Proximal Diversion Research Articles

Outcomes of Low Anterior Resection Anastomotic Leak after Preoperative Chemoradiation Therapy for Rectal Cancer

Anastomotic leak remains a major cause of morbidity and mortality after colorectal surgery, especially with low anastomoses. The aim of this study was to assess outcomes of patients who developed an anastomotic leak after low anterior resection of the rectum for rectal cancer. An Institutional Review Board-approved retrospective review of 89 consecutive patients undergoing open low anterior resection with primary anastomosis for cancer of the mid/lower rectum at a single institution between January 2001 and December 2008 was performed. All patients received neoadjuvant chemotherapy and radiation therapy. Proximal diversion was performed in all patients. Perioperative data were collected and analyzed with attention to management and outcomes after development of anastomotic leak. Nine patients (10.1%) developed anastomotic leak. Mean age was 62 years. Mean tumor level was 4.8 cm above the anal verge. Symptomatic anastomotic leak developed in seven (78%) patients. Percutaneous drainage was performed in five (55.6%) patients with an average of 4.4 procedures required for management of anastomotic leak. Five (55.6%) patients required reoperation. Only two procedures (25%) involved laparotomy. No operative procedures were performed emergently. There were no mortalities. Excluding one patient who received completion proctectomy for local recurrence, restoration of intestinal continuity was achieved in five (63%) of eight patients. Mean time to stoma closure was 289 days. The potentially lethal complication of anastomotic leak after low anterior resection for rectal cancer can be managed expectantly and electively in patients who are proximally diverted with the expectation of stoma reversal in the long term.

Regenerated Oxidized Cellulose Reinforcement of Low Rectal Anastomosis: Do We Still Need Diversion?: Retracted

The leak rate after low anterior resection is in the region of 10% to 15%. The highest risks of anastomotic leak are in anastomoses less than 5 cm from the anal verge. We evaluated the outcome of oxidized regenerated cellulose reinforcement of low rectal anastomosis. The study group consisted of 108 patients with rectal cancer. Patients with low rectal cancer had low anterior resection with stapled straight low colorectal or coloanal anastomosis without proximal diversion. They were prospectively randomized to either oxidized regenerated cellulose reinforcement or no reinforcement. Data collected included age, sex, hemoglobin percentage, albumin level, histopathologic type of the tumor, anastomotic leak, and stricture. The mean age of patients was 56 years, and sex was matched in both groups. Clinical leak occurred in 6 of 38 cases (15.7%) in the group that did not undergo reinforcement versus 2 of 33 (6.1%) in the oxidized regenerated cellulose reinforcement group (P < .01). In the case of a leak, diversion was needed in 3 of 6 patients in the group that did not undergo reinforcement vs no patients in the oxidized regenerated cellulose reinforcement group (P = .05). Generalized peritonitis occurred in 3 patients in the group that did not undergo reinforcement versus no patients in the oxidized regenerated cellulose reinforcement group (P < .01). Length of stay was 4.8 days in the oxidized regenerated cellulose reinforcement group versus 5.9 days in the group that did not undergo reinforcement (P = .047), with no mortalities in either group. Oxidized regenerated cellulose reinforcement of low rectal anastomosis significantly decreases the risk of postoperative leak in low rectal anastomosis and may reduce the requirement for proximal diversion. Potential benefits include avoidance of a stoma, lower morbidity, shorter hospital stay, and a lower cost of care.

Do older Americans undergo stoma reversal following low anterior resection for rectal cancer?

