Restorative Resection Research Articles

Early predictors of anastomotic leaks after colectomy

An anastomotic leak after colorectal surgery is associated with significant morbidity and decreased survival. Our aim was to identify the early predictors of anastomotic leaks. The records of patients undergoing restorative resection for colorectal disease from January 2000 to November 2005 were reviewed. Demographics, clinical events, and laboratory parameters were recorded. A total of 311 patients were included. An anastomotic leak was identified in 25 patients (8%). A leak was suspected and diagnosis confirmed at a mean of 10+/-1 days postoperatively. More respiratory and neurological events occurred in patients with an anastomotic leak (p<0.001). These events occurred early in the postoperative course and were usually the first signs and symptoms of a leak. More patients with a leak had absence of bowel activity by postoperative day 6 compared to patients without a leak (p<0.0001). Elevations of the white blood cell count or temperature were a late finding. The earliest clinical predictors of an anastomotic leak are pulmonary and/or neurological. Awareness of these findings might help in early diagnosis and treatment of an anastomotic leak.

V2 Prone abdomeno perineal excision of rectum

Traditionally, the perineal dissection during an Anbdomeno‐perineal resection of the rectum (APER) is conducted in conjunction with the trans‐abdominal pelvic dissection with the patient in Lloyd‐Davis and then the Lithotomy positions. There is a higher local recurrence rate in APER as compared to restorative anterior resection. The current practices in APER often result in a ‘surgical waist’ in the resection specimen, which might threaten the resection margin. There are many advantages to performing the perineal dissection with the patient in a prone Jack‐Knife position. The oncological benefit is that it facilitates the achievement of a more cylindrical resection specimen, giving a wider resection margin and hence lowering the risk of local recurrence. This video utilises annotated diagrams and a high definition digital recording of the perineal dissection in a 52 year old male patient with a low rectal cancer undergoing APER, following neo‐adjuvant long course chemo‐radiotherapy. We demonstrate how the use of the prone jack‐knife position gives excellent exposure and improved surgical access, facilitating a better oncological resection.

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.

A Randomized Multicenter Trial to Compare Long-Term Functional Outcome, Quality of Life, and Complications of Surgical Procedures for Low Rectal Cancers

Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer. : To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer. A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed. Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 +/-12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups. In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

Can the results of anorectal (abdominoperineal) resection be improved: are circumferential resection margins too often positive?

Carefully executed surgery for rectal cancer has reduced the incidence of local recurrence after restorative resection. Three recent large prospective series have confirmed the perception of a higher positive circumferential resection margin (CRM) rate after abdominoperineal resection. Tumour spread is different for low tumours and the surgical technique of abdominoperineal resection, perhaps better known as anorectal excision, may vary between surgeons. There is a need to redefine the place of anorectal excision and the contribution that can be made by pre-operative chemoradiation and/or extended surgery to reduce local recurrence and increase survival. Defined surgery, validated by histopathological assessment, as applied to TME surgery, would determine whether the perceived higher rates are due to the differences in routes of tumour spread or to surgically related variables. Unnecessary R1 or R2 resections and operative perforation can be minimized by an understanding of the surgical anatomy, the pattern of spread and difference in operative technique between anorectal excision and a low restorative operation. Surgical technique to maximize R0 resection should be based on a detailed understanding of the pelvic fascia and the levator ani and the use of pre-operative imaging to define lines of excision. With the adoption of even lower restorative resection (intersphincteric) there is a need to reassess the method of anorectal excision. This may be achieved by histopathological assessment of CRM positivity and MDT audit to improve results. Clinical trials are essential.

Long term results of a consistent policy of sphincter preservation in the treatment of carcinoma of the rectum.

