Elective Anterior Resection Research Articles

Preoperative use of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and diuretics increases the risk of dehydration after ileostomy formation: population-based cohort study.

Readmission rates following ileostomy formation are high. Dehydration and consecutive renal failure are common causes of readmission, potentially pronounced by drugs affecting the homeostasis. The aim of the study was to assess the risk of dehydration after ileostomy formation in patients treated with angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) or diuretics. This nationwide population-based cohort study used data derived from the Colorectal Cancer Data Base of several Swedish healthcare registers. The study included all patients operated on with elective anterior resection and temporary ileostomy for rectal cancer clinically staged I-III in Sweden in 2007-2016. Exposure was at least two dispensations of ACEI, ARB or diuretics within 1 year prior to surgery. Outcome was 90-day readmission due to dehydration including acute renal failure. In total, 3252 patients were included with 1173 (36.1%) exposed to ACEI, ARB or diuretics. The cumulative incidence for 90-day readmission due to dehydration was 29.0% (151 of 520) for exposed versus 13.8% (98 of 712) for unexposed. The proportion of readmissions due to any reason was 44.3% (520 of 1173) for exposed compared to 34.2% (712 of 2079) for unexposed. The incidence rate ratio for readmission due to dehydration was 2.83 (95% c.i. 2.21 to 3.63, P < 0.001). The hazard rate ratio was 2.45 (95% c.i. 1.83 to 3.27, P < 0.001) after adjusting for age, gender and comorbidity. Medication with ACEI, ARB or diuretics defines a vulnerable patient group with increased risk of readmission due to dehydration after ileostomy formation.

Evaluating the Role of Mechanical Bowel Preparation in Anterior Resection Through a Prospective Randomized Single-Blinded Trial.

Introduction Mechanical bowel preparation (MBP) before colorectal surgery is a common practice to reduce bacterial levels and infection. However, recent studies and data analyses have shown that this practice may increase the incidence of postoperative septic complications. Limited information is available regarding MBP for rectal surgeries. Our study aimed to examine the impact of MBP on postoperative outcomes in patients undergoing anterior resection with primary anastomosis for rectal cancer in a single-blinded, single-center, prospective, randomized trial. Materials and methods Data were collected between September 2013 and December 2015 at the Amrita Institute of Medical Sciences, Kochi, India. All patients scheduled for elective anterior resection with primary anastomosis for cancer between 5 cm and 15 cm were included in the study. All patients were randomized into the MBP and non-MBP groups after obtaining consent using a computer-based randomizer. The MBP group underwent bowel preparation with polyethylene glycol 24 hours before the operation and received sodium phosphate rectal enemas the night before the procedure. In the non-MBP group, only dietary restriction with a low-residue diet for 48 hours was recommended. Laparoscopic and open surgeries were performed. A contrast enema with barium was performed on all patients on postoperative days 6-8 to detect an anastomotic leak. Our primary endpoint was to assess the rate of anastomotic leakage between the two groups. The secondary endpoints were surgical site infection and postoperative morbidity. Results A total of 78 patients were recruited in the trial, and 18 were excluded because the surgery was the Hartmann procedure or abdominal perineal resection. The remaining 60 patients were divided equally into the MBP and non-MBP groups. No clinically significant disparities were evident between the groups concerning the preoperative prognosticators of anastomotic leak. Among the cohort, anastomotic leakage occurred in eight patients, representing a 13.3% incidence. Remarkably, within this subset, seven patients (23.3%) were attributed to the non-MBP cohort, whereas only one patient (3.3%) belonged to the MBP group. These findings demonstrated a statistically noteworthy discrepancy. The two groups had no statistically significant difference in surgical site infection and postoperative morbidity. Conclusion Our study suggests the benefit of preoperative MBP in sphincter-preserving rectal surgery to reduce the anastomotic leak rate. Additionally, incorporating large-scale studies and meta-analyses could enhance the robustness of our conclusions.

Functional outcomes following anterior resection for colorectal cancer: a needs assessment and proposal of a nurse-led remote management algorithm.

