Symptomatic Anastomotic Leakage Research Articles

Predictors for temporary stomas non-closure among non-metastatic rectal cancer patients undergoing curative resection: a retrospective analysis

BackgroundThe primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop a predictive model for stoma non-closure in rectal cancer patients who underwent curative-intent low anterior resection.MethodsConsecutive patients diagnosed with non-metastatic rectal cancer between January 2005 and December 2017, who underwent low anterior resection, were retrospectively included in the Chang Gung Memorial Foundation Institutional Review Board. A comprehensive evaluation and analysis of potential risk factors linked to stoma non-closure were performed.ResultsOut of 956 patients with temporary stomas, 10.3% (n = 103) experienced non-closure primarily due to cancer recurrence and anastomosis-related issues. Through multivariate analysis, several preoperative risk factors significantly associated with stoma non-closure were identified, including advanced age, anastomotic leakage, positive nodal status, high preoperative CEA levels, lower rectal cancer presence, margin involvement, and an eGFR below 30 mL/min/1.73m2. A risk assessment model achieved an AUC of 0.724, with a cutoff of 2.5, 84.5% sensitivity, and 51.4% specificity. Importantly, the non-closure rate could rise to 16.6% when more than two risk factors were present, starkly contrasting the 3.7% non-closure rate observed in cases with a risk score of 2 or below (p < 0.001).ConclusionPrognostic risk factors associated with the non-closure of a temporary stoma include advanced age, symptomatic anastomotic leakage, nodal status, high CEA levels, margin involvement, and an eGFR below 30 mL/min/1.73m2. Hence, it is crucial for surgeons to evaluate these factors and provide patients with a comprehensive prognosis before undergoing surgical intervention.

Preoperative neutrophil-to-lymphocyte ratio predicts symptomatic anastomotic leakage in elderly colon cancer patients: Multicenter propensity score-matched analysis.

The neutrophil-to-lymphocyte ratio (NLR), a composite inflammatory biomarker, is associated with the prognosis in patients with colorectal tumors. However, whether the NLR can be used as a predictor of symptomatic postoperative anastomotic leakage (AL) in elderly patients with colon cancer is unclear. To assess the role of the NLR in predicting the occurrence of symptomatic AL after surgery in elderly patients with colon cancer. Data from elderly colon cancer patients who underwent elective radical colectomy with anastomosis at three centers between 2018 and 2022 were retrospectively analyzed. Receiver operating characteristic curve analysis was performed to determine the best predictive cutoff value for the NLR. Twenty-two covariates were matched using a 1:1 propensity score matching method, and univariate and multivariate logistic regression analyses were used to determine risk factors for the development of postoperative AL. Of the 577 patients included, 36 (6.2%) had symptomatic AL. The optimal cutoff value of the NLR for predicting AL was 2.66. After propensity score matching, the incidence of AL was significantly greater in the ≥ 2.66 NLR subgroup than in the < 2.66 NLR subgroup (11.5% vs 2.5%; P = 0.012). Univariate logistic regression analysis revealed statistically significant correlations between blood transfusion intraoperatively and within 2 d postoperatively, preoperative albumin concentration, preoperative prognostic nutritional index, and preoperative NLR and AL occurrence (P < 0.05); multivariate logistic regression analysis revealed that an NLR ≥ 2.66 [odds ratio (OR) = 5.51; 95% confidence interval (CI): 1.50-20.26; P = 0.010] and blood transfusion intraoperatively and within 2 d postoperatively (OR = 2.52; 95%CI: 0.88-7.25; P = 0.049) were risk factors for the occurrence of symptomatic AL. A preoperative NLR ≥ 2.66 and blood transfusion intraoperatively and within 2 d postoperatively are associated with a higher incidence of postoperative symptomatic AL in elderly patients with colon cancer. The preoperative NLR has predictive value for postoperative symptomatic AL after elective surgery in elderly patients with colon cancer.

High-output stoma is a risk factor for stoma outlet obstruction in defunctioning loop ileostomies after rectal cancer surgery.

