutive patients who underwent curative colorectal cancer resection were included. Skeletal muscle area was measured at L3, with pre-defined gender-specific cut-offs applied to a height standardized index. Albumin, body mass index and Subjective Global Assessment scores were recorded alongside measures of comorbidity. Predictors of complications, mortality, and recurrence were identified through multivariate logistic regression. Computed tomography assessed sarcopenia was significantly associated with longer stays, complications, 30-day mortality, readmissions and recurrence at 1 year. Specific associations with major, respiratory and cardiac complications were seen. It independently predicted overall complications (odds ratio 2.96, confidence interval 1.19-7.35 P=0.019), recurrence at 1 year (odds ratio 8.00, confidence interval 1.45-44.21, P=0.017) and an increase in comprehensive complication index of 14 (P=0.002). Subgroup analysis found sarcopenia predicted overall complications in rectal surgery and major complications in colonic surgery. American Society of Anesthesiologists predicted complications but not major complications while cancer stage also predicted recurrence rates. Sarcopenia presents an objective, available predictive factor that may be superior to current biochemical and clinical measures of nutritional and functional status. This study found it to be predictive of complication rates and recurrence after curative in colorectal cancer resection.

The "reverse air leak test": a new technique for the assessment of low colorectal anastomosis.

PurposeAnastomotic leakage is a fearsome complication in rectal surgery. Surgeons perform the classic air leak test, although its real effectiveness is still debated. The aim of this study was to describe a personal technique of reverse air leak test in which low colorectal anastomosis was assessed transanally through the intrarectal irrigation of a few mL of saline solution.MethodsFrom October 2014 to November 2019, 11 patients with low rectal cancer (type 1 in Roullier classification) were included in this study. At the beginning of the procedure, a circular anal dilator was inserted into the anus. A side-to-end colorectal anastomosis was performed. A few mL of saline solution were injected into the rectum and the entire anastomotic line was directly explored. The appearance of bubbles was considered as an anastomotic defect and repaired with an interrupted suture. A fluorescence angiography after intravenous injection of indocyanine green was performed in order to evaluate the perfusion of the anastomosis.ResultsThe reverse air leak test was positive in 4 cases (36.4%). The defect was repaired and a confirmation test was performed. In all patients, near-infrared evaluation showed no perfusion defect (grade 0) in low colorectal anastomosis. No postoperative fistula was detected in cohort study. A protective stoma was performed in 10 patients. On day 90, there were no complications and stoma closure was performed as planned.ConclusionThe reverse air leak test is a simple, feasible, and effective procedure to identify anastomotic leaks in low colorectal anastomoses.

Prospective Study Comparing Clinical vs Indocyanine Green Fluorescence-Based Assessment of Line of Transection in Robotic Rectal Cancer Surgery-Indian Study.

Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.

Early Metabolic and Inflammatory Intraperitoneal Changes After Rectum Perforation.

Purpose Anastomotic leakage (AL) is the most dreaded complication in rectal surgery. It has a great impact on postoperative morbidity and mortality. This animal model, in which we have studied postoperative metabolic and inflammatory changes, is designed to imitate an AL.Methods Twelve pigs were randomized into 2 groups. In the experimental group, an iatrogenic rectal perforation was performed, with the control group having a sham operation. The 2 groups were followed for 10 hours after operation with regard to vital parameters, arterial lactate, and cytokines interleukin (IL) 1, IL6, and IL10 in the blood and intraperitoneally. Intraperitoneal microdialysis analyses of glucose, lactate, glycerol, and pyruvate were performed and the lactate/pyruvate ratio was calculated.Results Glucose levels were lower in the experimental group after 4 hours. After 7 hours, lactate and lactate/pyruvate ratio was higher in the experimental group. At the same time intraperitoneal cytokines IL6 and IL10 were higher in the experimental group. Blood samples showed higher IL6 after 7 hours in the experimental group. Conclusion In this study, several significant differences between the groups in metabolic and inflammatory values were detected. Further clinical studies are recommended to evaluate the importance of intraperitoneal metabolic and inflammatory analyses as a diagnostic tool for early identification of an AL.