With increasing emphasis on sphincter preservation in the treatment of low carcinomas of the rectum, it is important to know whether such a policy results in satisfactory rectal function and long term survival. In 368 patients operated upon for carcinoma of the rectum between 1958 and 1980, a consistent policy of sphincter preservation was followed, and resulted in 222 (61 per cent) patients having a restorative resection (RR), whilst 132 (37 per cent) had an abdominoperineal excision (APE); 271 (76 per cent) had a radical operation with a hope of cure. Overall operative mortality was 5 per cent (2.6 per cent in the radical group) and the leakage rate in the 222 restorative anastomoses was 5 per cent. Follow-up of 98 per cent of patients treated over 5 years ago has been possible. Special attention has been paid to the late results in patients having a restorative resection of tumours at and below 8 cm: all these patients are continent and there is no excess of late pelvic recurrent. Corrected 5-year survival rates are 72 per cent for abdominoperineal excision and 84 per cent for restorative resection.

Resection and sutured colo-anal anastomosis for rectal carcinoma.

Resection with preservation of the anal sphincters is new widely accepted as providing satisfactory treatment for carcinoma of the upper rectum. However, restorative resection is less widely performed for tumours of the lower rectum because anastomosis can be technically difficult when performed low in the pelvis. Between 1973 and 1980, 76 patients with rectal carcinoma underwent rectal resection and restoration of bowel continuity by means of a sutured anastomosis between colon and anal canal. The pathological characteristics of these tumours were similar to those of all cases of carcinoma of the rectum treated at St. Mark's Hospital between 1948 and 1972. Two patients developed pelvic sepsis following colonic necrosis and anastomotic breakdown. Eight developed pelvic sepsis without major anastomotic breakdown. No patient died as a result of pelvic sepsis. Sixty-nine of the 70 patients who were able to be assessed were either completely normal functionally or had only minor deficiencies of bowel function. Six patients have been observed to develop recurrent pelvic tumour, localized to the pelvis in 4 patients and concurrent with the development of widespread metastases in 2. Twenty-one of 32 patients are alive 3 years and 12 of 19 patients are alive 5 years after a curative operation for rectal carcinoma. These results are comparable with those seen following total excision of the rectum and pelvic floor for similarly sited tumours.

Total excision or restorative resection for carcinoma of the middle third of the rectum.

Summary Restorative resection is being used increasingly for carcinoma of the mid rectum but it is not yet certain whether this operation is as curative as total excision. Between 1963 and 1972, 209 patients left St Mark's Hospital after a radical operation for a single rectal carcinoma situated between 8 and 12 cm from the anal verge. A total of 199 patients was followed up for 5 years. Of these, 112 had been treated by total excision of the rectum and 87 by restorative operation. Survival was correlated with the Dukes' stage, histological grade and extent of local spread in the two groups. There was no significant difference in 5-year survival after either total excision or restorative resection for Dukes' B (74 per cent, 71 per cent respectively) or average grade (61 per cent, 73 per cent respectively) tumours. Patients with Dukes' C tumours fared better when treated by restorative resection (36 per cent, 63 per cent), probably due to fewer high grade tumours in the restorative group (38 per cent, 18 per cent). Combining two variables, survival was not significantly different for patients with Dukes' B tumours of average grade (69 per cent, 62 per cent) or for Dukes' C tumours of average grade (48 per cent, 76 per cent). When the three pathological variables were combined, there was an improved survival after restorative resection for some pathological combinations. It is concluded that restorative resection for carcinoma of the mid rectum is as curative as total excision in terms of 5-year survival.

Local recurrence after potentially curative resection for rectal cancer in a series of 1008 patients.

Local recurrence and its related mortality after potentially curative resection for rectal cancer have been analysed in a series of 1008 patients managed by one of the authors. Nine hundred and thirty-four were available for analysis of recurrence. One hundred and seven (11 per cent) patients developed local recurrence without evidence of systemic spread and 84 (9 per cent) both local and systemic recurrence. Local recurrence was less common (14 per cent) after resection of tumours of the upper third of the rectum compared with the middle (21 per cent) (P = 0.02) or lower thirds (26 per cent) (P less than 0.001). Local recurrence was related to both tumour stage and differentiation (P less than 0.001). There was no significant relationship between local recurrence and tumour size or the type of curative resection performed, restorative or non-restorative. The distal margin of clearance after restorative resection did not influence the local recurrence rate. Of patients who developed metastases recurrence was evident within 2 years in 60 per cent. Three hundred and thirty-two patients died from recurrence, 91 (27 per cent) with evidence of local recurrence only, 80 (24 per cent) with combined local and systemic recurrence and 161 (48 per cent) with evidence of systemic spread only. The corresponding median survivals were 35, 34 and 39 months.

Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis.

Anorectal manometry and electromyography were studied in 17 patients before and after restorative proctocolectomy with stapled pouch-anal anastomosis, in ten patients before and after low anterior resection with stapled coloanal anastomosis, and in 35 normal controls. More than 80 per cent of patients in both groups developed abnormal oscillation of anal pressure after operation (amplitude 15-60 (median 25) cmH2O, frequency 4-10 (median 8) per min) and showed no anal relaxation in response to intermittent neorectal distension. All patients lost discriminative rectal sensation and none could perceive a normal desire to defaecate. Patients with postoperative soiling had a greater amplitude of anal pressure oscillation and lower minimum basal pressure, although those who underwent coloanal anastomosis had a greater risk of incontinence because of large asynchronous oscillations in neorectal pressure. The common pathophysiological features after restorative proctocolectomy and coloanal anastomosis probably relate to damage to the autonomic and enteric nerve supplies. The presence of an unstable internal anal sphincter may be an important cause of postoperative nocturnal incontinence.

Towards fewer colostomies--the impact of circular stapling devices on the surgery of rectal cancer in a district hospital.

Circular stapling devices can be used to extend the range of anterior resection of the rectum to encompass most of anterior resection of the rectum to encompass most rectal carcinomas. In one district general hospital the number of abdominoperineal resections performed in a 12-month period has been reduced from 27 to 4. A personal series is presented of 40 patients in whom the new technique allowed restorative resection to replace permanent colostomy. Special care is essential in the preparation of the colon for the low anastomosis.

Restorative rectal resection: an audit of 220 cases.

Two hundred and twenty consecutive, unselected cases of restorative rectal resection are reported. The operative mortality was 8.3 per cent; 3.5 per cent in patients less than 70 years old and 13 per cent over that age. Leakage at the colorectal suture line was an intractable problem, uninfluenced by anastomotic technique, but the introduction of antimicrobial prophylaxis as a routine was followed by a statistically significant reduction in the leak rate. Postoperative rectal function was satisfactory but temporary stenosis at the suture line was not uncommon. In only one case was it permanent, requiring regular dilatation. Recurrence of malignant disease occurred in 50 per cent of cases followed for at least 2 years; 35 per cent general disease, 15 per cent localized to the pelvis. These figures do not differ significantly from those following total rectal excision, which is now necessary in only 1 in 10 cases where the growth lies within 10 cm of the anus.

Influence of temporary faecal diversion on long-term survival after curative surgery for colorectal cancer.

Experimental carcinogenesis is enhanced at colorectal anastomoses, inhibited by proximal faecal diversion and promoted by the closure of a defunctioning stoma. The clinical relevance of these observations was investigated in a retrospective study of curative restorative resection for colorectal carcinoma. The 5-year disease-free survival rate (95 per cent confidence interval) in 122 patients with a temporary stoma (50.4 (41.1-59.7) per cent) was significantly reduced (P < 0.01) compared with that in 218 with no stoma (66.8 (59.4-73.5) per cent). In patients with Dukes B tumours early stoma closure (within 3 months of resection) was associated with a worse survival (P < 0.005) and a higher tumour recurrence rate (P < 0.05) than in those with no stoma. Survival rates after late stoma closure were no different from those in patients with no stoma. Multivariate analysis revealed Dukes stage (P < 0.0001), tumour differentiation (P = 0.02) and timing of stoma closure (P = 0.02) as independent predictors of survival. In curative surgery for colorectal cancer temporary faecal diversion confers a survival disadvantage that can be prevented by delayed closure of the stoma.

Rectal cancer in the elderly: patients' perception of bowel control after restorative surgery.

