Leakage In Rectal Cancer Surgery Research Articles

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials.

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery. PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool. Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG. Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Transanal tube for the prevention of anastomotic leakage in rectal cancer surgery

Transanal tube for the prevention of anastomotic leakage in rectal cancer surgery

Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series

PurposeComparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR.MethodsThis retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up.ResultsOverall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008).ConclusionProactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.

Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors.

Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality. To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study. To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated. The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did. Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.

The role of transanal drainage tube in preventing the anastomotic leakage in rectal cancer surgery without a defunctioning stoma: A meta-analysis

BackgroundAnastomotic leakage is a common and serious complication after rectal cancer surgery. The role of transanal drainage tube (TDT) in the prevention of anastomotic leakage is still controversial. The aim of this study was to evaluate the role of TDT in preventing anastomotic leakage. MethodsTwo reviewers individually searched the PubMed, Embase and Cochrane Library ranging from January 2000 to June 2022. The pooled odds ratio (ORs) and weighted mean difference (WMD) with the 95% confidence interval (95% CI) were used to assess anastomotic leakage and other parameters. ResultsA total of 3383 patients (1508 in the TDT group and 1875 in the cohort study group) were included in 13 studies. The study found that patients treated with TDT had a lower incidence of anastomotic leakage with or without neoadjuvant radiotherapy. Moreover, patients who received TDT had lower rates of reoperation and tended to reduce the severity of anastomotic leakage. ConclusionsFor rectal cancer patients without defunctioning stoma, TDT could reduce the incidence of anastomotic leakage, decrease the reoperation rate of patients, and tend to reduce the severity of anastomotic leakage. More RCT are needed to assess the role of TDT in rectal cancer surgery.

Treatment Modalities for Anastomotic Leakage in Rectal Cancer Surgery.

Despite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.

Clinical impact of the triple-layered circular stapler for reducing the anastomotic leakage in rectal cancer surgery: Porcine model and multicenter retrospective cohort analysis.

AimTo investigate the impact of the triple‐layered circular stapler compared with the double‐layered circular stapler on anastomotic leakage after rectal cancer surgery.MethodsThe bursting pressure was compared between porcine ileocolic anastomoses created using a double‐ or triple‐layered stapler. We also retrospectively analyzed the incidence of severe anastomotic leakage in 194 patients who underwent colorectal anastomosis using a double‐ or triple‐layered circular stapler during rectal cancer resection performed in two cancer centers between January 2015 and April 2021.ResultsIn the porcine model, the bursting pressure was higher in anastomoses created using the triple‐layered stapler than the double‐layered stapler (end‐to‐end anastomosis: 26.4 ± 6.2 mm Hg vs 14.5 ± 4.3 mm Hg, P = .0031; side‐to‐side anastomosis: 27.7 ± 5.0 mm Hg vs 18.0 ± 2.9 mm Hg, P = .0275). Intersectional leakage occurred in 41% and 83% of anastomoses created using the triple‐ or double‐layered stapler, respectively (P = .0821). In the clinical cohort, the double‐ and triple‐layered stapler was used in 153 and 41 patients, respectively. The incidence of anastomotic leakage was lower for anastomoses created using the triple‐layered stapler vs the double‐layered stapler (0.0% vs 5.8%, P = .0362). In multivariate analysis, the factors independently associated with a lower incidence of anastomotic leakage were female sex (odds ratio: 0.16, 95% confidence interval: 0.01‐0.90, P = .0354) and triple‐layered stapler usage (odds ratio: 0.00, 95% confidence interval: 0.00‐0.96, P = .0465).ConclusionAnastomoses created using a triple‐layered circular stapler had high bursting pressure, which might contribute to a lower incidence of anastomotic leakage after rectal cancer surgery.

Indocyanine green fluorescence angiography prevents anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis.