With the rise of structured, remote follow-up of colorectal cancers, there is the potential risk of underdiagnosing and undermanaging low anterior resection syndrome (LARS). This cohort study aims to determine the rate of LARS and its patterns of care, with the aim of generating a risk-stratified management algorithm that can be employed for nurse-led follow-up. Patients who underwent elective anterior resection for the management of colorectal cancer between 1 January 2017 and 31 December 2021 were sent quality-of-life questionnaires (EORTC-QLQ-CR29 and LARS score) and surveyed for LARS symptoms and management utilized. Out of 70 patients who completed questionnaires, 71.4% had LARS and 42.9% had major LARS. The international Delphi consensus definition identified more patients (n = 50) with LARS than the LARS score (n = 41). Tumours located <8 cm from the anal verge, ULAR, and temporary stoma were predictive of major LARS on univariate analysis. However, only temporary stoma was predictive for LARS (OR 7.89 (1.15-53.95), P = 0.035) and majors LARS (8.14 (1.79-37.01), P = 0.007) on multivariate analysis. Forty-four percent of patients with LARS did not have input from any health professional for this condition. Consultation with specialist allied health and/or colorectal surgeons ranged from 4% to 22%. Our study highlights that with the current remote follow-up system focused on cancer outcomes a significant proportion of patients with LARS are overlooked, resulting in the underutilization of relevant health professionals and management options. We propose a nurse-led management algorithm to address this issue while still minimizing surgical outpatient load.

608 Oral Antibiotic Bowel Preparation in Elective Anterior Resection

Abstract Aim A single centre retrospective cohort study investigating the impact of oral antibiotic prophylaxis (OAP) for lower anterior resections on length of hospital stay and post-operative complications. Method The pre-intervention group were all elective anterior resections between 2015 and 2016. They received mechanical bowel preparation only. The intervention group were patients undergoing elective anterior resection between 2020 and 2021. These patients were given OAP in addition to standard mechanical bowel preparation. Outcomes investigated were surgical site infections, overall length of hospital stay, anastomotic leak and return to theatre. These were then compared between the two cohorts and statistical analysis was conducted. Results The pre-intervention group consisted of 221 patients and there were 201 patients in the intervention group. 61% of patients were male, whilst other patient demographics were comparable between cohorts. The mean length of hospital stay was reduced by 26.4% (p = 0.002) and the median length of stay was reduced by one day. There was a 1.5% decrease (p = 0.50) in post-operative infections, a decrease of 26.7% (p = 0.25) in anastomotic leaks and a decrease of 45% (p = 0.13) in patients who returned to theatre. Conclusions There was a statistically significant reduction in length of hospital stay with OAP alongside mechanical preparation. Although post-operative complications such as anastomotic leaks and return to theatre were reduced, these were not statistically significant, but may still have clinical and economic importance. There is strong evidence towards the benefit of OAP reducing length of stay, which reduces cost and improves patient flow and bed capacity.

A retrospective audit of robotic versus laparoscopic anterior resection for diverticular disease in a single surgeon’s experience

Background: There has been a shift towards elective resection for recurrent or complicated diverticular disease to prevent recurrent episodes of diverticulitis. Our study aims to compare the outcomes in elective robotic and laparoscopic anterior resection for diverticular disease by a single surgeon experienced in both techniques. Methods: This is a retrospective study of patients who underwent elective anterior resections at Nepean Public Hospital, Nepean Private Hospital, and Sydney Adventist Hospital (SAN) in the last 10 years. The single surgeon is an experienced surgeon who has performed laparoscopic anterior resections from January 2013 to December 2018; and mainly robotic anterior resections from January 2018 to July 2022. The primary outcome of this study was to determine if there were any differences in length of stay and post-operative complications in laparoscopic and robotic anterior resections. Secondary outcome measures included operating time, rate of conversion to open surgery, and 30-day mortality and morbidity. Results: There were 53 patients included in this study. There was no significant difference in conversion to open rates (p=0.528), mean operative time (p=0.095), stoma formation rates (p=0.528) and post-operative complication rates (0.609). Length of stay was significantly shorter in the robotic group (p=0.024), and a higher proportion of patients who had laparoscopic surgery stayed for ≥6 days (p=0.08). There were no anastomotic leakages, or 30-day mortality and morbidity. Conclusions: Robotic anterior resection is a feasible approach in experienced hands and produces comparable results to laparoscopic anterior resection for diverticular disease in terms of length of stay, post-operative complications, and operative timings.