Defunctioning loop ileostomy has been reported to reduce symptomatic anastomotic leakage after rectal cancer surgery; however, stoma outlet obstruction (SOO) is a serious postileostomy complication. We, therefore, explored novel risk factors for SOO in defunctioning loop ileostomy after rectal cancer surgery. This is a retrospective study that included 92 patients who underwent defunctioning loop ileostomy with rectal cancer surgery at our institution. Among them, 77 and 15 ileostomies were created at the right lower abdominal and umbilical sites, respectively. We defined the output volumeMAX as the maximum output volume the day before the onset of SOO or-for those without SOO-that was observed during hospitalization. Univariate and multivariate analyses were performed to evaluate risk factors for SOO. SOO was observed in 24 cases, and the median onset was 6days postoperatively. The stoma output volume in the SOO group was consistently higher than that in the non-SOO group. In the multivariate analysis, the rectus abdominis thickness (p < 0.01) and output volumeMAX (p < 0.01) were independent risk factors for SOO. A high-output stoma may predict SOO in patients with defunctioning loop ileostomy for rectal cancer. Considering that SOO occurs even at umbilical sites with no rectus abdominis, a high-output stoma may trigger SOO primarily.

Neutrophil-to-Lymphocyte Ratio as an Early Predictor of Symptomatic Anastomotic Leakage in Patients after Rectal Cancer Surgery: A Propensity Score-Matched Analysis.

Background: This study aimed to explore the role of postoperative neutrophil-to-lymphocyte ratio in predicting symptomatic anastomotic leakage in patients who underwent laparoscopic low anterior resection for rectal cancer. Methods: In this retrospective cohort study, we analyzed data of patients who underwent laparoscopic low anterior resection from May 2009 to May 2019. A receiver operating characteristic curve analysis was performed to evaluate the cut-off values with the best predictive efficacy of a symptomatic anastomotic leakage. In addition, a propensity score-matched analysis was performed by considering all covariate variables, and 61 patients with or without symptomatic anastomotic leakage were included in the analysis. Results: The present study included 306 patients; of these, 17 (5.56%) developed symptomatic anastomotic leakage after surgery. On postoperative day 5, compared with patients without symptomatic anastomotic leakage, those with leakage had significantly higher neutrophil-to-lymphocyte levels. Notably, a neutrophil-to-lymphocyte cut-off score of 6.54 indicated the best area under the curve of 0.818 (95% confidence interval: 0.697−0.940, p < 0.001) in predicting symptomatic anastomotic leakage, with a sensitivity and specificity of 76.5% and 79.4%, respectively. Conclusions: Although evidence for the predictive role of neutrophil-to-lymphocyte ratio is accumulating, it remains inconclusive. In addition, neutrophil-to-lymphocyte levels should be considered a predictive biomarker for symptomatic anastomotic leakage; however, it can more accurately be viewed as an adjunct that helps increase the clinical suspicion of emerging symptomatic anastomotic leakage.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients.

Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients. A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019. The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001). The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.

Perpetuation of defunctioning stoma: risk factors and countermeasures

Defunctioning stoma is an effective method to reduce symptomatic anastomotic leakage after rectal cancer surgery. It is of concern that about 1 in 5 defunctioning stomas will not be restored, that is, becoming permanent. And that is usually beyond expectation by physicians and patients, which deserves enough attention. The causes are complex, including anastomotic complications, tumor progression, perioperative death, poor anal function and patient willingness. Possible risk factors include symptomatic anastomotic leakage, age, tumor location, neoadjuvant therapy, anal function, TNM stage, ASA score, hospital factors, etc. Those factors may occur in various stages of patient referral such as before neoadjuvant therapy, prior to surgery, intra or post-operative period, and follow-up. Adequate physician-patient communication and shared decision-making, comprehensive tumor and patient function assessment, rational treatment strategy, careful manipulation during operation and good quality control, and meticulous perioperative management are important steps to reduce the permanent stoma. When shared decision-making, patients' needs should be fully considered while unnecessary expectations of anal preservation should be avoided. The risk of perpetuation of defunctioning stoma should be fully informed. Safe operation, especially anastomosis, is the key to avoid permanent stoma. And attention should be paid to the early detection and intervention of postoperative anastomotic stenosis.

Novel surgical procedure for preventing anastomotic leakage following colorectal cancer surgery: A propensity score matching study.

