Preventive Ileostomy Research Articles

Prediction of anastomotic leakage after anterior rectal resection.

Objective:Anastomotic Leakage (AL) is one of the most common complications after resection of rectal cancer. Recognition of the incidence and risk factors related to AL is important. This study aimed develops a model that can predict anastomotic leakage after anterior rectal resection.Methods:Data from 188 patients undergoing anterior resection of rectal cancer were collected for retrospective analysis. Patients were randomly divided in the development set and validation set at a 1:1 ratio. We first included age, sex, preoperative chemoradiotherapy, tumor size, degree of tumor differentiation, stage, TNM stage, lymph vascular invasion, distance, anastomotic method, diabetes, intraoperative time, intraoperative bleeding and smoking as candidates for variable selection with a LASSO method. A ROC curve was constructed with the validation set to assess the accuracy of the prediction model.Results:AL occurred in 20 of 188 patients (10.6%). Preoperative chemoradiotherapy (p=0.04), medium degree of tumor differentiation (p=0.04), anastomotic method (p<0.01), intraoperative bleeding≥400ml (p<0.01), smoking (p<0.01), diabetes (p<0.01) were significantly related to AL. The area under the ROC curve of the prediction model is 0.952.Conclusions:This study developed a model that can predict anastomotic leakage after anterior rectal resection, which may aid the selection of preventive ileostomy and postoperative management.

Prevencinės ileostomos uždarymo artimieji rezultatai

[straipsnis ir santrauka lietuvių kalba; santrauka anglų kalba]&#x0D; Įvadas&#x0D; Prevencinės ileostomos (PI) dažniausiai formuojamos siekiant apsaugoti žemą tiesiosios žarnos jungtį nuo jos nepakankamumo. PI dažniausiai atliekamos operuojant apatinės tiesiosios žarnos dalies vėžį.&#x0D; Tikslas&#x0D; Apžvelgti PI uždarymo artimuosius rezultatus.&#x0D; Metodika&#x0D; Atlikta retrospektyvi 2015–2017 m. LSMU KK Chirurgijos skyriuje, Koloproktologijos sektoriuje operuotų pacientų, kuriems operacijos metu buvo uždaryta ileostoma, duomenų analizė. Analizuotas amžius, lovadienių skaičius, komplikacijos, nagrinėta, ar buvo taikytas neoadjuvantinis gydymas prieš operaciją, laikas iki iloestomos uždarymo, rezekcijos tipas, jungties rūšis,operacijos trukmė ir pooperacinis laikotarpis. Statistinė duomenų analizė atlikta naudojant Microsoft Excel programą.&#x0D; Rezultatai&#x0D; Išanalizuotos 64 pacientų – 34 vyrų (53,12 %) ir 30 moterų (46,88 %) – ligos istorijos. Pacientai operuoti dėl tiesiosios, klubinės, riestinės žarnos navikų ir dėl perforavusio divertikulito. Pacientų amžiaus vidurkis – 64±3,1 metų. Neoadjuvantinis gydymas prieš operaciją skirtas 16 pacientų (25 %). Prevencinė ileostoma buvo uždaryta vidutiniškai po 5,17±0,95 mėnesių.&#x0D; Pacientų hospitalizacijos trukmės vidurkis – 5,7±0,74 dienos. Operacijos trukmė vidutiniškai buvo 75,93±8,57 min. Operacijos metu žarnos segmento rezekcija atlikta 38 pacientams (59,37 %). Suformuotos jungtys: „galas su galu“ – 20 pacientų (52,63 %), „galas su šonu“ – 13 pacientų (34,21 %) ir „šonas su šonu“ – 5 pacientams (13,16 %). Po PI uždarymo ankstyvosios komplikacijos pasireiškė septyniems pacientams (10,94 %). Kraujavimas iš anastomozės vietos pasireiškė dviem pacientams (3,12 %). Vienam iš jų buvo atlikta jungtis „galas į šoną“, kitam – kraštinė rezekcija. Ritmo sutrikimas atsirado dviem pacientams (3,12 %). Žarnų nepraeinamumo simptomai pasireiškė taip pat dviem pacientams (3,12 %). Vienam iš jų buvo atlikta kraštinė rezekcija, kitam – segmento rezekcija ir suformuota jungtis „galas su galu“. Po kraštinės rezekcijos vienam pacientui (1,58 %) susiformavo pilvo sienos abscesas. Pakartotinės operacijos nereikėjo.&#x0D; Išvados&#x0D; 1. Uždarant PI operacijos metu, segmento rezekcija atliekama 59,37 % pacientų. 2. Vidutinis laikas iki ileostomų uždarymo yra penki mėnesiai. 3. Atliekant segmento rezekciją, dažnesnė nesklandi pooperacinė eiga. 4. Palyginti su segmento rezekcijos pooperacine eiga, formuojant jungtį „galas su galu“, laikotarpis po operacijos yra sklandesnis.