3656 Background: Recent studies demonstrate that proximal diversion can decrease rates of anastomotic leak and subsequent morbidity and mortality after sphincter-preserving surgery for low lying rectal cancer. However, not all patients who receive a “temporary” diverting stoma undergo reversal. Studies suggest that delay and failure to undergo reversal may be associated with age among other factors. Methods: This is a retrospective population-based cohort study. Using SEER-Medicare linked data, we identified 1028 primary stage I-III rectal cancer patients diagnosed 1991-2005 and undergoing low anterior resection (LAR) with creation of a diverting stoma. We evaluated the proportion of patients who had stoma reversal within 18 months of primary resection and the timing of reversal with respect to initial surgery. Patient, clinical and hospital characteristics were included in a multivariable logistic regression model with random hospital effects to determine likelihood of reversal. A Cox proportional hazard model was fit for time to reversal, accounting for clustering within hospitals when calculating p-values. Results: Within 18 months of LAR, 49% (502/1,028) of patients underwent stoma reversal. Patients were more likely to have their stoma reversed if they were <80 years old (OR 2.8 [95% CI 2.1, 3.9]), had no comorbidities (OR 1.7 [95% CI 1.3, 2.2]), lower tumor stage (1 vs. 3; OR 2.0 [95% CI 1.3, 3.0]), received neoadjuvant radiation (OR 2.4 [95% CI 1.7, 3.4]), and were married (OR 1.5 [95% CI 1.1, 2.0]). Median time to reversal was 288 days (95% CI: 237- 385). Shorter time to reversal was associated with younger age (p < 0.0001) less comorbidity (p = 0.013), lower tumor stage (p = 0.0003), receipt of neoadjuvant radiation (p < 0.0001), and rectal tumor location (vs. rectosigmoid, p = 0.022). Conclusions: Over half of rectal cancer patients over the age of 65 who undergo sphincter-sparing surgery with temporary stoma have not undergone stoma reversal by 18 months. For those reversed, this usually is performed 8-12 months after LAR. Identifiable risk factors predict both delay and nonreversal. It is critical that providers are aware of and include this information in preoperative discussions with elderly rectal cancer patients. No significant financial relationships to disclose.

Ultimate Fate of the Leaking Intestinal Anastomosis: Does Leak Mean Permanent Stoma?

BackgroundThe ultimate fate of the leaking intestinal anastomosis is unknown. We sought to analyze long-term outcomes of anastomotic leak with an emphasis on identifying the likelihood of re-establishing intestinal continuity and the potential for releak with corrective surgery. MethodsAll consecutive subjects treated for clinical anastomotic leak from January 2001 through December 2007 were retrospectively reviewed. Patients were stratified by management of leak: (1) drainage alone, (2) proximal loop diversion, (3) repair/revision without diversion, (4) end stoma, or (5) tube enterostomy. We then determined management of anastomotic leak, mortality, corrective procedures, releak, and re-establishment of intestinal continuity. ResultsIn a database of 2,627 intestinal procedures, 79 patients had 88 anastomotic leaks with a final overall mortality of 10.1%. The aggregate rate of re-establishment of intestinal continuity was lowest for the patients treated by end stoma (44.4%) as compared to other initial management options (p < 0.01). Of the patients who survived their initial anastomotic leak, 20.5% had another leak (releak). ConclusionsPatients who underwent resection of the leaking anastomosis and end stoma or proximal loop diversion have a high rate of long-term fecal diversion. The proportion of patients who experience an anastomotic releak is substantial following further corrective surgery to re-establish intestinal continuity.

Risk Factors for Anastomotic Leak Following Colorectal Surgery

To assess anastomotic leak (AL) risk factors in a large patient series. Case-control study. The Mount Sinai Hospital. Ninety patients with AL following colorectal resection and 180 patients who underwent uncomplicated procedures. Risk factors associated with development of AL. The AL rate was 2.6%. Five risk factors for AL were identified: (1) preoperative albumin level lower than 3.5 g/dL (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.3-5.1) (P = .03); (2) operative time of 200 minutes or longer (OR, 3.4; 95% CI, 2.0-5.8) (P = .01); (3) intraoperative blood loss of 200 mL or more (OR, 3.1; 95% CI, 1.9-5.3) (P = .01); (4) intraoperative transfusion requirement (OR, 2.3; 95% CI, 1.2-4.5) (P = .02); and (5) histologic specimen margin involvement in disease process in patients with inflammatory bowel disease (IBD) (OR, 2.9; 95% CI, 1.4-6.1) (P = .01). Patients with all 3 intraoperative risk factors had an OR of 22.1; 95% CI, 2.8-175.4 (P < .001) for development of AL. Histologic resection margin involvement in disease process in patients with IBD, preoperative albumin levels lower than 3.5 g/dL, intraoperative blood loss of 200 mL or more, operative time of 200 minutes or more, and/or intraoperative transfusion requirement increased AL risk. Enteral nutritional optimization prior to elective surgery is essential. Proximal diversion should be considered for patients with all 3 intraoperative risk factors because they are at high risk for AL.