Hypoperfusion is the main cause of anastomotic leakage (AL) following colorectal surgery. The conventional method for evaluating anastomotic perfusion is to observe color change and active bleeding of the resection margin of the intestine and the pulsation of mesenteric vessels. However, the accuracy of this method is low, which may be due to insufficient observation time. A novel surgical procedure that separates the mesentery in advance at the intended transection site can delay the observation of anastomotic perfusion, and can potentially detect more anastomotic sites with insufficient vascular supply and reduce the rate of AL. This study aimed to investigate the effects of a novel surgical procedure on AL following sigmoid colon and rectal cancer surgeries. A total of 343 patients who underwent rectal and sigmoid colon cancer surgeries were included in the study. From August 2021 to June 2022, patients with sigmoid colon or rectal cancer underwent a new surgical procedure of pre-division of the mesentery (PDM) at the intended transection site (PDM group). Patients with colorectal cancer who underwent conventional surgical procedures from August 2018 to July 2021 were categorized as the non-PDM group. Symptomatic AL (SAL) within 30 days and other outcomes were retrospectively analyzed using propensity score matching and compared between the two groups. The incidences of SAL were 1.3% and 11.3% in the PDM and non-PDM groups, respectively. PDM significantly reduced the SAL rate in sigmoid colon and rectal cancer surgeries (P = 0.009). The incidence of total postoperative complications (P < 0.05) was significantly lower in the PDM group than that in the non-PDM group. There were no significant differences between the two groups for operative time (P = 0.662), intraoperative blood loss (P = 0.651), intraoperative blood transfusion (P = 0.316), and intensive care rate (P = 1). The length of postoperative hospital stay (P = 0.010) and first exhaust (P = 0.001) and defecation time (P < 0.05) were shorter in the PDM group than in the non-PDM group. PDM can effectively prevent AL, and this procedure can be safely performed in sigmoid colon and rectal cancer surgeries.

The impact of multiple firings on the risk of anastomotic leakage after minimally invasive restorative rectal cancer resection and the impact of anastomotic leakage on long-term survival: a population-based study.

The aim of this study was to evaluate the anastomotic leakage (AL) rate and predictors for AL following minimally invasive restorative rectal resection (RRR) among rectal cancer patients managed according to up-to-date standardized treatment. Furthermore, we explored the impact of symptomatic AL on long-term survival. The study cohort was rectal cancer patients undergoing minimally invasive RRR in Central Denmark Region between 2013 and 2017. Data was retrieved from a prospective clinical quality database and supplemented with data from medical records. The AL rate was calculated as the proportion of patients who developed symptomatic AL within 30days. Predictors for AL were identified through logistic regression. The impact of AL on long-term survival was analyzed using Kaplan-Meier methods and Cox regression. AL occurred in 15.1% of 604 patients. The AL rate for males was 20.1% (95% CI 16.3-24.3) and 5.0% (95% CI 2.4-9.0) for females. Odds ratio (OR) of AL in females vs. males was 0.25 (95% CI 0.12-0.51). The use of at least three firings when transecting the rectum was associated with OR of 2.71 (95% CI 1.17-6.26) for AL. The 5-year survival for patients with vs. those without AL was 76.1% (95%CI 65.1-84.0) and 83.6% (95%CI 79.8-86.7), corresponding to adjusted hazard ratio of 1.43 (95%CI 0.84-2.41). Symptomatic AL is still a challenge in a standardized setting using minimally invasive surgery in rectal cancer patients undergoing RRR, especially in men. Multiple firings should be avoided in transection of the rectum with an endoscopic stapler. AL had a statistical non-significant negative impact on survival.

Correlation between Colon Perfusion and Postoperative Fecal Output through a Transanal Drainage Tube during Laparoscopic Low Anterior Resection.

Simple SummaryAnastomotic leakage (AL) is a major problem in patients who undergo operations for rectal cancers. Various solutions, such as ICG angiography and transanal drainage tubes (TDT), have been proposed to prevent AL. Although the microbiota has recently been recognized to play a role in the pathogenesis of AL, mainly from the results of experimental animal models, it remains unclear whether this mechanism can occur in humans. In this study, we investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection, and found that the need of a proximal shift of the transection site due to insufficient intestinal perfusion was significantly associated with high fecal volume, which might reflect the correlation between intestinal perfusion and postoperative diarrhea. In addition, we found that the intensity of ICG fluorescence at the transection site was significantly associated with fecal volume through TDT. To the best of our knowledge, this is the first clinical study to examine the relationship between intestinal perfusion and fecal volume through TDT. In order to prevent anastomotic leakage (AL) following rectal surgery, various solutions—such as intraoperative indocyanine green (ICG) angiography and transanal drainage tubes (TDT)—have been proposed. This study investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection (LAR). A total of 59 rectal cancer patients who underwent laparoscopic LAR with both intraoperative ICG angiography and postoperative TDT placement were retrospectively analyzed. The relationship between intestinal perfusion and fecal volume through TDT was examined. Based on the ICG fluorescence, the transection site was shifted more proximally in 20 cases (33.9%). Symptomatic AL occurred in seven patients (11.8%). The AL rate of the patients whose daily fecal volume exceeded 100 mL/day in 2 or more days was significantly higher than that of those whose daily fecal volume exceeded it in 0 or 1 day (44.4% vs. 6.0%; p < 0.01). Univariate and multivariate analyses showed that the need for a proximal shift of the transection site was significantly associated with a high fecal volume. The quantitative analysis of ICG fluorescence indicated that Fmax (the fluorescence difference between the baseline and maximum) was significantly associated with fecal volume through TDT.