Successful treatment of a patient with Turcot syndrome

We report a case of successful treatment of a 15-year-old female patient (body mass index 16) diagnosed with Turcot syndrome (familial adenomatous polyposis of the colon) combined with multiple primary malignant tumors, including anaplastic astrocytoma (received combination therapy in 2007), metachronous cecal cancer (underwent subtotal colectomy and 12 courses of polychemotherapy in 2016–2017), and metachronous stage III pT3N1M0 rectal cancer at 8 cm. The patient underwent laparoscopic low resection with extirpation of the ileosigmoid anastomosis, creation of a reservoir-rectal anastomosis, and preventive ileostomy. The patient had minimal intraoperative blood loss and uneventful postoperative period (with an accelerated rehabilitation protocol). She was discharged from a hospital on day 9. Considering previous treatment episodes and the disease stage, we also included into the treatment regimen adjuvant FOLFOX polychemotherapy in a reduced dose for 6 months. During one-year follow up, there was no evidence of disease progression. Later, the patient underwent ileostomy closure with forming a side-to-side mechanical anastomosis. The patient is fully rehabilitated in term of her social activity.

OUTCOMES OF LOOP ILEOSTOMY CLOSURE METHODS

BACKGROUND: Preventive ileostomy closure has potential risk of severe complications with 30% rate of postoperative morbidity and 4% rate of mortality. There is no relevant data (evidence) which method of ileostomy closure is a method of choice. AIM. To identify effective and safe method of ileostomy closure. PATIENTS AND METHODS. A prospective randomized controlled single centre trial was carried out in State Scientific Centre of Coloproctology (Moscow, Russia) during the period 2015-2017. Patients with defunctioning ileostomy were randomized to closure by hand-sewn end-to-end anastomosis group, by hand-sewn side-to-side anastomosis group and by stapled side-to-side anastomosis group. RESULTS. The trial recruited 327 patients. Mortality rate was 0.3%, one post-op death occurred in hand-sewn side-to-side anastomosis group (p=1.0). Morbidity rate was 14.4% in hand-sewn end-to-end anastomosis group, 18.4% in hand-sewn side-to-side anastomosis group and 11.7% stapled side-to-side anastomosis group (p=0.5). Hand-sewn side-to-side anastomosis was associated with longest time of anastomosis creation (49.3 min p<0.05), longest total operative time (105.7 min p<0.05) and longest post-op stay (9.3 days; p<0.05). Stapled anastomosis was faster than hand-sewn (20 min vs 33.1 min and 49.3 min; p<0.001). CONCLUSION. Superiority in ileostomy closure methods was not obtained. Stapled side-to-side method makes procedure significantly faster and significantly reduces postoperative ileus rate.

Effect of anastomotic reinforcing sutures on the incidence of anastomotic leakage after laparoscopic radical resection of rectal cancer: a prospective randomized controlled trial