Factors Associated With Septic Complications After Restorative Proctocolectomy

Few studies have evaluated factors that may be associated with the development of septic complications after restorative proctocolectomy. Therefore, the aim of this study is to evaluate preoperative and operative factors that might be associated with septic complications after restorative proctocolectomy. Patients developing abdominal and pelvic septic complications after restorative proctocolectomy were identified from a prospective database. Patients with subclinical leaks and ileostomy closure leak were not included in the septic complication group. A multivariable logistic regression model for sepsis was constructed using a forward stepwise selection with entry criterion of P < 0.05. From 1983 to 2007, 3233 patients (56% male) were included in the database. Eight-four percent (2597) of patients underwent proximal diversion. Two hundred patients (6.2%) developed septic complications within 3 months of restorative proctocolectomy or within 3 months of ileostomy closure. On multivariate analysis, body mass index > 30 (P = 0.02, OR = 1.77), final pathologic diagnosis of ulcerative/indeterminate colitis (P = 0.02, OR = 2) or Crohn's disease (P = 0.02, OR = 3.6), intraoperative (P = 0.02, OR = 1.6), and postoperative transfusions (P = 0.01, OR = 1.9) were all independently associated with septic complications. We also demonstrated an independent association among individual surgeons (P = 0.04) with decreased septic complications. Body mass index greater than 30, final pathologic diagnosis of ulcerative/indeterminate colitis or Crohn's disease, intraoperative and postoperative transfusions, and surgeon were all independent factors associated with septic complications after restorative proctocolectomy.

Laparoscopic colectomy is safe and leads to a significantly shorter hospital stay for octogenarians

Concerns about prolonged postoperative recovery may detract surgeons from offering colectomy to patients older than 80 years. The adoption of a minimally invasive approach may help to counter these beliefs, but concerns remain as to whether these patients can tolerate a pneumoperitoneum. This study compared outcomes after laparoscopic colectomy (LC) and open colectomy (OC) for patients older than 80 years. From a prospectively maintained database, 97 patients undergoing elective LC between 1994 and 2008 were identified and matched 1:1 to OC patients for age, gender, year of surgery, extent of resection, proximal diversion, American Society of Anesthesiology score, and body mass index. Short-term outcomes including postoperative mortality, morbidity, and discharge status were assessed. The LC and OC patients were similar for the matched characteristics. Their mean age was 82.8 years (range, 80-94 years). The conversion rate for the LC patients was 14.4%. The OC group had a higher proportion of cancer patients (93.8% vs. 59.8%; P = 0.001). The discharge status for the LC and OC patients was similar, and most patients were discharged home without assistance (63.9% vs. 62.9%; P = 0.88). The median hospital stay was significantly shorter for LC (6 days; range, 1-67 days) than for OC (7 days; range, 2-53 days; P = 0.001). The 30-day postoperative complications (OC, 43.3% vs. LC, 37.1%; P = 0.38), reoperations (OC, 5.2% vs. LC, 4.1%; P = 0.73), and readmissions (OC, 6.2% vs. LC, 9.3%; P = 0.41) were similar. The overall mortality rate was 5.2% and similar between the two groups. Complications and other outcomes are similar for LC and OC, and the earlier recovery associated with LC, as evidenced by a shorter hospital stay, may encourage a wider adoption of LC for patients older than 80 years.

Emergency management of diverticulitis.

The most common indications for emergency operative intervention in the treatment of sigmoid diverticulitis are peritonitis and failure of medical therapy. Primary resection and diversion (Hartmann's procedure) followed by delayed colostomy closure is the current standard of emergency surgical care. Guidelines for best operative strategy, however, remain controversial and continue to evolve based on recent comparative reviews of surgical outcomes. Primary resection and anastomosis with or without proximal diversion and laparoscopic lavage are alternatives to Hartmann's procedure that may provide an improved outcome in properly selected patients. Ongoing changes in the historical paradigm of the surgical approach to this disease mandate the need for large multicentered prospective randomized trials to determine the best surgical strategy under emergent conditions for the treatment of diverticulitis. The current literature is reviewed with suggestions for a management algorithm.