Evaluation of the SafeHeal Colovac+ Anastomosis Protection Device: A Preclinical Study.

BackgroundThe protective ostomy is the current standard of care to protect a low colorectal anastomosis from leakage, but exposes patients to complications requiring an alternative strategy. The Colovac+ is a vacuum-based intraluminal bypass device designed to shield the anastomosis from fecal content, preventing the clinical outcomes of anastomotic leakage. The objective of this study was to evaluate the preliminary efficacy, safety, and technical feasibility of the Colovac+ in a porcine model. Methods: Twelve pigs received a colorectal anastomosis with Colovac+ implantation. The device was left in situ for 10 days and then retrieved endoscopically. Six pigs were to be sacrificed immediately after device retrieval and the other 6 were to be sacrificed on day 38. Clinical, endoscopic, and histopathological examinations were performed to evaluate the following endpoints: prevention of contact between the anastomosis and fecal content, device migration, feasibility of the implantation and retrieval procedure, collateral damage to the colonic wall, colon healing after device retrieval, and systemic toxicity related to the device. Results: Eleven pigs completed the study. One pig died prematurely due to a surgical complication unrelated to the device (bladder damage with uroperitoneum). There was no evidence of contact between the anastomosis and fecal content, none of the pigs developed symptomatic anastomotic leakage, there were no significant device migrations, and there was no evidence of systemic toxicity. Colovac+ implantation was easily performed in all cases except 1 (due to an inappropriate lubricant). Colovac+ retrieval was achieved successfully in all cases. Postretrieval examinations on day 10 revealed ulcerations at the anchoring site in 4 cases indicating mechanical damage caused by the stent. However, in the recovery group, no ulcerations were observed on day 38, and the colonic wall had properly healed in all animals. Conclusions: The Colovac+ is a technically feasible, safe, and efficient device for the protection of a colorectal anastomosis in a porcine model. The device holds promise for clinical use and warrants further research.

Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort.

Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA). In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded. Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p=0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p=0.064), disease-free survival was 67.0% and 55.8%, respectively (p=0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p=0.084). The long-term, stoma-free rate was 89.1% overall. Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.

Risk factors of symptomatic anastomotic leakage and its impacts on a long-term survival after laparoscopic low anterior resection for rectal cancer: a retrospective single-center study

BackgroundPostoperative symptomatic anastomotic leakage (AL) is a serious complication after low anterior resection (LAR) for rectal cancer. AL can potentially affect short-term patient outcomes and long-term prognosis. This study aimed to explore the risk factors and long-term survival of symptomatic AL after laparoscopic LAR for rectal cancer.MethodsFrom May 2009 to May 2015, 298 consecutive patients who underwent laparoscopic LAR for rectal cancer with or without a defunctioning stoma were included in this study. Univariate and multivariate logistic regression analyses were used to explore independent risk factors for symptomatic AL. Survival analysis was performed using Kaplan–Meier curves, and log-rank tests were used for group comparisons.ResultsAmong the 298 patients enrolled in this study, symptomatic AL occurred in eight (2.7%) patients. The univariate analysis showed that age of ≤65 years (P = 0.048), neoadjuvant therapy (P = 0.095), distance from the anal verge (P = 0.078), duration of operation (P = 0.001), and pathological tumor (T) category (P = 0.004) were associated with symptomatic AL. The multivariate analysis demonstrated that prolonged duration of operation (P = 0.010) was an independent risk factor for symptomatic AL after laparoscopic LAR for rectal cancer. No statistically significant differences were observed in the 3-year (P = 0.785) and 5-year (P = 0.979) overall survival rates.ConclusionsA prolonged duration of operation increased the risk of symptomatic AL after laparoscopic LAR for rectal cancer. An impact of symptomatic AL on a long-term survival was not observed in this study; however, further studies are required.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (ChiCTR2000033413) on May 31, 2020.

Efficacy of a robotic stapler on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer.