To investigate the effect of anastomotic reinforcing sutures on the incidence of anastomotic leakage after laparoscopic radical resection of rectal cancer. In this study, 300 patients diagnosed with rectal cancer, scheduled to undergo laparoscopic anterior resection at the Department of Gastrointestinal Surgery of Anhui Provincial Hospital, between September 2014 and December 2016, were prospectively enrolled. Patients were randomly assigned to undergo laparoscopic rectal resection with (reinforcing group, n=150) or without (control group, n=150) anastomotic reinforcing sutures. The laparoscopic total mesorectal excision was followed for all patients. In the reinforcing group, 4-0 absorbable sutures were used to reinforce the 2-4 needles used for the 2 cross-cutting lines that formed the stapler. Concurrent obstructions; the need for hemorrhagic emergency surgery, preventive ileostomy, Hartmann operation, abdominoperineal resection, or open surgery; and the presence of unresectable cancer were all reasons for excluding patients from the study. Univariate and multivariate analyses were performed on the clinical data collected for the two groups. According to the multivariate analysis results, patients were further divided into high-risk(≥2 high risk factors) and low-risk (≤1 high risk factor) groups, and were stratified to analyze the relationship between reinforcing suture use and the incidence of anastomotic leakage. This trial, approved by the Ethics Committee of Anhui Provincial Hospital, was registered as NCT02830633. A total of 291 patients were included in the study, namely 145 in the reinforcing group and 146 in the control group. There were no significant differences between the two groups with respect to their general data or intra-operative conditions(all P>0.05). The overall incidence of anastomotic leakage was 7.6%(22/291); 3.4%(5/145) in the reinforcing group and 11.6% (17/146) in the control group(χ2=6.992, P=0.008). Multivariate analyses showed that the lack of reinforcing sutures was an independent risk factor for anastomotic leakage (OR=2.75; 95%CI, 1.72-5.48; P=0.014). Other independent risk factors included NRS2002 score ≥3 points, tumor diameter ≥4 cm, and tumor to anal margin distance <5 cm. There were 80 patients in the high-risk group and 211 in the low-risk group, based on the aforementioned 3 risk factors. The incidence of anastomotic leakage was 27.1%(13/48) among the control patients in the high-risk group, but only 6.2% (2/32) among high-risk patients receiving reinforcing anastomotic sutures(χ2=5.470, P=0.019). In the low-risk group, the incidence of anastomotic leakage was 2.7%(3/113) among patients receiving reinforcing anastomotic sutures, and 4.1%(4/98) among those not receiving reinforcing sutures. No significant difference was observed (χ2=0.333, P=0.564). Anastomotic reinforcing sutures for the prevention of anastomotic leakage after laparoscopic radical resection of rectal cancer is convenient and effective, particularly for patients with multiple risk factors.

Choice of surgical procedures and control of surgical risks in chronic constipation

Surgery, as one of the methods for the treatment of chronic constipation, is the final choice after the failure of non-surgical treatment with its specific particularity. The history of surgical treatment of chronic constipation is complex and tortuous. How to select operation among many kinds of surgery, and control risk is difficult for clinician. The choice of surgical procedure depends mainly on the patient's conditions, the objective examination basis and the experience of physician teams. Based on the previous reports and the team's experience, this paper discusses the choice of surgical treatment for the following types of chronic constipation: (1) Slow transit constipation: subtotal colorectal resection plus ileorectal anastomosis or ascending colon rectum anastomosis is widely used at present in the domestic, and its efficacy is quite good. (2) Outlet obstructive constipation: surgical treatment needs to be cautious with no consensus, and surgeons must follow the advice of "minimally invasive first" principle. (3) Mixed constipation: there is no clear and unified surgical treatment, while Jinling surgery is a promising way of operation. (4) Adult Hirschsprung's disease: surgery is the only treatment, and removing the stenosis segment, transitional segment and obvious expansion segment is the basic principle, and preventive ileostomy at the same time is also recommended. (5) Adult idiopathic megacolon: subtotal colectomy with ileorectal anastomosis or ascending colon rectum anastomosis is highly recommended. (6) Hypoganglionosis: it is rare, and no consensus has been reached in surgical treatment. How to select the proper timing and mode of operation, and how to control the operation risk are the contents that clinicians must master. With the development of laparoscopic surgical technology, minimally invasive surgery is becoming the main direction of constipation treatment.

Risk factor analysis of low anterior resection syndrome after anal sphincter preserving surgery for rectal carcinoma

