Higher Anastomotic Leakage Rate Research Articles

Comparison of laparoscopic and open surgery for colorectal malignancy in obese patients: a propensity score-weighted cohort study.

Insufficient evidence exists to ascertain the long-term prognosis in patients with obesity undergoing laparoscopic surgery versus open surgery for colorectal cancer. Employing an institutional database from 2009 to 2019, we assessed individuals with a body mass index of ≥30kg/m2 who underwent surgery for primary stage I-III colorectal adenocarcinoma. We used propensity score-weighted analysis to compare short-term and oncologic outcomes between laparoscopic and open surgical approaches. This study enrolled 473 patients (open vs. laparoscopic surgery: 220 vs. 253; median follow-up period, 60mo). The laparoscopy group showed a significantly longer operative time (252 vs. 212 min), a higher anastomotic-leakage rate (5.14% vs. 0.91%), and a greater proportion of Clavien-Dindo class > III complications (5.93% vs. 1.82%). The open group showed a higher wound infection rate (7.27% vs. 3.16%) and a higher readmission rate (6.36% vs. 2.37%). After propensity-score weighting, laparoscopy was inferior to open surgery in terms of long-term overall survival (hazard ratio: 1.43), disease-free survival (1.39), and recurrence rate (21.1% vs. 14.5%). In the subgroup analysis, female patients, older individuals, stage III patients, patients with rectal cancer, and those who underwent surgery after 2014 showed inferior long-term outcomes after laparoscopy. Laparoscopic colorectal cancer surgery for patients with obesity requires significant caution. Despite good short-term outcomes, this procedure is associated with hidden risks and poor long-term prognoses. In female patients, older individuals, stage III patients, patients with rectal cancer, and those treated in the late surgery era subgroups, caution is advised when performing laparoscopic surgery.

486. ENDOSCOPIC VACUUM THERAPY FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGEAL RESECTION—A RETROSPECTIVE SINGLE-CENTER ANALYSIS

Abstract Esophagectomy still comes with a high rate of anastomotic leakage resulting in a persisting high postoperative mortality. Endoscopic vacuum therapy (EVT) is an upcoming technique for the treatment of anastomotic leakages. We aimed to evaluate our experience with the efficacy of EVT for anastomotic leakages after esophagectomy for cancer. We retrospectively analyzed all 96 patients who had undergone Ivor-Lewis resection for esophageal malignancy from January 2015 until December 2021 for the need of EVT within the same hospital stay. Patients demographics, perioperative parameters, treatment efficacy and success were analyzed. Patient data were expressed as mean ± standard deviation. We included fourteen patients treated with EVT following Ivor-Lewis resection for esophageal malignancy within the same hospital stay. 12 EVTs were due to anastomotic leakage whereas two procedures were performed prophylactically. We started the EVT 10.71 ± 8.04 days after surgery with a mean duration of 13.86 ± 7.39 days and a mean number of 4.36 ± 2.37 endoscopies per patient. Successful treatment was achieved in 10 patients (71.4%), one patient needed an esophageal stenting and an additional surgery for re-anastomosis was needed in 3 patients (21.4%). EVT can prevent re-operation in a high proportion of patients with anastomotic leakage and therefore provides a good non-surgical option for these patients. The periinterventional risk and possible complications of repetitive endoscopies should be analyzed in larger studies.

351. SUPERIOR MEDIASTINAL DISSECTION DURING MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER—A MULTICENTER PROPENSITY SCORE MATCHED (PSM) ANALYSIS