The role of intraoperative use of indocyanine green (ICG) fluorescence angiography (ICGFA) to prevent anastomotic leakage (AL) in rectal cancer surgery remains controversial. The systematic review for studies evaluating ICGFA in patients undergoing rectal cancer surgery in PubMed, Embase, Web of Science, and the Cochrane Library was performed up to April 30, 2020. The primary outcome was the incidence of AL. The analysis was performed using RevMan v5.3 and Stata v12.0 software. Eighteen studies comprising 4038 patients were included. In the present meta-analysis, intraoperative use of ICGFA markedly reduced AL rate (OR = 0.33; 95% CI: 0.24-0.45; P< 0.0001; I2= 0%) in rectal cancer surgery, which was still significant in surgeries limited to symptomatic AL (OR = 0.44; 95% CI: 0.31-0.64; P< 0.0001; I2= 22%). This intervention was also associated with shorter postoperative stays (MD = - 1.27; 95% CI: - 2.42 to - 0.13; P= 0.04; I2= 60%). However, reoperation rate (OR = 0.61; 95% CI: 0.34-1.10; P= 0.10; I2= 6%), ileus rate (OR = 1.30; 95% CI: 0.60-2.82; P= 0.51; I2= 56%), and surgical site infection rate (OR = 1.40; 95% CI: 0.62-3.20; P= 0.42; I2= 0%) were not significantly different between the two groups. The use of ICGFA was associated with a lower AL rate after rectal cancer resection. However, more multi-center RCTs with large sample size are required to further verify the value of ICGFA in rectal cancer surgery.

Laparoscopic anterior resection with or without transanal tube for rectal cancer patients – A multicenter randomized controlled trial

BackgroundIn rectal cancer surgery, insertion of transanal tube has been shown to have efficacy to prevent anastomotic leakage. This randomized controlled study aims to clarify the incidence of anastomotic leakage with or without transanal tube in patients with rectal cancer. MethodsPatients who underwent elective low anterior resection were randomly allocated to either have transanal tube insertion or not for five days after surgery. We examined the incidence of anastomotic leakage, postoperative 30-day morbidity and mortality. Results157 patients were randomized to the transanal tube group or the no-transanal tube group. Symptomatic anastomotic leakage occurred in six patients (7.6%) of the former group and eight patients (10.3%) in the latter group, without significant difference (p = 0.559). There was also no significant difference in morbidity between groups (p = 0.633) and no mortality was detected. ConclusionsTransanal tube insertion had no significant benefit towards prevention of anastomotic leakage in rectal cancer surgery.

Different clinical features according to the anastomotic leakage subtypes after rectal cancer surgeries: contained vs. free leakages.

BackgroundAnastomotic leakage can be classified by free and contained leakage according to clinical manifestations. The risk factors and their comparison between these leakage subtypes are uncertain. This study aims to evaluate anastomotic leakage patterns and to compare clinical features between free and contained leakages after low anterior resection for rectal cancer.Materials and methodsBetween January 2005 and December 2012, a total of 2035 consecutive patients who underwent low anterior resection for primary rectal cancer were evaluated retrospectively at two-tertiary referral centers. The primary end points of this study were to assess detailed clinical features among leakage subtypes. The secondary end point was to compare risk factors between free and contained leakages.ResultsPatients were subdivided into a no leakage group (n = 1890), free leakage group (n = 73), and contained leakage group (n = 72). Free leakage occurred more frequently in laparoscopic and robotic surgeries than open surgery (p = 0.015). On the other hand, contained leakage was developed in a higher rate of patients who received preoperative chemoradiotherapy (p<0.001). The mean development time was 4.6 days in the free leakage group, and 23.6 days in the contained leakage group. Patients with free leakage had a lower rate of a defunctioning stoma than contained leakage (5.5% vs. 29.2%, p<0.001). Risk factors for free leakage were smoking, tumor location, and laparoscopic surgery. However, tumor location and preoperative chemoradiotherapy increased the risk for contained leakage.ConclusionsContained leakage in rectal cancer surgery showed different clinical manifestations and risk factors compared to free leakage. It is necessary to pay more attention to patients with particular risk factors for anastomotic leakage subtypes.

Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery.

Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.

Mechanical Bowel Preparation Does Not Affect Clinical Severity of Anastomotic Leakage in Rectal Cancer Surgery.

Previous multicenter randomized trials demonstrated that omitting mechanical bowel preparation (MBP) did not increase anastomotic leakage rates or other infectious complications. However, the most serious concern regarding the omission of MBP is ongoing fecal peritonitis after anastomotic leakage occurs. The aim of this study was to compare the clinical manifestations and severity of anastomotic leakage between patients who underwent MBP and those who did not. This study was a single-center retrospective review of a prospectively maintained database. From January 2006 to September 2013, 1369 patients who underwent elective rectal cancer resection with primary anastomosis were identified and analyzed. Anastomotic leakage rates were not significantly different between patients who did not undergo MBP (77/831, 9.27%) and those who did (42/538, 7.81%). However, a significantly lower rate of clinical leakage requiring surgical exploration was observed in the leakage without MBP group (30/77, 39.0%) compared with the leakage with MBP group (30/42, 71.4%) (P=0.001). There were no significant differences in the clinical severity of anastomotic leakage as assessed by the length of hospital stay, time to resuming a normal diet, length of antibiotic use, ileus rate, transfusion rate, ICU admission rate, and mortality rate between the leakage without MBP and leakage with MBP groups. MBP was not found to affect the clinical severity of anastomotic leakage in elective rectal cancer surgery.

