Complication Of Low Anterior Resection Research Articles

Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium

PurposeAnastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes.MethodsThis is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence.ResultsOf 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19–2.14]; p = 0.002), but significance was not met in multivariate models.ConclusionLack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.

A trinity technique for prevention of low rectal anastomotic leakage in the robotic era

BackgroundAnastomotic leakage (AL) is a severe complication of low anterior resection (LAR) for rectal cancer, and effectiveprevention is urgently needed. In the robotic era, this study aimed to explore the role of innovative techniques in preventing AL in rectal cancer patients undergoing robotic LAR. MethodsFrom May 2012 to May 2017, a total of 601 patients underwent robotic LAR, with 191 patients participated as control subjects (non-PST group) and 410 patients are subjected to a trinity technique (PST group). The AL rate, short-term and long-term outcomes are analyzed and compared. ResultsThe overall rate of AL was 6.8% out of 601 patients, with Grade B at 5.7% and Grade C at 1.1%, using the ISREC grading system. The PST group presented lower incidence of both overall AL (5.1% vs 10.5%, P = 0.015) and major AL (0.2% vs 3.2%, P = 0.005), when compared with the non-PST group, respectively. Furthermore, the PST group had similar surgical complications (17.3% vs 20.9%, P = 0.286), while with lower re-hospitalization rate (2.7% vs 6.3%, P = 0.038) and reoperation rate (0.2% vs 4.2%, P = 0.001), compared with the non-PST group, respectively. Short-term recovery and long-term oncological outcomes were not significant in the two groups. By multivariate logistic regression models, the risk factors of AL of robotic LAR are confirmed as non-PST technique, estimated blood loss ≥100 mL, anastomosis from anal verge <5 cm, and distal resection margin from tumor <2 cm. ConclusionsThe innovative PST technique may shed light on an effective method for preventing occurrence of AL in robotic LAR.

A nomogram for predicting rectovaginal fistula after low anterior resection for rectal cancer.

Rectovaginal fistula (RVF) is a complicated and troublesome complication of low anterior resection (LAR) for rectal cancer. We aimed to investigate the risk factors for post-LAR RVF and develop a predictive nomogram. We performed a retrospective analysis of 821 female patients with rectal cancer who underwent LAR between October 2010 and October 2018. Logistic regression was performed to identify risk factors. A nomogram was developed to predict RVF. The incidence of post-LAR RVF was 3.4% (28/821). A multivariate analysis showed that the preoperative serum hemoglobin level (OR 2.449, 95% CI 1.144-5.239), the distance between the tumor and anal verge (OR 4.158, 95% CI 1.392-12.418), surgical procedure (OR 2.369, 95% CI 1.117-5.027), hysterectomy (OR 2.996, 95% CI 1.106-8.833), and bilateral oophorectomy (OR 5.823, 95% CI 1.639-20.689) were significantly associated with the development of RVF. A nomogram was developed, which showed a C-index of 0.824 (95% CI 0.730-0.918) and an adjusted C-index of 0.790. This study identified the preoperative serum hemoglobin level, the distance between the tumor and the anal verge, the type of surgical procedure, hysterectomy, and bilateral oophorectomy as predictors of post-LAR RVF. A nomogram was successfully developed. It could aid in the prediction of RVF in patients undergoing LAR.