Abstract Minimally invasive esophagectomy (MIE) is currently the preferred approach of surgery for esophageal cancer. Systematic superior mediastinal lymphadendectomy along bilateral recurrent laryngeal nerve is enhanced by the magnified view in thoracoscopy, and is increasingly performed to achieve complete nodal dissection. Both participating centers began MIE with systematic superior mediastinal dissection in recent 5 years. In the current study, we aim to compare the short- and medium-term outcomes of MIE with or without superior mediastinal dissection. Consecutive patients who received MIE for esophageal cancers from 2004 to 2021 were recruited, data were collected from a prospectively maintained database. Patients were divided into ‘systematic superior mediastinal dissection’ and ‘control’ groups, and propensity score matching was performed with age, tumor location, tumor stage and neoadjuvant therapy. Total 157 patients were recruited, 67 (42.7%) in the extended superior mediastinal dissection group. After PSM, 48 patients were identified in each group. Short term surgical outcomes as well as medium term survival results were compared. Operative time was significantly longer with extended superior mediastinal dissection. Higher number of lymph nodes were yielded in total and from the superior mediastinum. Recurrent laryngeal nerve palsy developed in 52.1% and 43.8% of the MIE with or without extended dissection respectively, but significantly fewer palsies required intervention in the extended dissection group. Higher rate of anastomotic leakage was observed in the extended dissection group, but there was no difference in the overall severe adverse event (> = Grade III: 31.3% vs 35.4%). There was no statistical difference in the survival, but a trend towards improved 2 year disease-free survival was observed. Minimally invasive esophagectomy with systematic superior mediastinal dissection achieved a higher lymph node yield and a trend towards improved disease free survival. The overall adverse event rate was similar with conventional dissection. While better cancer staging could be achieved with extended dissection, further research is required to confirm the oncological benefit of extended dissection.

594. TOTALLY MINIMALLY INVASIVE 2-STAGE ESOPHAGECTOMY VERSUS HYBRID 2-STAGE ESOPHAGECTOMY. A SINGLE CENTER EXPERIENCE

Abstract Totally minimally invasive 2-stage esophagectomy (TMIE) eliminates the thoracotomy associated with hybrid 2-stage minimally invasive esophagectomy (hybrid-MIE). This has an important role in minimizing post-operative respiratory complications. There is ongoing growing evidence in published literature of improved clinical and oncological outcomes in totally MIE comparing to hybrid MIE, due to enhanced optics and extend of lymphadenectomy as well as to shorter length of hospital stay and surgical trauma associated to thoracoscopy. This is a retrospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. TMIE combines a laparoscopic and thoracoscopic approach while hybrid-MIE includes laparoscopic open thoracotomic phase. Study included adult patients with no upper age limit (>18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively. During an 8-year-period, 150 patients underwent hybrid-MIE, while 200 underwent TMIE. Operative-time was shorter in the hybrid-MIE group (320 vs 280 min). Anastomotic leak was significantly reduced in the TMIE group comparing to the hybrid-MIE group (2.5% vs 9.5%). Respiratory complications were reduced in the TMIE group (10 vs 25%). Median LOS was similar (7 vs 7.5 days). Median number of resected-lymph nodes was increased in the TMIE group (28 vs 35 lymph nodes). OS survival rate was 60 versus 51 months and PFS was 52 vs 43 months in the TMIE and hybrid-MIE groups respectively. In general, TMIE was associated with moderately lower morbidity compared to hybrid-MIE, but randomized controlled evidence is lacking. The higher anastomotic leakage rate, higher rate of pulmonary complications and lower lymph node count that was found after hybrid-MIE in comparative analysis, indicate that TMIE can significantly improve clinical outcomes of patients undergoing esophagectomy. The findings of this study should be considered carefully by surgeons when moving from hybrid-MIE to TMIE.

Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease-A Retrospective Analysis of 54 Cases at a Tertiary Care Center.

BackgroundDespite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.MethodsBetween 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.ResultsOf the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (>C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).DiscussionMorbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.

Salvage Surgery for Recurrent Disease after Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma.