Should a Contrast Enema Be Performed Before Reversal of a Diverting Stoma in Lower Rectal Surgery?

See Article on Page 131-137 A defunctioning loop ileostomy is often used to reduce the consequences of anastomotic leakage, especially in a low rectal anastomosis. Hanna et al. [1] showed that fecal diversion could be recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. Tan et al. [2] also argued that the creation of diverting stomas could potentially minimize the fatal outcomes of anastomotic leakage, although it might not substantially decrease the incidence of anastomotic leakage in rectal cancer surgery. However, some authors reported that a diverting stoma did not have a significant relationship with symptomatic anastomotic leakage before and after their propensity score matching [3]. Another study also argued that a diverting stoma did not affect postoperative morbidity in a large cohort of patients undergoing low rectal anastomosis and that the routine use of a diverting stoma could rather delay postoperative recovery [4]. In the stage of stoma reversal, there are many different concepts and ideas about the effectiveness of a water-soluble contrast enema for the assessment of anastomotic integrity after low rectal surgery. Some investigators report that the contrast enema does not provide additional information when the results of rectoscopy and digital rectal examination (DRE) are normal [5]. However, in other studies, a contrast enema was effective in excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks [6]. Most surgeons perform the closure of the ileostomy after using a water-soluble contrast enema to check the anastomosis to confirm there is no sign of leakage. However, Palmisano et al. [7] performed the reversal of a protective stoma, despite a finding of persistent radiological and subclinical leakage, in selected patients. Seo et al. [8] evaluated the efficacy of a water-soluble contrast enema in predicting anastomotic healing after low rectal anastomosis and categorized the abnormal radiologic features into four types of their design based on the morphologic patterns: namely, dendritic, horny, saccular, and serpentine. They found that certain types of leakage forming cavitary lesions had better clinical outcomes after leakage had been arrested and the stoma had been restored. This issue should be discussed and evaluated through a larger-scale study for more definitive clinical implications. A water-soluble contrast enema study is helpful in detecting radiologic leakage before reversal of a diverting stoma, but these examinations are sometimes difficult to interpret, especially in the presence of a pouch or a dog-ear from a colo-anal anastomosis constructed by using the double-stapling technique. Therefore, for patients with a diverting stoma, surgeons should always be mindful to select the best way and the appropriate time to perform the stoma restoration, or they should decide to delay the stoma restoration, based on the radiologic finding, as well as clinical information, such as the results of a digital rectal examination.

Anastomotic leakage in rectal cancer surgery: The role of blood perfusion.

Anastomotic leakage after anterior resection for rectal cancer remains a common and often devastating complication. Preoperative risk factors for anastomotic leakage have been studied extensively and are used for patient selection, especially whether to perform a diverting stoma or not. From the current literature, data suggest that perfusion in the rectal stump rather than in the colonic limb may be more important for the integrity of the colorectal anastomosis. Moreover, available research suggests that the mid and upper rectum is considerably more vascularized than the lower part, in which the posterior compartment seems most vulnerable. These data fit neatly with the observation that anastomotic leaks are far more frequent in patients undergoing total compared to partial mesorectal excision, and also that most leaks occur dorsally. Clinical judgment has been shown to ineffectively assess anastomotic viability, while promising methods to measure blood perfusion are evolving. Much interest has recently been turned to near-infrared light technology, enhanced with fluorescent agents, which enables intraoperative perfusion assessment. Preliminary data are promising, but large-scale controlled trials are lacking. With maturation of such technology, perfusion measurements may in the future inform the surgeon whether anastomoses are at risk. In high colorectal anastomoses, anastomotic revision might be feasible, while a diverting stoma could be fashioned selectively instead of routinely for low anastomoses.

Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials.

Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80–1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.