Proximal Diversion at the Time of Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

Pelvic sepsis is a serious complication after ileal pouch-anal anastomosis for ulcerative colitis that may lead to pouch failure or poor function. Although a temporary loop ileostomy may be created at the time of ileal pouch-anal anastomosis to prevent or minimize the consequences of an anastomotic leak, research has suggested that an ileostomy can be safely omitted in selected patients. The purpose of this study was to examine the use of proximal diversion by colorectal surgeons at the time of ileal pouch-anal anastomosis for ulcerative colitis. A questionnaire was mailed to all practicing fellows of The American Society of Colon and Rectal Surgeons in North America. Surgeons were asked to describe their typical practice for a number of clinical scenarios. Questionnaires were mailed to 913 American Society of Colon and Rectal Surgeons fellows, and 63 percent responded. For a patient who has had a prior colectomy and is not taking steroids, 27 percent of surgeons would perform ileal pouch-anal anastomosis alone, and 73 percent would perform ileal pouch-anal anastomosis with a loop ileostomy. For a patient who has not had previous surgery and is taking prednisone 40 mg/day, 16 percent of surgeons would perform a subtotal colectomy with an end ileostomy, 82 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis with a loop ileostomy, and 2 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis without an ileostomy. There was no relationship between practice setting, annual ileal pouch-anal anastomosis volume, or years in practice and surgeon response for either scenario. The majority of surgeons create a temporary loop ileostomy at the time of ileal pouch-anal anastomosis for ulcerative colitis.

Anastomotic Leak Testing After Colorectal Resection

To determine the value of anastomotic leak testing of left-sided colorectal anastomoses. Cohort analysis. Subspecialty practice at a tertiary care facility. Consecutive subjects were selected from a prospective colorectal database of 2627 patients treated between January l, 2001, and December 31, 2007. Creation of left-sided colorectal anastomoses and air leak testing per surgeon preference. Anastomosis type, method (handsewn vs stapled), performance of air leak testing, repair method of anastomoses after air leak tests yielding positive results, and development of postoperative clinical leak. A total of 998 left-sided colorectal anastomoses were performed without proximal diversion; 90.1% were stapled and 9.9% were handsewn. Intraoperative air leaks were noted in 65 of 825 tested anastomoses (7.9%), that is, 7.8% of stapled anastomoses and 9.5% of handsewn anastomoses. A clinical leak developed in 48 patients (4.8%). Clinical leaks were noted in 7.7% of anastomoses with positive air leak test results compared with 3.8% of anastomoses with negative air leak test results and 8.1% of all untested anastomoses (P < .03). If air leak testing yielded positive results, suture repair alone was associated with the highest rate of postoperative clinical leak compared with diversion or reanastomosis, 12.2% vs 0% vs 0%, respectively (P = .19). Our data indicate a high rate of air leaks at air leak testing of left-sided colorectal anastomoses. In addition, the high rate of clinical leaks in untested anastomoses leads us to recommend air leak testing of all left-sided anastomoses, whether stapled or handsewn.

The impact of pre‐ or postoperative radiochemotherapy on complication following anterior resection with en bloc excision of female genitalia for T4 rectal cancer