Outcomes of salvage surgery after failed definitive chemoradiation (CRT) for esophageal cancer have been well defined. However, only a few studies have focused on salvage esophagectomy for recurrent disease after CRT. In 227 patients with esophageal cancer who underwent salvage esophagectomy after definitive CRT, consisting of 116 patients who underwent esophagectomy for persistent disease (the persistent group) and 111 patients who underwent esophagectomy for recurrent disease (the recurrent group), the short- and long-term outcomes were investigated. The rates of any postoperative complication were similar between the groups (49.1% in the persistent group vs. 49.5% in the recurrent group, p = 0.951), although there was a higher rate of anastomotic leakage in the recurrent group (p = 0.027). Thirty-day mortality was also similar between the groups (1.7% in the persistent group vs. 0.9% in the recurrent group, p = 0.587). The 3-year and 5-year overall survival rates were 33.7% and 28.0% in the persistent group and 48.7% and 41.7% in the recurrent group, respectively (p = 0.0175). In the recurrent group, clinically nodal status before CRT as well as pathologically nodal status and time to relapse were identified as independent prognostic factors. In the persistent group, pT and resection margin were identified as independent factors associated with survival. The present study showed that salvage surgery for recurrent disease can provide acceptable short- and long-term outcomes. Considering clinically and pathologically nodal status and time to relapse, adjuvant therapy might be offered for patients who underwent salvage esophagectomy for recurrent disease after definitive CRT.

Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy

Abstract Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. The main aim of the present study was to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of AL was 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p = 0.038), in the elective-laparoscopic approach subgroup (p = 0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p = 0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgery may improve short-term outcomes.

792 OUTCOMES AFTER TOTALLY MINIMALLY INVASIVE VERSUS HYBRID OR OPEN IVOR LEWIS ESOPHAGECTOMY: RESULTS FROM THE INTERNATIONAL ESODATA STUDY GROUP.

Abstract To compare complications following totally minimally invasive (TMIE), laparoscopically assisted (hybrid) and open Ivor Lewis esophagectomy in patients with esophageal cancer. Three randomized trials have reported benefits for minimally invasive esophagectomy. Two studies compared TMIE versus open esophagectomy and another compared hybrid versus open Ivor Lewis esophagectomy. Only small retrospective studies compared TMIE with hybrid Ivor Lewis esophagectomy. Methods Data were used from the International Esodata Study Group assessing patients undergoing TMIE, hybrid or open Ivor Lewis esophagectomy. Primary outcome was pneumonia, secondary outcomes included incidence and severity of anastomotic leakage, (major) complications, length of stay, escalation of care and 90-day mortality. Data were analyzed using multivariate multilevel models. Results In total, 4733 patients were included in this study (TMIE:1472, hybrid:1364 and open:1897). Patients undergoing TMIE had lower incidence of pneumonia compared to hybrid (10.9% vs 16.3%, Odds Ratio (OR):0.56, 95%CI: 0.40–0.80) and open esophagectomy (10.9% vs 17.4%, OR:0.60, 95%CI: 0.42–0.84) and had shorter length of stay (median 10 days (IQR 8–16)) compared to hybrid (14 (11–19), p = 0.041) and open esophagectomy (11 (9–16), p = 0.027). Patients undergoing TMIE had higher rate of anastomotic leakage compared to hybrid (15.1% vs 10.7%, OR:1.47, 95%CI: 1.01–2.13) and open esophagectomy (7.3%, OR:1.73, 95%CI: 1.26–2.38). No differences were reported between hybrid and open esophagectomy. Conclusion Compared to hybrid and open Ivor Lewis esophagectomy, TMIE resulted in a lower pneumonia rate, a shorter hospital length of stay but a higher anastomotic leakage rate. The impact of these individual complications on survival and long-term quality of life should be further investigated.

Outcomes of elective left colectomy in renal-transplanted patients: a single-center case-control study (LECoRT study).

Renal-transplanted patients are reported to have a high anastomotic leakage (AL) rate after colorectal surgery. We aimed to define AL-related morbidity and mortality rates after elective left colectomy in renal-transplanted patients. Data were prospectively collected between 2010 and 2015 from patients who underwent elective left colectomy with supra-peritoneal anastomosis in a single French referral hospital. We compared AL rate, and morbidity and mortality rates between renal-transplanted patients and controls. We identified 120 patients who underwent elective left colectomy during the study period. We retrospectively divided this cohort into 20 (17%) kidney-transplanted recipients (KTR-group) and the remaining 100 patients comprised the control group (C-group). There were no significant differences in sex, age, ASA score, body mass index, history of abdominal surgery and benign/malignant disease ratio between the KTR-group and the C-group. The AL rate was approximately four times higher in the KTR-group versus the C-group (25% vs 7%, p = 0.028). Intra-abdominal septic complications (p = 0.0005) and reoperation rates (p = 0.025) were also higher in the KTR-group. The laparoscopic approach was performed less in the KTR-group (35% versus 93%, p < 0.0001). Renal transplantation was identified as a risk factor of AL following elective left colectomy, as well as increased intra-abdominal septic morbidity and higher reoperation rate. Further multicentric studies are required to identify potential independent risk factors of AL after colorectal surgery in these frail populations. The present study was declared on ClinicalTrials.gov (ID: NCT04495023).