1524 Using Transillumination to Aid Dilation of a Severe Colorectal Anastomotic Stricture

INTRODUCTION: Colorectal anastomotic strictures are common complications of low anterior resection. Strictures in the lower rectum can be treated with direct digital dilation, but if in the upper rectum, endoscopic balloon dilation or electrocautery can be done. However, both procedures depend on the advancement of the wire through the circumferential scar/narrowed lumen. We present a unique case of endoscopic dilation of a severe anastomotic stricture using an innovative method. CASE DESCRIPTION/METHODS: A 44-year-old male with a history of rectal adenocarcinoma s/p low anterior resection with colorectal anastomosis and loop ileostomy formation presented to the GI clinic for constipation. Barium enema study revealed a stricture at the anastomotic site. A flexible sigmoidoscopy confirmed a severe anastomotic stricture, which could not be traversed nor lumen distal to the stricture visualized. And despite multiple attempts the guidewire could not pass through the stricture. Ten weeks after surgery, a pediatric colonoscope was passed through the ileostomy and advanced to the area of the stricture. Position was confirmed with fluoroscopy. At the same time an adult upper endoscope was inserted into the rectum and advanced to the stricture. The pediatric colonoscope was used to transilluminate the stricture and a needle was then used to puncture through the stricture under direct visualization. A guidewire was advanced through the newly created lumen retrograde and the tract was dilated up to 8 mm. A double pigtail plastic stent was inserted across the newly created tract. On repeat colonoscopy three weeks later, the double pigtail stent was removed and the stricture was dilated up to 15 mm. On subsequent colonoscopy, the stricture was dilated to 18 mm and the patients loop ileostomy reversed. The stricture was dilated again to 20 mm via Flexible sigmoidoscopy a month after the reversal after which constipation and bowel habits significantly improved. DISCUSSION: In patients who develop severe colorectal anastomotic strictures after a low anterior resection, endoscopic dilation can be challenging. In such patients ileoscopy and colonoscopy can be done simultaneously and using transillumination, position can be confirmed and a needle can be used to create a lumen through which a guide wire can be passed, allowing for serial dilation. Endoscopic dilation, should be tried and exhausted before considering surgical correction of a stricture, which can be difficult and increase morbidity.

Management of rectovaginal fistulas secondary to use of stapling device for rectal cancer surgery

Aim: Scarce data are available for rectovaginal fistula (RVF) as a serious complication of low anterior resection with a double-stapled anastomosis for rectal cancer. In this study, we aimed to evaluate our surgical management of RVFs formed due to stapler use.Material and Methods: Between 2010 and 2018, patients who developed rectovaginal fistula after the use of circular stapler during rectal surgery were included. Clinic characteristics, type of surgical treatment performed and details of surgery in patients were retrospectively evaluated.Results: Ten patients for whom stapler device was used for rectal cancer surgery and diagnosed with RVF were included in our study. The mean age of the patients was 45.7±11.8 and mean BMI value was 27±2.4. For 9 patients who had primary repair for RVFs, 7 patients experienced recurrence after their first operation. For this subgroup, muscle flap was performed in 3, vaginal mucosa advancement flap 2, sartius flap one, and another primary repair plus fibrin glue application one patient. After the second interventions, two patients were managed with muscle flap creation and primary repair plus fibrin glue was required for one patient, for their recurrence. For patient who had primary repair plus fibrin glue application for her second operation, sigmoid colostomy followed by abdominoperineal resection was required for persisting complaints.Conclusion: The management of postoperative (RVF) after low anterior resection for rectal cancer is difficult and the results are often unsatisfactory. Endoanal mucosal flaps and muscle flaps are the treatment modalities we recommend, especially in patients with recurrence.Keywords: Circular stapler; rectovaginal fistula; rectal cancer.

Refractory Anastomotic Rectal Stricture After Lower Anterior Resection and Radiation Exposure