Potential short-term outcome advantage of low vs. high ligation of inferior mesenteric artery for sigmoid and rectal cancer: propensity score matching analysis

BackgroundWhether to ligate the inferior mesenteric artery at its root during anterior resection for sigmoid colon or rectal cancer is still under debate. This study compared the surgical outcomes, postoperative recovery, and anastomotic leakage between high and low ligation of the inferior mesenteric artery through a subgroup analysis.MethodsThis was a retrospective analysis of prospectively collected data. All patients who underwent colorectal resection for rectosigmoid cancer between December 2016 and December 2019 were enrolled. According to the surgical ligation level of the inferior mesenteric artery, the patients were categorized into either the high or low ligation group. The investigated population was matched using the propensity score method.ResultsOverall, 894 patients with sigmoid or rectal cancer underwent elective anterior resection with high (577 patients) or low (317 patients) ligation of the inferior mesenteric artery. After the propensity score matching, 245 patients in each group were compared. High ligation of the inferior mesenteric artery was associated with higher incidence of anastomotic leakage (14.9% vs. 5.6%, P = 0.041) for mid- to low-rectum tumors and a higher incidence of complications (8.6% vs. 3.3%, P = 0.013) of grades 1–2 according to the Clavien–Dindo classification system.ConclusionCompared with high ligation, low ligation of the inferior mesenteric artery resulted in lower likelihood of morbidity and mortality in rectal and sigmoid cancers. Moreover, low ligation was less likely to result in anastomosis leakage in mid- to low-rectal cancers.

124 AN INTERDISCIPLINARY PREHABILITATION PILOT FOR FRAIL ADULTS UNDERGOING ELECTIVE ANTERIOR RESECTION AND HARTMANN’S REVERSAL SURGERIES IN AN IRISH ACUTE HOSPITAL

Abstract Background Frailty affects 21.5% of individuals aged 65 and over in Ireland (TILDA, 2017).Timely interventions can limit or reverse the impacts of frailty. Local HIPE data from 2016-2020 highlighted correlations between increased average Length of Stay (aLOS) and median age (&amp;gt;65 years) for those undergoing elective Anterior Resections and Hartmann’s reversal surgeries. Prehabilitation aims to identify and manage modifiable risk factors that may impact on LOS, as well as optimise patients’ resilience and physiological reserves to reduce postoperative complications. Modifiable factors include pre-operative function, co-morbidities and post-operative delirium. In the Republic of Ireland, surgical interdisciplinary Prehabilitation services exist only in one hospital. Methods An interdisciplinary prehabilitation pilot for individuals undergoing elective colorectal surgeries was developed. Patients are referred from surgical clinics to Physiotherapy, Occupational Therapy or Dietitian preoperatively. Interventions include respiratory optimisation, exercise prescription, discharge planning, equipment provision and pre-operative nutritional reviews. Results Three elective patients have completed the first phase of the pilot. Two underwent anterior resections and one underwent a Hartmann’s reversal. The LOS for each individual was 4 days respectively, 4 days under the KPIs. Patients received virtual assessment and individualised interventions including an interdisciplinary educational booklet. Interventions included: exercise programmes, nutritional support, discharge planning discussion and equipment as indicated. No post-operative complications were identified and no interim beds or home supports were required. Qualitative feedback surveys were completed by all participants. Subjective feedback from patients has been overwhelmingly positive. Conclusion Patients report feeling physically and psychologically better prepared for surgery with better knowledge of post-operative expectations. Patients are more proactive in their postoperative recovery meaning they can return home sooner. This pilot enhances evidence-based ERAS practice, improving the quality and safety of patients journey. Participants also had a 12 day cumulative reduction in aLOS with financial savings of €12000.