Effect of indocyanine green fluorescence angiography on preventing anastomotic leakage after colorectal surgery: a meta-analysis.

Anastomotic leakage (AL) is a serious but not uncommon complication after colorectal surgery. We conducted this study to evaluate the effect of routine indocyanine green fluorescence angiography (ICG-FA) on reducing the AL rate after colorectal surgery. We identified all research articles about colorectal surgery using ICG-FA, published in the PubMed, EMBASE, and Cochrane Library databases from the date of database establishment to May 2020. Revman 5.3 was used for statistical analysis. We analyzed 22 controlled studies and 7 non-controlled studies on ICG-FA, including 6312 patients. The controlled studies included 2354 patients in the ICG group and 3522 patients in the non-ICG group. Meta-analysis showed that ICG-FA reduced the AL rate after colorectal surgery significantly (RR = 0.39; 95% CI 0.30-0.50; P < 0.00001). However, patients whose resection line was changed based on the fluorescence angiography had a higher AL rate than those whose resection line was not changed (OR = 5.37; 95% CI 2.67-10.81; P < 0.00001). The overall complication rate, severe complication rate, and reoperation rate in the ICG group were significantly lower than those in the non-ICG group (RR = 0.79, 95% CI 0.67-0.92, P = 0.002; RR = 0.67, 95% CI 0.47-0.96, P = 0.03; RR = 0.53, 95% CI 0.29-0.96, P = 0.04, respectively), whereas the postoperative ileus rate was significantly higher in the ICG group than in the non-ICG group (RR = 1.65; 95% CI 1.09-2.50; P = 0.02), especially in Western countries (RR = 1.6; 95% CI 1.04-2.47; P = 0.03).ICG-FA may reduce the AL rate after colorectal surgery, but ICG-FA group patients with transection line change for insufficient blood perfusion to the anastomotic stoma after evaluation had a higher AL rate than those without transection line change. Therefore, ICG-FA can help to identify patients at high risk of AL and intercept its occurrence. Moreover, ICG-FA may reduce the overall complication rate, severe complication rate, and reoperation rate, but induce postoperative ileus. High-quality randomized-controlled trials with a placebo control are needed to further evaluate the effectiveness and safety of ICG-FA.

Impact of Early Oral Feeding on Anastomotic Leakage Rate After Esophagectomy: A Systematic Review and Meta-analysis.

Esophageal cancer occupies a vital position in fatal cancer-related disease, with esophagectomy procedures helping to improve patient survival. The timing when oral intake should be resumed after esophagectomy and whether early oral feeding (EOF) or delayed oral feeding (DOF) should be the optimal regimen are controversial. Databases (PubMed, Embase, Cochrane library) were searched. All records were screened by two authors through full-text reading. Data on the anastomotic leakage rate were extracted and synthesized in meta-analyses. Postoperative pneumonia rate and length of hospital stay were also assessed. Seven studies from 49 records were included after full-text reading; 1595 patients were totally included in the analysis. No significant difference was observed between the EOF and DOF groups (odds ratio [OR] 1.68; 95% confidence interval [CI] 0.70-4.03; p = 0.2495; I2 = 70%). Higher anastomotic leakage rate was observed in EOF compared with DOF (OR 2.89; 95% CI 1.56-5.34; p = 0.0007; I2 = 10%) in the open subgroup. No significant difference was observed in the MIE (OR 0.48; 95% CI 0.22-1.02; p = 0.0564; I2 = 0%). Patients performed similarly in pneumonia (OR 1.12; 95% CI 0.57-2.21; p = 0.745; I2 = 34%). In cervical subgroup, anastomosis leakage may be less in DOF (OR 2.42 95% CI 1.26-4.64; p = 0.0651; I2 = 58%), while in thoracic subgroup, there is no obvious difference (OR 0.86 95% CI 0.46-1.61; p = 0.01; I2 = 84.9%). Anastomotic leakage related to the timing of oral feeding after open esophagectomy, which is more favorable to the DOF regimen. However, timing of oral feeding did not impair anastomotic healing in patients undergoing MIE.

Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal. Análisis multivariado de 748 pacientes

Introduction : Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. Aim : Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. Materials and Method : Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. Results : There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). Conclusion : Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

Clinical features and risk factors of surgical complications after intersphincteric resection for low rectal cancer following neoadjuvant chemoradiotherapy

Objective: To explore clinical features and prognosis factors of surgical complications after intersphincteric resection (ISR) for low rectal cancer following neoadjuvant chemoradiotherapy. Methods: The clinical data of 132 patients with low rectal cancer who underwent ISR following neoadjuvant chemoradiotherapy from September 2010 to June 2017 at Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University were retrospectively reviewed. There were 100 males and 32 females, with the age of (52.9±11.4) years and distance to anal verge of 3.9 cm. Records of perioperative complication (POC) within 30 days after surgery, anastomotic leakage (AL), and anastomotic stenosis (AS) were analyzed. POC was recorded according to the Clavien-Dindo classification. AL was graded by ISREC system and classified into the early AL within 30 days after surgery and delayed AL beyond 30 days. AS was defined as narrowing of the bowel lumen at the anastomosis that prevented passage through a colonoscope with a 12 mm diameter. According to the shape of narrowing, AS was recorded as the stenosis in situ or stenosis with long-segment bowel above. Univariate and multivariate analysis were used to identify risk factors of anastomotic complications. Results: Among the 132 patients, full-dose radiotherapy and diverting stoma were performed in 128 (97.0%) patients, respectively. In entire cohort, AL was found in 41 (31.1%) patients, including 32 patients with clinical leakage (24.2%). The median time for diagnosis of AL was 37 days (2 to 214 days) after surgery. There were 25 patients (18.9%) who were diagnosed with delayed AL beyond 30 days. Chronic presacral sinus formation was detected in 22 of 129 (17.1%) patients at 12 months from surgery. Among the 128 eligible patients, 36 (28.1%) were diagnosed as AS, including 24 (18.8%) patients with stenosis in situ and 12 (9.4%) patients with bowel stenosis above. After a median follow-up of 26 months, 7(5.3%) patients received permanent colostomy and the other 20(15.2%) patients retained a persistent ileostomy, owing to anastomotic complications. Results of multivariate analysis showed that radiation colitis was an independent prognosis factor of AL after ISR (OR=5.04, 95% CI: 2.05 to 12.43, P=0.000); male gender (OR=5.19, 95% CI: 1.24 to 21.75, P=0.024) and AL (OR=8.49, 95% CI: 3.32 to 21.70, P=0.000) were independent prognosis factors of AS after ISR. Conclusions: Surgical complications are common after ISR for low rectal cancer patients with neoadjuvant chemoradiotherapy. A high rate of AL is observed after long-term follow-up, which is associated with AS. Increasing awareness of anastomotic complications after ISR should be raised, especially for male patients with radiation colitis.

The Safety of Selective Use of Splenic Flexure Mobilization in Sigmoid and Rectal Resections-Systematic Review and Meta-Analysis.

Background: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. Methods: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. Inclusion criteria: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. Results: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61–41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10–3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. Conclusions: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery.