We present a patient with history of neoadjuvant radiation and chemotherapy, with lower anterior resection, complicated with rectal anastomotic stricture refractory to endoscopic intervention. In the past, colorectal surgery had been the preferred method of treatment of rectal strictures, but endoscopic techniques, such as balloon dilation, have become the preferred modality. However, there is a high stricture recurrence rate of up to 18-20%, with increased risk of perforation due to uncontrolled stretching reported after balloon dilatation. A 68 year old female who migrated from West Africa with medical history of hypertension, Stage IIIB rectal cancer with low anterior resection and neoadjuvant chemo-radiation one year ago, presented to our gastrointestinal clinic for colon cancer surveillance. She denied melena, hematochezia, abdominal pain, diarrhea, nausea and vomiting, however noted a decrease in frequency of bowel movements. Colonoscopy performed revealed a very tight fibrotic stricture ˜8 cm from anal verge. With the use of a Through the scope (TTS ) balloon (6-7-8mm) dilation was performed. Minimal self limited mucosal oozing was noted. A subsequent flexible sigmoidoscopy was performed 2 weeks later with TTS using a larger sized balloon (8-9-10mm), which was inserted and dilation repeated. During a repeat colonoscopy performed 3 weeks later a very tight stricture was observed again in the rectum. Given recurrent stricturing / fibrosis - dilation was not attempted and was referred to colorectal surgery for surgical correction of stricture. Anastomotic stricture is a relatively common complication of low anterior resection especially in patients who had preoperative radiation. Endoscopic balloon dilatation is the most effective method to correct strictures, although repeated dilation over time is often required. There is some evidence in literature that dilating for the third or subsequent times may be futile. Even though balloon dilatation is a safe treatment, additional treatment modalities described in literature include; the use of neodymium: yttrium-aluminum-garnet laser treatment, electro-incision, electrocautery, and use of sphincterotomes. Colorectal Surgery should be considered in patients with recurrent strictures refractory to endoscopic therapy.2940 Figure 1. A very tight stricture ˜8 cm from anal verge seen. A TTS CRE ballon was inserted (6-7-8 cm) and dilation was performed. Minimal self limited oozing noted.

Multicenter analysis of transanal tube placement for prevention of anastomotic leak after low anterior resection.

Anastomotic leak (AL) is a serious complication of low anterior resection (LAR). This study aimed to evaluate the effect of transanal tube placement for prevention of AL. This multicenter retrospective cohort study enrolled 328 consecutive patients who underwent LAR for rectal cancer at participating hospitals from 2009 to 2014. Multivariate logistic regression was used to adjust for confounding factors. A transanal tube was placed in 205 patients (TA group) and not placed in 123 patients (non-TA group). Symptomatic AL occurred in 36 cases (11%), with significantly higher incidence of symptomatic AL in the non-TA group than in the TA group (15% vs 8.3%, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.01-4.06). After adjusting for confounding factors, multivariate analysis revealed that placement of a transanal tube could decrease the incidence of symptomatic AL (adjusted OR 0.37, 95%CI 0.15-0.91). There was no significant difference in postoperative morbidity, mortality, length of hospital stay, or local recurrence rate between the two groups. Local recurrence rate tended to be higher in patients with symptomatic AL (3/36) than in those without it (10/292). Transanal tube placement is effective for decreasing the incidence of symptomatic AL after LAR.

Rectovaginal fistula after low anterior resection in Chinese patients with colorectal cancer.

Rectovaginal fistula is a postoperative complication of low anterior resection. We investigated the incidence of rectovaginal fistula (RVF) after low anterior resection, its risk factors and its optimal treatment. We analyzed data from 1,493 female patients who underwent low anterior resection for colorectal cancer between January 2006 and March 2016. We calculated the incidence of RVF and performed univariate and multivariate logistic regression analyses to identify risk factors. Twenty-four patients experienced RVF, giving an incidence of 1.61%. Univariate analysis revealed a short distance between the tumor and the anal verge (p < 0.001), longer surgery duration (p = 0.009), unsatisfactory anastomosis (p < 0.001), and greater intraoperative blood loss (p = 0.002) to be risk factors for RVF. Multivariate analysis showed that only distance between the tumor and the anal verge and unsatisfactory anastomosis were risk factors for RVF. Sixteen patients (66.7%) healed within a range of 30-1,225 days (median, 210 days). Twenty-one patients underwent surgery for diverting stoma; of those, 15 of them (71.4%) recovering after ostomy. These results indicate the primary risk factors for RVF are unsatisfactory anastomosis and short distance between the tumor and the anal verge. Most cases of RVF can be healed using a diverting stoma alone, without the need for additional surgery.