Diverting stomas reduce reoperation rates for anastomotic leak but not overall reoperation rates within 30 days after anterior rectal resection: a national cohort study

PurposeA diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma.MethodsA 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located < 15 cm from the anal verge. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry. Primary end point was relaparotomy or relaparoscopy for anastomotic leak within 30 days from index surgery. Secondary endpoints were postoperative complications including reoperation for any cause.ResultsSome 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p > 0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97–7.24, p < 0.001) was associated with increased risk for anastomotic leak. However, there were no differences in overall reoperation rates following anterior resection with or without diverting stoma (9.3% vs 10.9%, p = 0.423), and overall complication rates were similar. Reoperation was associated with increased mortality irrespective of the main intraoperative finding.ConclusionDiverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not affect overall rates of reoperation or complications within 30 days.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis.

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Efficacy of side-to-end anastomosis to prevent anastomotic leakage after anterior resection for rectal cancer.

The present study aimed to investigate whether side-to-end anastomosis could provide an improved surgical outcome, such as lower anastomotic leakage rate, compared with end-to-end anastomosis, following anterior resection for rectal and rectosigmoid cancer. This retrospective study included 162 patients with rectal cancer who underwent elective anterior resection between January 2012 and October 2019 at a single institution. Patients with double cancers or colonic J-pouch were excluded. Anastomotic leakage was defined clinically and radiologically. Side-to-end anastomosis was introduced in the International University of Health and Welfare Mita Hospital in January 2017. Side-to-end anastomosis was performed in 63 patients, while end-to-end anastomosis was performed in 99 patients. Tumors tended to be located lower in the rectum in the side-to-end anastomosis group than in the end-to-end anastomosis group. No significant differences were observed in other patient characteristics. The incidence of anastomotic leakage was significantly lower in the side-to-end anastomosis group than in the end-to-end anastomosis group (3/63, 4.8% vs. 18/99, 18.2%, respectively, P=0.02). No significant differences were observed in the incidence rates of other complications. Univariate and multivariate analyses revealed that a smoking habit (P=0.04) and side-to-end anastomosis (P=0.02) were significantly associated with anastomotic leakage. In conclusion, side-to-end anastomosis using a double-stapling technique following anterior resection for rectal cancer may prevent anastomotic leakage.

Minimally invasive ileostomy as treatment procedure in anastmotic leak management, after elective surgery for rectal carcinoma

Background: Anastomotic leakage following elective colorectal surgery is relatively common and serious complication, potentially life-threatening for the patients, leading to distortion in their quality of life. Up to now there aren’t clearly defined reasons why it occurs and many efforts are made to predict and manage it afterwards. Defunctioning ileostomy failed to reduce the rates of anastomotic leaks, but was proven to be effective in developed peritonitis management and local control of the complications. Relaparoscopy and ileostomy in strictly selected patients- without septic complications and who have good compliance, has a potential to me eligible therapeutic modality to treat anastomotic insufficiencies on unprotected colorectal anastomosis. Aims: Sharing one centers experience with patients, managed with re-laparoscopy and defunctioning ileostomy due to anastomotic leak, as effective therapeutic approach after elective anterior resection of the rectum in colorectal cancer patients. Methods: In this retrospective study we elected 12 patients, re-operated after anastomotic leakage, in the Clinic of Endoscopic, Endocrine surgery and Coloproctology in Military Medical Academy- Sofia, for the time period 2018-2021. Indicators for evaluation of the procedure were duration of hospital stay, CRP(C-reactive protein) values and WBC(white blood cells) count on the 1st and 4th day after re-operation, other complications including sepsis, need of ICU treatment, need of re-operation, patients death, possibility and time of GIT passage restoration. A review of literature was made, using PubMed Central database. Results: In the elected patients cohort we observed medium hospital stay of 20 days. On day 3rd to 4th after surgery, drop in laboratory indicators was observed, compared to the values on the day of the leak : mean CRP 265,5mg/l and mean WBC 9,1^109 on day one, to mean CRP 103mg/l and mean WBC 8,81^109 on 3rd to 4th postoperative day after reoperation. One patient was with rapid onset of sepsis on the day of the leak, with need of ICU treatment, but it didn’t have effect on short and long term results of the surgery. Most common observed nonsurgical complications were cardiovascular- arrhythmias in ¼ of the patients. Mortality rate was 0%. Six patients safely underwent GIT passage restoration 3 months after the surgery, 3 patients are still under recovery and 3 were lost to follow up. Conclusions: Laparoscopic ileostomy is a good therapeutic alternative to reduce colorectal anastomotic leak complications. Research limitations come from the small patients sample, retrospective design and loss of long-term follow up on patients. There is a need of bigger randomized controlled trials to determine advantages and disadvantage of the procedure, as well as expected quality of life of the patients. Keywords: Minimally invasive ileostomy, Anastomotic leak. Rectal cancer