Loop transverse colostomy versus loop ileostomy after low and ultralow anterior resection

Background: Since the introduction of sphincter saving procedures for low and mid-rectal carcinoma and the associated high anastomotic leakage rate is a matter of troublesome. There is a consensus between surgeons that diverting proximal stoma decreases the incidence of clinical leakage. But the choice between loop transverse colostomy (LTC) and loop ileostomy (LI) still a matter of debate. In this study we tried to compare both methods and evaluate the outcome of each.Methods: This is a prospective observational study included 28 patients suffering from mid- or low-rectal cancer who underwent elective low anterior resection (LARs), admitted to Sohag University Hospital between July 2013 to July 2017. Patients were randomly allocated into two groups; group (A) included 15 patients and managed with LTC, and group (B) included 13 patients and managed with LI. The data of the patients were collected, tabulated and analyzed, with special consideration of the general outcome measures related to stoma construction, special outcome measures related to stoma construction, and the outcome measures related to stoma closure. All of the patients were followed up for 6 months.Results: Author found a significantly higher incidence rate of skin excoriation (p&lt;0.001), leaks from the appliance (p&lt;0.005), in the LI group than in the LTC group and higher incidence of parastomal hernia (p=0.042) in the LTC than in the LI. Also, author found a significantly higher incidence rate of intestinal obstruction in the LI group (p&lt;0.001), also we found a significantly higher incidence of wound infection after stoma closure (p=0.006) in the LTC group than in the LI group. The mean time to first bowel movement (days) was earlier in the LI than LTC group and showing also a significant value (p&lt;0.001). The mean cumulative total hospital stay was significantly longer in the LTC group than in the LI group (p&lt;0.001).Conclusions: LTC and LI; both have advantages and disadvantages and the use of any for fecal diversion after low and mid-rectal carcinoma should be considered for every patient individually according to his circumstances.

Gender-related differences in patients with colon cancer resection

In recent years, studies have revealed gender-related differences in many fields of medicine. Data on oncologic surgical patients show different pathologic, perioperative, and long-term outcomes between men and women with conflicting results. Very limited data are available on gender-related differences in colorectal cancer patients. We analyzed a cohort of patients who had surgery for colon cancer at our center between 01/1990 and 12/2015. Clinical, pathological, perioperative, and long-term survival data were retrieved from a prospective database and gender-related differences were calculated for the overall cohort as well as for open and laparoscopic sub-cohorts. In total, 1786 patients, 909 (50.9%) male, 877 (49.1%) female, were included. Women had clinical symptoms more often, but histopathologic and resection parameters as well as tumor location did not differ significantly between groups. The majority (n = 1609, 90.1%) underwent resection with anastomosis (male vs. female n.s.). Laparoscopic surgery was performed in 640 (35.8%, male vs. female n.s.). Men had a higher rate of anastomotic leakage (n = 50 [5.5%] vs. n = 30 [3.7%], p = 0.034). Other complications also occurred significantly more often in males. Analysis of open and laparoscopic surgery showed significant differences in complication rates only within the open group. The 5‑ and 10-year overall survival rates did not differ significantly. Female and male patients encounter different rates of perioperative complications when undergoing surgery for colon cancer. In times where individualized treatment regimens are attempted to be established, future studies should take gender-related differences more into account. This study describes (1) gender-related differences in complication rates in the defined cohort of colon cancer patients, (2) higher rates of gender-related differences with regard to open versus laparoscopic procedures, and (3) equal long-term survival rates with regard to gender and laparoscopic versus open surgery.

A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks. We performed a non-randomized retrospective observational study on the 75 (subcutaneous: 21, intrathoracic: 54) esophageal cancer patients who underwent esophageal reconstruction either through subcutaneous or intrathoracic route between January 2003 and February 2015. Preoperative data including the estimated reasons for the selection of the subcutaneous route were obtained from medical charts. Clinical outcomes were evaluated and compared between the two groups. The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group. Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Natural orifice specimen extraction with single-stapling anastomosis for distal colon resection