The aim of the study was to assess the mortality and morbidity following extended anterior resection with excision of internal female genitalia combined with pre- or postoperative chemoradiotherapy in women with extensive rectal cancer. The study included a consecutive series of 21 women with T4 adenocarcinoma of the rectum infiltrating the reproductive organs treated with curative intent between 1997 and 2003. All patients had an extended anterior sphincter preserving resection of the rectum (total mesorectal excision) and hysterectomy with or without posterior vaginal wall excision. In all patients, surgery was combined with adjuvant radiochemotherapy. Ten patients received preoperative radiotherapy (50.4 Gy) concurrently with two courses of chemotherapy [fluorouracil with folinic acid (FA)] followed by surgery within 6-8 weeks and subsequently four courses of postoperative chemotherapy. Eleven received postoperative chemoradiotherapy (50.4 Gy plus fluorouracil with FA). There was no postoperative mortality. Postoperative complications were observed in 57% patients (early in 14% and late in 52%). These included: anterior resection syndrome with anorectal dysfunction in 52% (requiring proximal diversion in 5%), urinary complications in 24% (complete incontinence requiring a permanent catheter in 5%). In addition, postoperative acute bleeding requiring relaparotomy, delayed wound healing caused by superficial infection, anastomotic leakage, prolonged bowel paralysis, benign rectovaginal fistula and anastomotic stricture occurred (5% each). The risk of postoperative morbidity (52%) was similar for patients with or without preoperative radiochemotherapy. Despite this aggressive therapeutic approach, most postoperative complications were transient or could be treated. Preoperative radiochemotherapy did not increase the risk of morbidity.

Necrotizing Enterocolitis in Full-term Neonates: Is it Aganglionosis?

While NEC is primarily a disease of prematurity, full-term infants account for approximately 10% of cases. The aim of this study was to highlight the association of Hirschsprung's disease and NEC in full-term babies which, as far as we could ascertain, has not been reported before. A retrospective study of all surgically treated neonates presenting with NEC from November 1999 to January 2007 was performed. A total of 20 surgically managed neonates presented with NEC during the study period. Three were excluded from the study because they underwent other treatments. Patients were divided into 2 groups: Group 1 consisted of pre-term neonates with weights below 2400 g and Group 2 consisted of full-term neonates with a weight above 2400 g. Nine out of 17 were in Group 2. Peritoneal drain and proximal diversion ileostomy in the most viable part of intestine was done in the neonatal intensive care unit (NICU). Rectal biopsy was taken from 7 out of 9 in Group 2 and from one presenting with cecal perforation in Group 1. Full thickness open rectal biopsy (H&E staining) was the definitive procedure for diagnosis until 2000, when AChE staining began to be used. Duhamel's pull-through was the procedure of choice for neonates with a positive rectal biopsy. Aganglionosis was found in 4 of 7 rectal biopsies in patients weighing more than 2400 g (Group 2). One died at home while waiting for definitive surgery. Duhamel's pull-through was performed for the rest. Altogether 3 patients died (17.6%). The survivors are developing normally, only one has exhibited retarded growth. One infant suffered from cholestatic jaundice. Our results support the suspicion that a large proportion of term neonates presenting with NEC have long segment or total colonic Hirschsprung's disease. This observation is in contrast to the currently available literature on this problem from the last decade.

Outcomes for Patients Developing Anastomotic Leak After Ileal Pouch-Anal Anastomosis

Outcomes for patients developing a leak after ileal pouch-anal anastomosis have not been well investigated. This study explored whether the use of a stapled or handsewn anastomosis was associated with different outcomes when an anastomotic leak developed. Patients were identified from a prospectively maintained pouch database. Functional outcomes regarding bowel movements, urgency, continence, and seepage were evaluated. Quality of life was assessed by the Cleveland Global Quality of Life Score. One hundred and seventy-five patients with anastomotic leak (141 stapled and 34 handsewn anastomosis) were identified. The two groups were similar in gender and diagnosis. Patients with handsewn anastomosis were younger (P = 0.04), had less perioperative steroid use (P = 0.05), more proximal diversion (P = 0.02), and S-pouch creation (P = 0.003). More handsewn cases had intraoperative transfusion (P = 0.04) and postoperative hemorrhage within the pelvis (P = 0.003). Long-term pouch failure was 35.3 percent in the handsewn group and 12 percent in the stapled group (P = 0.002), which was confirmed by Kaplan-Meier analysis (Log-rank P = 0.007). On multivariate analysis, leak after handsewn anastomosis was independently associated with pouch failure. Leak after stapled anastomosis carried a lower incontinence rate at 5 years (P = 0.03), while handsewn had higher nocturnal seepage rate at 3, 5, and 10 years, and most recent follow-up. Cleveland Global Quality of Life Score was comparable between the groups during follow-up. Outcomes including functional results and pouch failure rates for patients developing a leak after stapled anastomosis at ileal pouch-anal anastomosis were significantly better than outcomes for patients who develop a leak after handsewn anastomosis.