Prediction model for complications after low anterior resection based on data from 33,411 Japanese patients included in the National Clinical Database

Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential. Data from the National Clinical Database on patients who had undergone low anterior resection in 2011 and 2012 were retrospectively analyzed. Multiple logistic regression analyses were performed to generate predictive models of postoperative complications. Receiver-operator characteristic curves were generated, and the concordance index was used to assess the model's discriminatory ability. The number of patients who had undergone low anterior resection was 33,411. Seven complications, namely, overall operative site infections except for leakage, anastomotic leakage, urinary tract infection, pneumonia, renal failure, systemic sepsis, and cardiac events, were selected to construct statistical risk models. The concordance indices for the first 2 complications, which were dependent on the operative procedure, were relatively low (0.593-0.625), and the other 5, unrelated to operative procedures, showed high concordance indices (0.643-0.799). This study created the world's second risk calculator to predict the complications of low anterior resection as a model based on mass nationwide data. In particular, this model is the first to predict anastomotic leakage.

Seminal Vesicle-Rectal Fistula Secondary to Anastomotic Leakage After Low Anterior Resection for Rectal Cancer: A Case Report and Brief Literature Review

We report a case of a patient with seminal vesicle-rectal fistula, an extremely rare complication of low anterior resection of the rectum. A 53-year-old man with rectal adenocarcinoma underwent low anterior resection in our hospital. The patient experienced diarrhea, pneumaturia, and low-grade fever on postoperative day 13. A computed tomography scan showed emphysema in the right seminal vesicle. We concluded that anastomotic leakage induced a seminal vesicle-rectal fistula. The patient underwent conservative therapy with total parenteral nutrition and oral intake of metronidazole. Diarrhea and pneumaturia rapidly improved after metronidazole administration and the patient was successfully cured without invasive therapy such as colostomy or surgical drainage. A seminal vesicle-rectal fistula is a rare complication of low anterior resection, and therapeutic strategies for this condition remain elusive. Our report provides valuable information on the successful conservative treatment of a secondary seminal vesicle-rectal fistula that developed after low anterior resection of the rectum in a patient.

Retrospective analysis of protective stoma after low anterior resection for rectal cancer with total mesorectal excision: three-year follow-up results.

Anastomotic leakage is a complication of low anterior resection (LAR) for rectal cancer with total mesorectal excision (TME). This study evaluated the need for a protective stoma by a three-year follow-up. A retrospective study of 56 LAR patients was conducted. Thirty patients (53.6%) had a protective stoma. C-reactive protein (CRP), interleukin 6 (IL-6) and tumor necrosis factor (TNF) in peripheral blood on the first and third day after surgery were compared, in addition to short-term and later complications, long-term mortality and quality of life (QOL). There was significant difference between patients with and without a stoma in CRP, IL-6 on the third day after surgery (p<0.05). Anastomotic leakage occurred in two patients (6.7%) with a stoma and seven (26.9%) without (p=0.039). The incidence of leaks requiring re-operation was significantly lower with a stoma (p=0.012). After a mean follow-up of three years, there was no difference in long-term mortality, survival or scores on QOL questionnaires. A protective stoma can reduce the stress reaction, promote recovery of bowel function and reduce anastomotic leakage and re-operation rates in LAR for rectal cancer with TME. No significant difference was observed in long-term mortality or QOL.