Background: The double-stapling technique (DST) and triple-stapling technique used in laparoscopic anterior resection are considered risk factors of leakage or anastomotic leakage. A high anastomotic leakage rate could be avoided by the single-stapling technique (SST). Purposes: This study analyzed the feasibility, as well as the operative and immediate postoperative outcomes of natural orifice specimen extraction (NOSE) with single-stapled anastomosis. Materials and Methods: We retrospectively analyzed the data of 82 patients from China Medical University Hospital who underwent elective surgery from January 2012 to April 2015 for benign or malignant lesions that were between 10 and 40 cm from the anal verge, ≤5 cm in diameter on radiological examination, and in stage T1-T3/Nx/M0. All patients were monitored according to the enhanced recovery after surgery protocol. Results: NOSE with SST was feasible and showed intraoperative complication and morbidity rates of 2% and 7.3%, respectively. No patients needed conversion to open surgery. The rate of conversion to NOSE with DST was 6.1%. Moreover, the anastomotic leakage rate was 2.4%. Total hospital stay required was 4.8 ± 3.4 days. The first postoperative bowel movement observed was at 1.2 ± 0.5 days. Conclusions: Although SST is technically challenging, NOSE with SST is as feasible and as NOSE with DST.

Rectal cancer treatment in a teaching hospital

Background: Rectal adenocarcinomas surgery morbidity and mortality might be impaired by neoadjuvant therapy. We performed this retropsective study to be compared with the PROCARE study running afterwards.Methods: We performed a retrospective study of 95 patients operated on for rectal adenocarcinoma in a single institution during the period of 2007–2009. We used logistic regression to estimate the relationship between possible predictive parameters of anastomotic leakage (AL).Results: The laparoscopic approach is favored in 63.1% of the cases with a conversion rate of 11.6%, mainly in man (6 out of 7). For low rectal cancer though, laparotomy was the first choice (92.3%). From a carcinological point of view, laparoscopy allowed a complete tumor resection according to the PME (n = 27) and TME (n = 26) standards. Multivariate analysis revealed that women, lower BMI, lower rectum tumor, laparoscopic surgery, neoadjuvant treatment and anal suture were associated with higher risk of AL. The mean hospital stay was 15.4 days (3–46 days) with an in-hospital mortality rate of 3.1%. Adjuvant chemotherapy was completed in 42.1% of the patients. Despite these treatments, we registered a recurrence rate of 26.6%. Of these, 72% were distally localized and 12% exclusively locally. Among the patients operated on by laparoscopy, there was one local recurrence and one local with distant metastases (3.7%). The one- and three-year survival rates were 91.5% and 80.4%, respectively.Conclusions: Our study showed a higher rate of AL than expected (18%). In our series recorded in PROCARE-Home, our leak rate has dropped to 10%. It may be indicating a positive effect of PROCARE.

Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis: A case controlled study.

Background and aimsThe aim of this study was to investigate the clinical usefulness of the placement of a transanal drainage tube to prevent anastomotic leakage in colorectal anastomoses.Material and methodsThis single-center retrospective trial included all patients treated with surgery for benign or malign colorectal disease between January 2009 and December 2012. The transanal drainage tube was immediately placed after colorectal anastomosis until day five and was routinely used since 2010. Patients treated with a transanal drainage tube were compared with the control group. Statistical analysis was performed using Fisher's exact or Chi-square tests for group comparison and a linear regression model for multivariate analysis.ResultsThis study included 242 patients (46% female; median age 63 years; range 18–93); 34% of the patients underwent a laparoscopic procedure, and 57% of the patients received a placement of a transanal drainage tube. Anastomotic leakage occurred in 19 patients (7.9%). Univariate analysis showed a higher rate of anastomotic leakage in patients with an ASA score 4 (p = 0.02) and a lower rate in patients with transanal drainage placement (3.6% vs. 13.6%; p = 0.007). The grading of the complication of anastomotic leakage was reduced with transanal drainage (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006), and the hospital stay was shortened (17.6 ± 12.5 vs. 22.1 ± 17.6 days; p = 0.02). Multivariate analysis revealed that transanal drainage was the only significant factor (HR = −2.90; −0.168 to −0.032; p = 0.007) affecting anastomotic leakage.ConclusionsPlacement of a transanal drainage tube in patients with colorectal anastomoses is a safe and simple technique to perform and reduces anastomotic leakage, the severity of the complication and hospital stay.