To investigate the risk factors of low anterior resection syndrome (LARS) after anal sphincter preserving surgery (SPS) for rectal cancer patients. Clinicopathological and follow-up data of rectal cancer patients who underwent SPS from January 2010 to June 2014 in Department of Gastroenterological Surgery, Peking University People's Hospital, were retrospectively analyzed. Patients receiving permanent colostomy and local resection were excluded. Meanwhile, during October 2014 and March 2015, the enrolled patients were asked to fill out a specially designed questionnaire for LARS through face-to-face interview or telephone inquiry, according to the chronological order of operation. Based on the score of questionnaire, patients were divided into three groups: 0-20 points: non LARS; 21-29: minor LARS; 30-42: major LARS. The demographic and clinicopathologic features were compared among groups and the risk factors of major LARS were tested by logistic regression analysis. A total of 100 patients (61 males, 39 females) completed the bowel function survey, with an average age of 66.2(41-86) years, 33 patients <60 years versus 67 patients ≥60 years. No significant difference was observed in age distribution (P=0.204). Interval from operation to first follow-up was more than 1 year in 70 patients, and the median follow-up was 23 months. Thirty-seven patients were non LARS, 18 were minor LARS and 45 were major LARS. No significant differences in clinicopathological data (all P>0.05) were observed among three groups except radiotherapy history (P=0.025), tumor location(P=0.000) and distance from anastomotic site to anal verge(P=0.008). After comparison of non LARS group combined with minor LARS group versus major LARS, re-analysis of risk factors showed that radiotherapy history (RR=5.608, 95%CI:1.457 to 21.584, P=0.006), distance from tumor lower margin to anal verge (RR=0.125, 95%CI:0.042 to 0.372, P=0.000), distance from anastomotic site to anal verge (RR=0.255, 95%CI:0.098 to 0.665, P=0.004) and preventive ileostomy history(RR=3.643, 95%CI:1.058 to 12.548, P=0.032) were associated with major LARS. One potential risk factor detected in combined analysis was female (RR=2.138, 95%CI: 0.944 to 4.844, P=0.078). Multivariate analysis revealed that female (RR=2.654, 95%CI: 1.005 to 7.014, P=0.049), radiotherapy history (RR=10.422, 95%CI:2.394 to 45.368, P=0.002) and distance from tumor lower margin to anal verge ≤7 cm (RR=8.935, 95%CI:2.827 to 28.243, P=0.000) were independent risk factors of major LARS. LARS is a significant problem in most rectal cancer patients after SPS. The risk of major LARS increases on condition of radiotherapy, low tumor position and female. When dealing with these patients, preventive measures should be taken into consideration during SPS.

Advantages of Early Preventive Ileostomy Closure after Total Mesorectal Excision Surgery for Rectal Cancer: An Institutional Retrospective Study of 123 Consecutive Patients

Background/Aim: Preventive ileostomy is frequently constructed to minimizethe consequences of anastomotic leakage after resection of rectal cancer. There is no consensus regarding the best timing for temporary stoma closure after proctectomy for rectal cancer. This retrospective study sought to determine whether the timing of stoma closure influenced postoperative outcomes. Methods: Subjects were 123 patients with rectal cancer undergoing laparoscopic or open total mesorectal excision surgery with preventive ileostomy from 2012 to 2015. They were divided into 2 groups according the timing of stoma closure: the standard group who had closure within 90 (60-120) days (n = 78) and the late group who had closure after 180 (150-210) days (n = 45). Results: There was no significant difference in operative time, operative blood loss or postoperative complications between the 2 groups. Timing of postoperative fasting and length of hospital stay was similar in both groups. Adjuvant chemotherapy was not a risk factor for postoperative complications after stoma closure. Conclusions: There was no significant difference between different timings of temporary stoma closure in relation to postoperative complications. Delayed stoma closure showed no benefit in prevention of morbidity. Early closure is safe and can provide better quality of life for patients.

Endoscopic Management for the Assessment and Treatment of Anastomotic Bleeding in Laparoscopic Anterior Resection for Rectal Cancer

To evaluate the impact of routine intraoperative endoscopy (IOE) on postoperative anastomotic bleeding of laparoscopic anterior resection (LAR) for rectal cancer, and to investigate the value of the IOE in terms of prevention and treatment of postoperative anastomotic bleeding. Medical records of the 279 cases of LAR from January 2006 to December 2011 were retrospectively analyzed, of which postoperative anastomotic bleeding occurred in 18. Univariate analysis was taken to determine the possible influencing factors of the bleeding. Then related influencing factors were put into the multivariate logistic regression analysis to ultimately determine the independent influencing factors of anastomotic bleeding. The efficacy of treatments to the anastomotic bleeding was also evaluated. The incidence of anastomotic bleeding after LAR is 6.5% (18/279).The rates of anastomotic bleeding in lower tumor location group and upper tumor location group were 9.2% (16/173) and 1.9% (2/106), respectively, as in intraoperative colonoscopy and nonintraoperative colonoscopy group were 3.3% (5/151), and 10.2% (13/128), respectively. Comparing the location of the tumor, the coefficient of regression and relative risk value for lower tumor were 1.564 and 4.776. Comparing the intraoperative colonoscopy and nonintraoperative colonoscopy group, the value for intraoperative colonoscopy group were -1.085 and 0.338. Sex, age, tumor stage, pathologic type, and preventive ileostomy had no relevance with the anastomotic bleeding. In 18 cases of the anastomotic bleeding, 7 received conservative treatments, 9 underwent endoscopic treatment, and 2 underwent reoperation. All the 18 cases had reached hemostasis. IOE is an independent protective factor of anastomotic bleeding after LAR. Endoscopic hemostasis is recommended for an anastomotic bleeding after LAR for rectal cancer with a stapling technique.