Anastomotic Leak Following Low Anterior Resection in Stage IV Rectal Cancer is Associated with Poor Survival

Anastomotic leak is a serious complication of low anterior resection (LAR). The risk of leak in stage IV rectal cancer patients treated with synchronous or staged resection of the primary tumour and metastatic sites has not been reported. We measured the incidence of anastomotic leak and its association with clinical outcome. With institutional review board approval, patients undergoing LAR and resection of metastatic disease were analyzed from a prospectively collected colorectal database between 1992 and 2010. Data for use of ileostomy, clinical anastomotic leak, and clinical risk score (for liver metastases, n=86) were collected. Categorical variables were compared with the χ(2) test. Estimated overall survival was compared using log-rank method and Cox regression analysis. A total of 184 patients with LAR and stage IV disease were identified. Of those, 123 had curative resection for disease at distant sites. 72% underwent simultaneous resection, 28% staged resection. Median follow-up was 2.9years for survivors. Anastomotic leak occurred in 6.5%. There was one perioperative death (not attributable to leak). Overall 3-year survival following a leak was significantly worse compared with patients without a leak (35 vs. 73%, P=0.01). Clinical leak was associated with worse survival when controlled for use of diverting stoma, operative year, clinical risk score, and timing of resection of metastatic disease. In this series of patients with stage IV rectal cancer, anastomotic leak was uncommon. However, patients who developed a clinical leak following surgery had worse survival. This finding was independent of use of diverting stoma or staged resection.

Clinical analysis of the anastomotic leakage after low anterior resection of rectal cancer of 16 cases

Objectiye To explore the diagnostic and therapeutic methods of anastomotic leakage after low anterior resection of rectal cancer. Methods The clinical data of 16 cases with anastomotic leakage after sphincter saving operation which was performed through anterior resection for patients with lower rectal cancer were retrospectively analyzed. Results Among the 186 cases of low anterior resection of rectal cancer,16 cases occurred anastomotic leakage,incidence rate was 8.6% ;14 cases healed through local douche and drainage; 1 case healed by emergency operation and upper colostomy after bacterial peritonitis;only one elderly patient died for infectious shock. Conclusion Anastomotic leakage was the severe complication of low anterior resection,and timely correct treatment and doing well safety precautionary measures before operation could reduce the incidence rate of anastomotic leakage. Key words: Rectal neoplasms; Colorecta surgery; Stomas; Postoperative complications

Anastomotic leak following mesorectal excision for rectal cancer: true incidence and diagnostic challenges

Anastomotic leakage is a potentially serious complication of low anterior resection which may be accompanied by clinical symptoms (clinical leak) or may be silent (subclinical leak). In this study the true incidence of the complication was evaluated, and the diagnostic accuracy of clinical symptoms, conventional rectal radiography (CRR) and computed tomography (CT) was compared. Fifty-six consecutive patients were included in a prospective trial. Clinical parameters were recorded and CRR and CT performed 6-10 days postoperatively or earlier if a leak was suspected. Endoscopy was performed three months postoperatively. Based on all available information including late endoscopy, 5 (9%) patients had clinical leak and five a leak that was asymptomatic during the hospital stay. Clinical assessment, CRR and CT during the hospital stay had an accuracy of 82%, 93% and 94%, respectively, and a sensitivity of 50%, 60% and 57%, respectively. The specificity of clinical assessment was 89%, whereas both CRR and CT had a specificity of 100%. The incidence of anastomotic leakage seemed acceptable when compared with other series. Fifty per cent of the leaks were silent. CRR and CT may be false negative and immediate treatment should be started if clinical signs are highly suggestive of leak, irrespective of radiological findings CT was not more accurate than CRR in detecting anastomotic leak.

Seminal vesicle-rectal fistula

A previously unreported complication of low anterior resection of the rectum, seminal vesicle-rectal fistula, was encountered one month after surgery in an elderly patient with adenocarcinoma of the midrectum. Antibiotic-induced colitis in the immediate postoperative period led to anastomotic leakage with abscess formation and ensuing fistulization to the surgically denuded right seminal vesicle. Pneumaturia, bacteriuria, and right testicular pain were treated by cutaneous vasostomy and antimicrobial therapy. Despite recurrent low-grade urinary sepsis controlled by alternating courses of various antimicrobials, and radiation therapy for local tumor recurrence, the patient remained reasonably healthy until his death two years later due to stroke associated with cerebral metastases.