Predictive factors of acute kidney injury in patients undergoing rectal surgery

BackgroundDespite major advance in surgical techniques from open surgery to robot-assisted surgery, acute kidney injury (AKI) is still major postoperative complication in rectal surgery. The purpose of this study is to compare the incidence of postoperative AKI according to different surgical techniques and also the risk factors, outcomes of AKI in patients undergoing rectal cancer surgery. MethodsA retrospective medical chart review was done in a total of 288 patients who received proctectomy because of rectal cancer from 2011 to 2013. ResultsThe mean patient age was 62 ± 12 years, and male was 64.2%. Preoperative creatinine was 0.91 ± 0.18 mg/dL. Open surgery was performed in 9%, and laparoscopy assisted surgery or robot assisted surgery were performed in 54.8% or 36.1% of patients, respectively. AKI developed in 11 patients (3.82%), 2 (18%) of them received acute hemodialysis. Incidence of AKI was not different according to the surgical technique, however, the presence of diabetes, intraoperative shock, and postoperative ileus was associated with the development of AKI. In addition, AKI patients showed significantly longer hospital stay and higher mortality than non-AKI patients. ConclusionOur study demonstrated that despite advances in surgical techniques, incidence of postoperative AKI remains unchanged and also that postoperative AKI is associated with poor outcome. We also found that presence of diabetes, intraoperative shock and postoperative ileus are strongly associated with the development of AKI. More careful attention should be paid on high risk patients for the development of postoperative AKI regardless of surgical techniques.

Updates in the diagnosis and treatment of anastomotic leakage after surgery for rectal cancer

With the common application of total mesorectal excision (TME) technique,the proportion of sphincterpreserving surgery for the mid-low rectal carcinoma is significantly increased.Anastomotic leakage after sphincter-preserving surgery is the most severe complication of rectal surgery,and it is the main reason which will lead to other complications and death.Many researches on the early diagnosis,prevention and treatment of anastomotic leakage are conducted by surgeons at home and abroad,and a further understanding of this complication is deeply realized. Key words: Rectal neoplasms; Complications ; Anastomotic leakage

Dehiscence, stenosis and local recurrence after anterior resection in relation to the level of rectal cancer

Aim-Background Postoperative anastomotic leakage is a devastating complication of rectal surgery. A number of factors can influence the dehiscence rate, but the association between the levels of the tumour has been corroborated in numerous studies. Although not uniformly accepted, there are many reports demonstrating that anastomotic leakage can influence the oncologic outcome of surgery and predispose to stricture formation. The purpose of this review is to evaluate the relevance of the level of primary lesion and subsequent level of anastomosis from the anal verge, with the rate of dehiscence, anastomotic stricture and local recurrence during anterior resection for rectal cancer.

Obesity Increases Wound Complications in Rectal Cancer Surgery

Obesity increases the risk of wound infections following surgery for colon cancer. Considerably less data is available, however, regarding the impact of obesity on infections and wound complications after resection for rectal cancer. Additionally, the impact of minimally invasive surgery (MIS) on complications in rectal surgery remains unclear. We hypothesized that obesity is associated with prolonged operative time and more infectious complications in obese patients undergoing both MIS and open surgery for rectal cancer. Review of retrospective surgical database. One hundred fifty patients underwent surgery for rectal cancer from 2002 to 2009. Open cases accounted for 72% (n = 108) and MIS for 28% (n = 42) of cases. BMI did not correlate with increased operative time in open rectal surgery, but in MIS patients, operative time increased from a median of 254 min in the lowest quartile of BMI to 333 min in the highest quartile (P < 0.004). Superficial wound infections in open rectal surgery increased from 17% to 52% with increasing BMI (P < 0.005). The increased rate of wound complications persisted in the MIS group. Rate of superficial wound infections and subsequent open packing in the MIS group increased from 0% in the lowest BMI quartile to 33% in the highest quartile (P < 0.029 and P < 0.007, respectively). Elevated BMI is associated with increased wound complications in both minimally invasive and open rectal surgery. This trend may be related to prolonged operative time in obese patients, particularly in MIS. Our observations suggest that more aggressive techniques to prevent infection are warranted in obese patients undergoing rectal surgery.