Risk Assessment on Anastomotic Leakage after Rectal Cancer Surgery: An Analysis of 753 Patients

To investigate the risk factors for anastomotic leakage (AL) after anterior resection for rectal cancer with a double stapling technique. Between January 2004 and December 2011, 753 consecutive patients in Jiangsu Cancer Hospital and Research Institute diagnosed with rectal cancer and undergoing anterior resection with a double stapling technique were recruited. All patients experienced a total mesorectal excision (TME) operation. Additionally, decrease of postoperative tumor supplied group of factors (TSGF), which have not been reported before, was proposed as a new indicator for AL. Univariate and multivariate analysis were performed to determine risk factors for AL. AL was detected in 57 (7.6%) of 753 patients with rectal cancer. The diagnosis of anastomotic leakage was confirmed between the 6th and 12th postoperative day (POD; mean 8th POD). After univariate analysis and multivariate analysis, age (p<0.001), gender (p=0.002), level of anastomosis (p <0.001), preoperative body mass index (BMI) (p = 0.001) and reduction of TSGF in 5th POD was less than 10 μ/ml (p <0.001) were selected as 5 independent risk factors for AL. It was also indicated that a temporary defunctioning transverse ileostomy (p = 0.04) would decrease the occurrence of AL. AL after anterior resection for rectal carcinoma is related to elderly status, low level site of the tumor (below the peritoneal reflection), being male, preoperative BMI and the decrease of TSGF in 5th POD is less than 10 m/ml. Preventive ileostomy is advisable after TME for low rectal tumors to prevent AL.

Comparison of morbidity between preventive and therapeutic ileostomy repair

Backgrounds : The purpose of this study is to compare the complications after ileostomy take down between preventive and therapeutic ileostomy formation . Methods : From January 2006 through December 2010, 373 patients underwent closure of ileostomy. Inclusion criteria are as follows: 1) Patients undergoing an elective takedown of a temporary ileostomy in colorectal cancer; 2) age > 19. Excluded were patients with nonelective stoma take down and patients undertaken to treat anastomosis site stricture or anal stricture. 373 patients are included in the analysis: 280 Protective and 93 therapeutic. Results : The morbidity rate of protective ileostomy take down is 22.1% and therapeutic ileostomy take down is 30.3%. Ileus is the most common complication in both groups. Those who underwent therapeutic ileostomy have longer postoperative hospital stay (6.9 days vs 9.7 days)(p diet compared to preventive ileostomy group (3.9 days vs 6.8 days)(p complications after ileostomy take down in MultipleLogistic Regression Analysis analysis were therapeutic ileostomy take down(p Conclusion : In the colorectal cancer surgery, preventive ileostomy take down showed better outcomes than therapeutic ileostomy after take down. Thus, in the case whenanastomosis is unstable or low, it is important to consider inconvenience of patients, risk of re-surgery due to anastomosis site leakage and increase in complications after therapeutic ileostomy take down when we performing of preventive ileostomy formation.

Laparoscopic-assisted reversal of Hartmann's procedure

Postoperative morbidity after reversal of Hartmann's procedure remains high. to evaluate efficacy of laparoscopic-assisted approach. 36 patients (19 men, aged 55.71 +/- 1.5 years) underwent laparoscopic-assisted reversal procedures in May 2008 - June 2010. The comparable control group consisted of 35 patients (16 men, aged 51.5 +/- 13.9 years). operation time was 179.5 +/- 65.1 min, 266.9 +/- 71.8 min in controls. Blood loss was 64.7 +/- 33.7 ml, 181.8 +/- 120.4 ml in controls. No conversions occurred in the main group. In three patients of the main group preventive ileostomy was performed. There were 11 diverting stomas in the control group. Postoperative hospital stays were 9.1 +/- 2.7 days (12.9 +/- 3.4 days in controls). There were 2 (5.9%) postoperative complications in the main group: one wound infection and one parastomal fistula. No mortality occurred. In the control group 3 (9.1%) complications (wound infection and haematoma) were detected. laparoscopic-assisted reversal of Hartmann's procedure promotes faster rehabilitation, its results are not worse than after open approach.