The risk of incontinence is perceived as a relative contraindication to a sphincter-saving procedure in elderly patients with rectal cancer. To investigate this, we reviewed functional results one year after restorative surgery in patients older than aged 75 years. A total of 186 patients older than aged 75 years were diagnosed with rectal cancer during the study period. In 19 patients, no surgery was undertaken, and another 3 patients had a defunctioning stoma only. A local excision was performed in six patients. Of the remaining 158 having a major resection, 133 patients (84 percent) had a restorative anterior resection. The one-year, follow-up records of these patients were studied with particular reference to the patients' perception of bowel function and continence. At one year, 99 patients who had had an anterior resection were alive. In 92 patients, a stoma had been closed or avoided altogether, and these patients formed the study group. Significant problems with bowel function or continence were denied by 78 of 92 patients (85 percent). One patient had already reported severe difficulties and been given a definitive stoma for incontinence. The remaining 14 percent, although experiencing some problems with continence, did not consider the situation serious enough to contemplate a stoma. An elderly patient undergoing anterior resection for rectal cancer has a reasonable expectation of acceptable continence. Age alone should not be a contraindication to a restorative resection.

Colo-rectal anastomotic leakage often masquerades as a cardiac complication.

The aim of this study was to identify the mode of presentation of patients with clinical anastomotic leaks following restorative colorectal resection for carcinoma. Prospective information was collected on all patients having restorative resection of colorectal cancer. These data were reviewed for a five-year period (1994-1998) to identify all patients who had suffered a clinical anastomotic leak and their notes were retrieved and reviewed. Three hundred and seventy-nine patients underwent restorative resection for colorectal cancer during the study period (178 female, 201 male), mean age 70 years (range 36-94). There were 22 (6%) clinical anastomotic leaks. Seven (32%) patients presented with obvious abdominal peritonitis. The remaining 15 (68%) were initially misdiagnosed. Thirteen (59%) patients were treated for cardiac symptoms, 1 (5%) patient for obstruction and 1 (5%) for ascites. The delay in diagnosis ranged from 0 to 11 days (mean 4 days). For the whole series of 379 there were 30 patients who suffered cardiac symptoms (8%) 13(43%) of whom had an anastomotic leak. Patients who develop cardiac symptoms following restorative colorectal resection for carcinoma should have a water soluble enema as there is a 40% chance that they will have an anastomotic leak.

The Implications of Subspecialisation on the Management and Outcome of Surgery for Rectal Carcinoma

Background: The management of rectal carcinoma has changed significantly over the last decade. We studied the changing trends in the management of rectal carcinoma over a 7-year period in a district general hospital. Methods: A retrospective analysis of all patients with histologically proven rectal adenocarcinoma who underwent operative treatment between January 1991 and December 1997 was performed. The type of operative procedure, local recurrence rate and completeness of pathology reporting was documented. Results: There were 200 operative procedures: 102 anterior resections (AR), and 98 abdominoperineal resections (APR). This included 17 palliative resections because of metastatic disease (n = 8) or extensive local invasion (n = 7) or both (n = 2). The APR rate steadily declined from 72% in 1991 to 19% in 1997 (p < 0.005). Subspecialist ‘colorectal’ surgeons performed only 24% of the operations in 1991 but the figure for 1997 was 85% (p < 0.01). No circumferential resection margin was reported in 1991 but was reported in 85% of the cases in 1997 (p < 0.001). There was a steady increase in stapled anastomoses from 43% in 1991 to 93% in 1997 (p < 0.03). There were 15 local recurrences following ‘curative’ resection; 7 following APR and 8 following AR (n.s.). Conclusion: There was a significant increase in the rate of restorative resection of rectal cancer with a concomitant reduction in permanent stoma formation; this may be attributed to an increase in subspecialisation. Despite this, a low rate of local recurrence was maintained throughout the study period.