C-reactive protein as early predictor for infectious postoperative complications in rectal surgery

This study evaluated the role of the acute phase C-reactive protein (CRP) in the postoperative course of a large series of rectal resections on the basis of a prospective database. Main focus of this study was the early identification of complications. Three hundred eighty-three rectal resections with primary anastomosis for rectal cancer were screened for infectious postoperative complications. Forty-eight complicated cases were identified and matched with 48 patients with an uneventful postoperative course. In the postoperative setting, CRP peaked on postoperative day (POD) 2 with a median serum CRP of 140 mg/l and gradually declined thereafter in uncomplicated cases. In complicated cases, CRP elevation generally persisted after POD 2, whereas white blood cells and body temperature were within normal range in the early postoperative period. A cutoff CRP value of 140 mg/dl on PODs 3 and 4 resulted in predictive values of 85.7 and 90.5% (adjusted to the prevalence: 37.6 and 50.3%), sensitivities of 80.0 and 54.3%, and specificities of 81.0 and 92.3% for a complicated postoperative course (P<0.001), respectively. Persistent CRP elevation and elevation of serum CRP above 140 mg/dl on PODs 3-4 are predictive of infectious postoperative complications and should prompt intense clinical search for an inflammatory process, especially for an anastomotic leak if pneumonia and wound infection are unlikely or excluded.

Morbidity and mortality assessment of modified Duhamel operation with immediate mechanical end-to-side colorectal anastomosis for chagasic megacolon: the role of the diverting stoma

Dear Editor, Sepsis secondary to anastomotic leakage is the most important surgical complication of rectal surgery. Anastomosis performed close to the anal sphincter is considered in high risk for leakage. The lower the anastomosis is in the rectum, the higher the risk of leakage. In total mesorectal excisions for rectal cancer, the rate of anastomotic leakage varied from 3% to 17%. Therefore, in this procedure, either a defunctioning ileostomy or a colostomy is still routinely performed in many specialized centers. In Brazil, Chagas’ disease affects people in the rural area with poor living conditions. Megacolon is the most common complication in the gastrointestinal tract. Surgery is indicated to treat patients with severe constipation. Several techniques have been reported in the surgical treatment for chagasic megacolon. All of them have high morbidity and mortality rates. The Duhamel–Haddad operation with delayed coloanal anastomosis was popular amongBrazilian surgeons. However, this time-consuming procedure has been abandoned in most centers in Brazil. To avoid a two-stage procedure, abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis was proposed as a new technique for chagasic megacolon (modified Duhamel operation or Habr–Gama operation). The anastomosis is situated at the lower third of the posterior wall of the rectum. As occurs in rectal cancer surgery, the anastomosis is placed just above the anorectal ring. Therefore, intuitively, one should expect problems with this anastomosis. Another variable that could increase the risk for dehiscence in this group of patients is malnutrition; a usual finding in this group of patients. Therefore, a high rate of dehiscence should have been observed in this technique. However, a diverting stoma to avoid pelvic sepsis has not been recommended. Over the past 9 years, our own experience with chagasic megacolon has been based on 26 patients (11 females and 15 males) with a mean age of 56.0 years (range, 40–74 years) who underwent abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis. After mechanical and systemic antibiotic preoperative preparation, all operations were performed through a median laparatomy. The dilated colon was excised. The rectum was sectioned at the level of anterior peritoneal reflection and closed with hand-sewn or mechanical suture. The posterior dissection of the rectum was performed to clean the posterior wall of the mesorectum. Therefore, the mesorectum was not incorporated at the anastomotic site. The mechanical endto-side colorectal anastomosis was performed in all patients just above the anorectal ring. The final result was quite similar to the Duhamel technique. The diverting stoma was performed according to the preference of the surgeon. Pelvic tubular drains were used in all operations. A diverting stoma was performed in 10 (38.5%) patients. Among them, eight were an ileostomy and two were a transverse colostomy. All patients had the stoma closed until August 2006. The groups with and without diverting stoma were comparable in terms of preoperative characteristics, Int J Colorectal Dis (2008) 32:215–216 DOI 10.1007/s00384-007-0297-8

Urinary Tract Complication after Rectal Surgery.

The major postoperative complications in rectal surgery are urinary retention and urinary tract infection. Although the pelvic autonomic nerve preserving procedure is performed, urinary dysfunction may still occur. In this article, we report a patient with rectal cancer who developed a postoperative urinary tract infection (UTI). An insufficient estimation of bladder function and frequent periodical bladder catheterizations were considered to be the cause of the UTI. In conclusion, the careful management of urinary tract complications is required in patients undergoing surgery for rectal cancer.