Is routine splenic flexure mobilization always necessary in laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive meta-analysis.

Splenic flexure mobilization (SFM) is one of the most difficult steps in laparoscopic colorectal surgery and its role is harshly debated. Some surgeons considered it routinely necessary to obtain a safe anastomosis and to respect oncologic criteria; for others SFM is frequently unnecessary, not ensuring the aspects mentioned above and increasing the risk of morbidity (splenic, bowel and vessels injury, lengthened procedure). We performed a systematic review and a comprehensive meta-analysis, without any language restriction, about the peri-operative and post-operative outcomes (anastomotic leakage, intra-operative complication, conversion rate, operative time, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, post-operative mortality, R0 margin resection, local recurrence) in patients undergoing elective anterior rectal resection (ARR) with or without SFM, both in laparotomic (LT) and laparoscopic (LS) approach. Fourteen studies were meta-analyzed with a total amount of 42,221 patients. The comprehensive meta-analysis shows that the mobilization or the preservation (SFP) of the splenic flexure does not statistically influence the incidence of colorectal anastomotic leakage, conversion rate, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, R0 margin resection, and local recurrence results. The operative time is significantly longer in every group of patients undergoing SFM. The incidence of intra-operative complication is statistically increased in overall patients and also in the LS subgroup of patients undergoing SFM, in which also higher incidence of wound infection and re-operation is shown. The meta-analysis shows that SFM may be considered not necessary to ensure better peri-operative and post-operative outcomes in both LT and LS ARR.

A nomogram for predicting feasibility of laparoscopic anterior resection with trans-rectal specimen extraction (NOSES) in patients with upper rectal cancer

BackgroundLaparoscopic anterior resection with trans-rectal specimen extraction (NOSES) has been demonstrated as a safe and effective technique in appropriate patients with upper rectal cancer (RC). However, improper selection of RC candidates for NOSES may lead to potential surgical and oncological unsafety as well as complications such as bacteria contamination and anastomotic leak. Unfortunately, no tools are available for evaluating the risk and excluding improper cases before surgery. This study aims to estimate its clinical relevancy and to investigate independent clinical-pathological predictors for identifying candidates for NOSES in patients with upper RC and to develop a validated scoring nomogram to facilitate clinical decision making.MethodsThe study was performed at Shanghai East hospital, a tertiary medical center and teaching hospital. 111 eligible patients with upper RC who underwent elective laparoscopic anterior resection between February and October of 2017 were included in the final analysis. Univariate and multivariate analyses were performed to compare characteristics between the two surgical techniques. Odds ratios (OR) were determined by logistic regression analyses to identify and quantify the clinical relevancy and ability of predictors for identifying NOSES candidate. The nomogram was constructed and characterized by c-index, calibration, bootstrapping validation, ROC curve analysis, and decision curve analysis.ResultsUpper RC patients with successful NOSES tended to be featured with female gender, negative preoperative CEA/CA19-9, decreased mesorectum length (MRL), ratio of diameter (ROD) and ratio of area (ROA) values, while no significant statistical correlations were observed with age, body mass index (BMI), tumor location, and tumor-related biological characteristics (ie., vascular invasion, lymph node count, TNM stages). Furthermore, the two techniques exhibited comparably low incidence of perioperative complications and achieved similar functional results under the standard procedures. The nomogram incorporating three independent preoperative predictors including gender, CEA status and ROD showed a high c-index of 0.814 and considerable reliability, accuracy and clinical net benefit.ConclusionsNOSES for patients with upper RC is multifactorial; while it is a safe and efficient technique if used properly. The nomogram is useful for patient evaluation in the future.