Endométriose colorectale. Diagnostic et prise en charge

Endometriosis occurs in 5 to 10% of the female population. Bowel involvement present in 6 to 30% of cases is predominantly localized in the pelvic parts of the colon and rectum, close to the uterus. The goal of this work was to describe the present diagnostic and therapeutic management of deep colorectal endometriosis defined as infiltrating the digestive wall and usually requiring surgery. Colorectal endometriosis is a disabling disease. Anatomic lesions mimic those of a cancer. Modern investigations include endorectal endosonography, recognized as the best mean to assess the depth of invasion into the intestinal wall, and magnetic resonance imaging. Associated to exploratory laparoscopy, these investigations allow to select the optimal operative strategy for multifocal and complexe lesions. Surgical objective is a total resection of endometriomas, to guarantee symptom relief and avoid recurrence. Difficulties in these procedures are usually due to fibrotic and vascularised lesions and associated gynaecological disorders. In elective cases, preoperative GH-RH analog hormonal treatment makes easier the surgical procedure. Colonic and/or rectal restorative resections, performed through laparoscopic approach or more frequently through laparotomy, have to be done acccording to the usual standards of colorectal surgery. Conservative surgery of the ovaries is mandatory in premenopausal patients.

Colonic J pouch reconstruction of the radiation-damaged neorectum.

Postoperative radiotherapy after restorative resection for rectal carcinoma can cause fibrosis, stricture and proctitis. There are few accounts in the literature of the surgical approach to the radiation-damaged neorectum. Reported are four patients who underwent resection of the radiation-damaged neorectum with colonic J pouch reconstruction between September 1996 and July 1997. The operative and postoperative course is described. Parameters of bowel function were assessed by standardized interview 6 months after ileostomy reversal. Ongoing follow up has occurred to the present time. There was no mortality. Complications were splenic injury requiring splenectomy and a pelvic collection requiring percutaneous drainage. At 6 months after ileostomy reversal all patients had ongoing disturbance of bowel function, and two patients described some degree of incontinence. The mean frequency of bowel actions was four per day. Two patients have subsequently undergone further resection and formation of an end stoma. Resection of the radiation-damaged neorectum with colonic J pouch reconstruction is technically feasible. Functional results in the present series were disappointing and half the patients went on to formation of a permanent stoma.

Human defunctionalized colon: a histopathological and pharmacological study of muscularis propria in resection specimens.

Despite the regression of "diversion colitis," temporary functional disorders after bowel continuity restoration could be caused by changes in the smooth muscle of excluded segments; however, studies on the muscularis propria have yielded contradictory results. This study was aimed at evaluating possible histopathological changes in muscular layers and motility of the defunctionalized human colon. Ten patients with defunctionalized colorectum (group A) and 10 controls (group B) underwent restorative or primary resection surgery. Strips were taken proximal to the colostomy (specimens A1) and the defunctionalized segment (specimens A2), and from the proximal (specimens B1) and distal extremity (specimens B2) of resected colons. Measurements of the thickness of the muscularis propria and of the volume density of the myenteric plexus, as well as of spontaneous motility and responses to electrical and pharmacological stimulation were taken. The muscularis propria was thicker in A2 than in A1 specimens (P = 0.004) and in B2 than in B1 specimens (P = 0.007). No differences were recorded either in the myenteric plexus volume density or in colonic motility. No differences were recorded in intergroup comparisons. As no structural or functional changes related to defunctionalization were found, clinical disorders after colorectal restoration could rather result from underlying colonic pathology and/or incomplete distal colon resection.

Impact of distal clearance margin on oncologic outcome after restorative resection of the rectum.

There is considerable controversy about the distal clearance margin that needs to be maintained beyond the extent of a rectal tumor in order to reduce the risk of local recurrence. We investigated the rate of local recurrence, distant metastases and survival in 87 patients who had undergone radical restorative resection of the rectum for cancer and had been followed up for a median period of over 6 years, and we analyzed the statistical relation (log-rank test for trend) with the length of the distal margin. The distal margin length was divided into three categories: 1 cm, 2 cm, and > or = 3 cm. No significant correlation was found between the length of the distal clearance margin and the oncologic outcome. Taken together, our data suggest that if the resection line distally falls on healthy tissue, there is no need to resect additional rectum in order to achieve a better outcome.