Article Commentary: Current Management of Diverticulitis

Diverticulitis is classified as uncomplicated or complicated, i.e., associated with perforation, fistula, or obstruction. CT allows more reliable characterization of an acute attack of diverticulitis. Medical management is reserved for uncomplicated diverticulitis and the initial phase of treatment of diverticulitis associated with abscess formation. Percutaneous abscess drainage is a major advance, which permits one-stage resection in a majority of cases. Diverticulitis associated with free perforation can be selectively managed with resection and primary anastomosis, although a Hartmann resection is likely to be performed. A fistula associated with diverticulitis can usually be managed with a one-stage resection. Obstruction can be managed selectively with resection with on-table bowel preparation, primary anastomosis, and proximal diversion. Laparoscopic techniques permit successful performance of elective resections most of the time. Hand assistance is of particular value when the patient has dense fibrosis.

Impact of neoadjuvant chemoradiotherapy on functional outcomes for patients with uT3 rectal cancer undergoing restorative resection

4098 Background: Our aim is to determine whether neoadjuvant chemoradiation adversely affects functional outcomes for patients with ultrasound stage T3 (uT3) middle and lower third rectal cancer undergoing surgery. Methods: All patients with uT3 middle and lower third rectal cancers who underwent surgery from 1986–2007 were identified from a prospectively maintained cancer database. Prospectively accrued functional outcomes for patients who had neoadjuvant therapy (Group A) were compared with those for patients who did not (Group B). Quality of life (QOL) was measured using SF 36. Results: There were 297 patients in Group A and 153 in group B. Complete response rate was 16.6%. Group A had more males(76 vs 65%, p=0.02) and were younger (59±11.9 vs 66.5 ±12.2 yrs, p<0.001). Group A also had lower tumor distance from anal verge(5.5±2.4 vs 6.2±2.3 cm, p=0.004), greater use of hand-sewn anastomoses (29.9% versus 12.0%, p=0.002) and proximal diversion(38.2% vs19.2%, p<0.001). Tumor differentiation was similar in both groups. Group B had larger tumors (4.5±1.8 vs 2.6±1.7, p=<0.001) with more involved lymph nodes (1, 0–52; 0, 0–22, p=<0.001). Anastomotic leak rate was similar(Grp A: 4 vs 6.8%, p=0.27). Group A had lower local recurrence (12.6% vs. 24.4%, p<0.001) and greater disease free survival rate(75.7% vs. 51.9%, p<0.001). Long term functional outcome were measured by number of day and night time bowel movements, control of solid, liquid and gas and pad use. After adjusting for age, gender, complication and reservoir use, at the time of their most recent evaluation, functional outcomes for patients undergoing restorative resection (Grp A 67.8%, Grp B53.5%) were comparable between groups. Despite the greater proportion of patients with a permanent stoma in Group B, QOL was similar between groups. Conclusion: For uT3 cancer of the mid and lower rectum, neoadjuvant therapy is associated with better oncologic outcomes. With careful surgical technique and judicious use of a reservoir, chemoradiation prior to surgery does not appear to adversely influence functional outcomes. The presence of a permanent stoma does not seem to influence QOL. No significant financial relationships to disclose.

Comparison of Outcomes After Restorative Proctocolectomy With or Without Defunctioning Ileostomy

To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis. The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P = .002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P = .045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.

Proximal Diversion for Failed Rectal Anastomosis

Proximal Diversion for Failed Rectal Anastomosis

“Spontaneous,” delayed colon and rectal anastomotic complications associated with bevacizumab therapy