Use of prophylactic pelvic drain after elective anterior resection: (short- and long-term outcome)

Use of prophylactic pelvic drain after elective anterior resection: (short- and long-term outcome)

Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: A retrospective case-control study

BackgroundThe purpose of the study was to evaluate the association between microfibrillar collagen hemostat and anastomotic leakage after anterior resection. MethodBetween March 2015 and December 2019, a total of 203 consecutive rectal cancer patients who underwent elective anterior resection were included. Patient parameters were analyzed. The relevant risk factors were identified by univariate and multivariate analysis. Propensity score matching was performed to reduce the selection bias. ResultsIn total, 26 (12.8%) of the 203 study patients developed clinical anastomotic leakage. The length of hospital stay was significantly prolonged by anastomotic leakage. In univariate analysis and multivariate analysis, male sex, low tumor location, and intraoperative application of microfibrillar collagen hemostat significantly increased the risk of anastomotic leakage. Furthermore, analysis after propensity score matching confirmed the independent role of microfibrillar collagen hemostat in anastomotic leakage. In addition, the median time of anastomotic leakage occurrence from the initial operation in patients with microfibrillar collagen hemostat was 9.00 days, which was significantly later than that in patients without microfibrillar collagen hemostat. ConclusionIn addition to male sex and low tumor location, intraoperative application of microfibrillar collagen hemostat was demonstrated to be a significant risk factor for anastomotic leakage. This finding suggested that surgeons should be fully aware of this potential risk in anterior resection. Because of the limitation of retrospective study, however, randomized controlled trials are needed to confirm this association in the future.

The Incidence of Low Anterior Resection Syndrome as Assessed in an International Randomized Controlled Trial (MRC/NIHR ROLARR).

To investigate the incidence of LARS in patients undergoing elective anterior resection within the MRC/NIHR ROLARR trial and to explore perioperative variables that might be associated with major LARS. Sphincter-preserving rectal cancer surgery is frequently accompanied by defaecatory dysfunction known as Low anterior resection syndrome (LARS). This is distressing for patients and is an unmet clinical challenge. An international, retrospective cohort study of patients undergoing anterior resection within the ROLARR trial was undertaken. Trial participants with restoration of gastrointestinal continuity and free from disease recurrence completed the validated LARS questionnaire between August 2015 and April 2017. The primary outcome was the incidence of LARS and secondary outcome was severity (minor versus major). LARS questionnaires were received from 132/155 (85%) eligible patients. The median time from surgery to LARS assessment was 1065 days (range 174-1655 d). The incidence of LARS was 82.6% (n = 109/132), which was minor in 26/132 (19.7%) and major in 83/132 (62.9%). The most common symptoms were incontinence to flatus (n = 86/132; 65.2%) and defaecatory clustering (88/132; 66.7%). In a multivariate model, predictors of major LARS were: 1 cm decrease in tumor height above the anal verge (OR = 1.290, 95% CI: 1.101,1.511); and an ASA grade greater than 1 (OR = 2.920, 95% CI: 1.239, 6.883). Treatment allocation (laparoscopic vs robotic) did not predict major LARS. LARS is a common after rectal cancer surgery and patients should be appropriately counselled preoperatively, particularly before surgery for low tumors or in comorbid populations.

Protection of colorectal anastomosis with an intraluminal bypass device for patients undergoing an elective anterior resection: a pilot study.