Oncologic impact of anastomotic leakage in rectal cancer surgery according to the use of fibrin glue: case-control study using propensity score matching method

BackgroundThe oncologic impact of anastomotic leakage after rectal cancer surgery remains controversial. MethodsBetween January 1999 and December 2010, 1,148 patients with rectal cancer who underwent curative surgery with sphincter preservation were retrospectively reviewed. Using the propensity score matching method, 328 patients with fibrin glue were matched to 328 patients without fibrin glue, and oncologic outcomes were compared in the matched groups. ResultsAnastomotic leakage was diagnosed in 76 patients (6.6%). On multivariate analysis, fibrin glue was the independent predictor of prevention of anastomotic leakage. In the 656 matched groups, patients with anastomotic leakage had significantly worse 5-year local recurrence-free survival and disease-free survival than those without leakage. Multivariate analysis confirmed that anastomotic leakage was an independent prognostic factor of both local recurrence and disease-free survival, but the use of fibrin glue was not associated with the long-term outcomes when controlling for confounders. ConclusionsAnastomotic leakage is a major independent prognostic factor for long-term outcomes. Fibrin glue has a protective effect of anastomosis, without oncologic advantages.

Early detection and the prevention of serious complications of anastomotic leakage in rectal cancer surgery

Anastomotic leakage (AL) after low anterior resection for rectal cancer is a challenging complication in rectal cancer surgery. The reported frequency is 10–20 % in most publications, irrespective of the creation of a diverting stoma. AL has both immediate and long-term consequences that affect morbidity, mortality, functional and oncological outcome. The oncological impact of AL is still under discussion. Several studies have demonstrated an increase in local recurrence rate and a decreased overall survival, while other studies have failed to demonstrate this connection. A recent study showed that AL, which required reoperation, was associated with a significantly higher local recurrence and lower overall survival rate [1]. In most cases, the clinical presentation of AL is insidious with vague and uncharacteristic abdominal symptoms, which may be masked by the use of epidural analgesia. Some cases may present with extraintestinal manifestations such as atrial fibrillation or mental confusion. Thus, AL is typically not recognized until postoperative day 5–7, which in many cases means there is significant delay in diagnosis. Another explanation of delayed diagnosis might be the low diagnostic sensitivity and specificity of common clinical tests such as body temperature, C-reactive protein (CRP) concentration and leukocyte count in peripheral blood, which moreover may be obscured by other inflammatory conditions such as pneumonia, urinary tract infections and surgical site infections. The same may apply to other inflammatory parameters such as cytokines. A recent pilot study conducted by our group using a panel of 10 cytokines and 2 complement factors in patients with and without AL found that only combined changes in IL-4, IL-6 and IL-10 could accurately predict leak (submitted for publication). A study on postoperative CRP in elective abdominal surgery, published in the present issue, showed that patients with CRP 135 mg/L on postoperative day 3 were unlikely to develop AL. However, the sensitivity and specificity for AL of elevated values were dependent upon the duration of the elevation in the CRP concentration [2]. Regular computed tomography (CT) scan and endoscopy are other possible but less attractive investigations due to irradiation and the risk of iatrogenic anastomotic dehiscence. Early diagnosis of AL is important to reduce the negative effects on the patient’s health and to increase the success rate of treatment without reoperation. Therefore, new tests for early diagnosis of AL, before the development of overt symptoms, are warranted. The problem is that the complete pathophysiological background of AL is unknown. Several factors such as ischemia, inflammation, surgical techniques, comorbidity and preoperative radiochemotherapy may be involved. It is well documented that a diverting loop ileostomy reduces the risk of serious complications due to AL such as fecal peritonitis, reoperation, prolonged morbidity, permanent stoma and death. However, a diverting loop ileostomy is not without consequences and discomfort for the patient. In patients without AL, it has been demonstrated that a diverting stoma is associated with a higher long-term mortality rate than in patients without a stoma, due to stoma-related complications, missed adjuvant chemotherapy and complications of stoma closure. The use of ‘‘ghost’’ ileostomy, which allows selective loop ileostomy formation or early closure of the stoma before postoperative day 8–14, may be an alternative [3, 4]. The use of a transanal tube is dubious [5, 6]. Intraoperative laser M. Ellebaek (&) N. Qvist Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark e-mail: markep01@gmail.com

本邦における直腸癌術後の縫合不全に関する全国アンケート調査（第35回大腸疾患外科療法研究会アンケート調査結果）

本邦における直腸癌術後の縫合不全に関する全国アンケート調査（第35回大腸疾患外科療法研究会アンケート調査結果）