Bevacizumab, a humanized monoclonal antibody used to treat recurrent and metastatic colorectal cancer, targets the vascular endothelial growth factor (VEGF) molecule. It is hypothesized that bevacizumab works by both depriving tumors of the neovascularity they require to grow, and by improving local delivery of chemotherapy through alterations of tumor vasculature permeability and Starling forces. Complications of bevacizumab treatment include bowel ischemia and perforation, but to date, these complications have only rarely been described as occurring at the site of presumably healed anastomoses following surgery. We report two cases of delayed, "spontaneous" low anterior colorectal anastomotic dehiscence and one right colon anastomotic colocutaneous fistula associated with bevacizumab therapy. After seeing three patients with complications arising from apparently healed low anterior colorectal or right colon anastomoses following initiation of bevacizumab therapy for treatment of metastatic colorectal cancer, we reviewed the experience of The Cancer Institute of New Jersey (CINJ) with use of bevacizumab in approximately 50 patients between April 2004 and December 2006. The three index cases had been treated surgically at CINJ but received chemotherapy elsewhere. None of the 50 patients receiving bevacizumab at CINJ who had previous colon or rectal anastomoses were identified as having this complication. The medical records of the three index cases were reviewed and analyzed. Additionally, a Medline search was performed to identify other reports documenting similar cases. Two reports of related cases were found in the literature. In two of our index cases who underwent low anterior anastomoses, the patients had received preoperative pelvic irradiation before their initial low anterior resection. In one of the two cases, the initial resection was complicated by an anastomotic leak requiring proximal diversion and then subsequent stoma takedown. In both cases, the dehiscence occurred more than 1 year after anastomosis, and became evident 1-10 months following initiation of bevacizumab treatment. In the third index case, a colocutaneous fistula arising from the anastomotic site presented 5 months following right colon resection and 3 months after starting adjuvant systemic therapy with FOLFOX (5-fluorouracil (5-FU), leucovorin, and oxaliplatin) and bevacizumab. Delayed colorectal anastomotic complications may occur in association with bevacizumab therapy. Contributing factors may include anastomotic leak at the time of the original operation and history of anastomotic irradiation. Clinicians treating patients who receive bevacizumab following colectomy for colorectal cancer should be aware of this possible life-threatening complication. These findings may also be relevant to the design of trials of the use of bevacizumab for the postoperative adjuvant treatment of patients with colorectal cancer.

Chronic in-vivo experience with an endoscopically delivered and retrieved duodenal-jejunal bypass sleeve in a porcine model

The role of duodenal bypass as an underlying mechanism of action in gastric bypass surgery has received considerable attention. We report the initial feasibility study of a totally endoscopically delivered and retrieved duodenal-jejunal bypass sleeve in a chronic porcine model. The implant consists of a 60-cm fluoropolymer sleeve that is endoscopically deployed via a coaxial catheter system into the jejunum and fixed in the proximal duodenum with a Nitinol anchor. The system creates a proximal biliopancreatic diversion. Six female Yorkshire pigs were endoscopically implanted; all survived. Four animals (group 1) were slated to survive 90 days, two animals (group 2) for 120 days, and three animals (group 3) underwent sham endoscopy and were survived 120 days. Animals were fed standard dry pig chow 0.5 kg three times daily. Data points included daily general health, weekly weight, serum blood tests (complete blood count, amylase, lipase, liver function tests), and monthly evaluation of anchor/sleeve position/patency by fluoroscopy and endoscopy. Following the in-vivo period, the devices were endoscopically removed and the animals were sacrificed. Duodenal and jejunal tissue samples were assessed histologically. All six test animals were implanted and explanted without significant adverse events. In group 1, the first animal had no device-related issues. The second animal had a pivoted anchor requiring repositioning at day 63. That animal had no further difficulties. The third animal had an incidental partial rotation of the anchor noted at the 90 day explantation. The fourth animal was incidentally implanted with a crossover of the anchor struts, which was endoscopically corrected on day 14. However, on day 20 the animal had persistent vomiting, and the device was explanted. Both group 2 animals survived 120 days. One animal had a partially rotated anchor but was asymptomatic. The average weight gain between test and sham groups was 0.23 kg/day and 0.42 kg/day, respectively (p = 0.01). A totally endoscopic and reversible bypass of the duodenum and proximal jejunum has been achieved for 90-120 days. Initial experience suggests patency of the sleeve and acceptable tissue response. Reduced weight gain in the test animals suggests device efficacy. Further investigation is warranted.

Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality

The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses -- less than 6 cm from anal verge, with or without a diverting ostomy -- was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.