Currently, the only clinically valid method to prevent morbidity and mortality related to colorectal anastomotic leaks is byconstruction of aprotective ileostomy. Intraluminal bypass might also be a possible way to proctect the anastomosis.The aim of the present study was to evaluate the CG-100 intraluminal bypass device for the reduction of anastomosis-related morbidity and stoma creation in cases of rectal resection. A prospective study was conducted on patients having sphincter-preserving rectal resection who were treated with the CG-100 device at Soroka University Medical Center, Beer Sheva, Israel between May 2015 and February 2017. The device was implanted during surgery and removed after 10 ± 1days. All patients underwent a radiologic leak test with water-soluble contrast prior to removal of the device. Patients were followed for 30days. Information about adverse events, anastomotic leaks, device usability and tolerance were collected. Forty-seven patients participated in the study. Most patients were operated on due to cancer 44 (93.6%). Four (9%) patients received a primary protective stoma on top of the CG-100 device as part of the learning curve of the surgical team and none required a stoma after device removal. Five (9%) serious adverse events were reported, but only 2 (4%) were classified as related to the device. One was a transient enterocutaneous fistula after removal of the device. The second was an asymptomatic radiologic leak in 1 (2.1%) patient which was treated by keeping the device in place and antibiotic treatment for another 10days without creation of diverting ileostomy. CG-100 may provide a safe method for fecal diversion over a newly created anastomosis without the complications related to stoma creation and closure. A larger prospective randomized study in patients originally scheduled to receive diverting stoma is needed to confirm these findings.

Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly.

Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.

Determinants of stoma reversal in rectal cancer patients who had an anterior resection between 2009 and 2012 in the English National Health Service.

The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified. The records of 4879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics. Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate the impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk. Within 18months from anterior resection, 3536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients [hazard ratio (HR) 0.90; 95% CI 0.84-0.96, aged 80 vs 70years], male gender (HR 0.90; 0.84-0.97), higher American Society of Anesthesiologists (ASA) grade (HR 0.64; 0.56-0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69-0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74-0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84-1.00, one vs no comorbidity) and open surgical procedure (HR 0.90; 0.84-0.97, open vs laparoscopic). Overall, two-thirds of ileostomies were reversed within 18months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness and stage), mode of surgical access and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access.

Factors associated with anastomotic leak following anterior resection for rectal cancer

To explore the related factors of anastomotic leakfollowing anterior resection for the rectal cancer and the association of the preoperative nutritional risk screening 2002(NRS2002) score. Clinical data of 396 rectal cancer patients who underwent elective anterior resection from January 2010 to July 2015 at Affiliated Lu'an Hospital of Anhui Medical University were collected. Patient's nutritional risk score on admission was calculated by NRS2002 scoring system according to original medical records. NRS2002 score less than 3 was defined as nutritious risk. Chi-squared test, or Fisher exact test and multivariate logistic regression wereused to analyze the association of the clinical pathological factors and NRS2002 risk factor with anastomotic leak. Of the 396 patients, NRS2002 score≥3, and anastomotic leak occurred in 157(39.6%) and 13(3.3%), respectively. In univariate analysis, different ages, NRS2002 score, preoperative intestinal obstruction, distance from anastomosis to anal vergeand tumor TNM stage were significantly associated with postoperative anastomotic leak(all P<0.05). The incidence of postoperative anastomotic leak among patients with NRS2002 score≥3 was significantly higher than those with NRS2002 score<3[6.4%(10/157) vs. 1.3%(3/239), χ(2)=7.806, P=0.005]. Multivariate analysis showed that NRS2002 score≥3(OR=3.988, 95% CI:1.004-15.837, P=0.049), existence of preoperative intestinal obstruction(OR=5.780, 95% CI:1.320 ~ 25.311, P=0.020),distance from anastomosis to anal verge≤5 cm(OR=0.236, 95% CI: 0.071 ~ 0.785, P=0.019) were the independent risk factors of anastomotic leak following anterior resection for the rectal cancer. Rectal cancer patients undergoing anterior resection with preoperative NRS2002 score≥3 should receive reasonable perioperative nutritional support to prevent anastomotic leak.