Clinical evidence demonstrating risk factors for anastomotic leakage including robotic staplers has remained limited, even though the use of robotic surgery has increased substantially. The purpose of this study was to evaluate the effects of robotic staplers on symptomatic anastomotic leakage in robotic low anterior resection for rectal cancer. A total of 427 consecutive patients with primary rectal cancer who underwent robotic low anterior resection without diverting stoma were investigated retrospectively. Symptomatic anastomotic leakage was defined as anastomotic leakage of Clavien-Dindo Grade ≥ II. We compared the symptomatic anastomotic leakage rates between manual and robotic staplers using propensity score matching and investigated the risk factors for symptomatic anastomotic leakage. After propensity score matching, 168 pairs of manual and robotic stapler cases were selected. The symptomatic anastomotic leakage rate was significantly higher for manual staplers (6.5%) than for robotic staplers (1.2%, p = 0.02). In a multivariate analysis, the use of a manual stapler (p = 0.04, OR 4.86, 95% CI 1.08-21.8) and anastomosis < 4cm from the anal verge (p < 0.01, OR 4.36, 95% CI 1.48-12.9) were identified as independent risk factors for symptomatic anastomotic leakage. Robotic stapler use was associated with a significantly decreased rate of anastomotic leakage in robotic low anterior resection without diverting stoma for rectal cancer.

Defunctioning stoma and short- and long-term outcomes after low anterior resection for rectal cancer\u2014a nationwide register\u2013based cohort study

PurposeA defunctioning stoma reduces the risk of symptomatic anastomotic leakage after low anterior resection for rectal cancer and mitigates the consequences when a leakage occurs, but the impact on mortality and oncological outcomes is unclear. The aim was to investigate the associations of a defunctioning stoma with short- and long-term outcomes in patients undergoing low anterior resection for rectal cancer.MethodsData from all patients who underwent curative low anterior resection for rectal cancer between 1995 and 2010 were obtained from the Swedish Colorectal Cancer Register. A total of 4130 patients, including 2563 with and 1567 without a defunctioning stoma, were studied. Flexible parametric models were used to estimate hazard ratios for all-cause mortality, 5-year local recurrence, and distant metastatic disease in relation to the use of defunctioning stoma, adjusting for confounding factors and accounting for potential time-dependent effects.ResultsDuring a median follow-up of 8.3 years, a total of 2169 patients died. In multivariable analysis, a relative reduction in mortality was observed up to 6 months after surgery (hazard ratio = 0.82: 95% CI 0.67–0.99), but not thereafter. After 5 years of follow-up, 4.2% (173/4130) of the patients had a local recurrence registered and 17.9% (741/4130) had developed distant metastatic disease, without difference between patients with and without defunctioning stoma.ConclusionA defunctioning stoma is associated with a short-term reduction in all-cause mortality in patients undergoing low anterior resection for rectal cancer without any difference in long-term mortality and oncological outcomes, and should be considered as standard of care.

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.

What is the risk of permanent stoma beyond 5years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial.

Low anterior resection of the rectum for cancer (LAR) entails a risk of symptomatic anastomotic leakage as well as impaired anorectal function, both of which may eventually result in the need for a permanent stoma (PS). The aim was to investigate the incidence of and risk factors for PS beyond 5years following LAR. Patients undergoing LAR and included in a multicentre trial with randomization to defunctioning stoma or not were followed for a median of 15years. The reasons for a PS up to 5years (PS≤5years) and beyond 5years (PS >5years) were identified and compared. Risk factors for PS were analysed. Of all patients, 25% (57/232) had a PS. PS≤5years occurred in 19% (44/232) at a median of 12.5months and PS >5years in 6% (13/232) at a median of 118months following LAR. The main reason for PS≤5years was impaired anorectal function in 55% (24/44) and the main reason for PS >5years was pelvic sepsis related to the colorectal anastomosis in 46% (6/13). The major risk factor for PS was symptomatic anastomotic leakage, which occurred in 56% (32/57) of patients with PS and 10% (17/175) of patients without PS (P<0.001). One-fourth of the patients who ended up with a PS had it fashioned beyond 5years at a median of 10years following LAR. Symptomatic anastomotic leakage was the major risk factor for PS, and impaired anorectal function was the main overall reason for a PS.

Long term outcome of anastomotic leakage in patients undergoing low anterior resection for rectal cancer

BackgroundThe influence of anastomotic leakage (AL) on local recurrence rates and survival in rectal cancer remains controversial. The aim of this study was to analyze the effect of asymptomatic anastomotic leakage (AAL) and symptomatic anastomotic leakage (SAL) on short- and long-term outcome after curative rectal cancer resection.MethodsAll patients who underwent surgical resection of non-metastatic rectal cancer with curative intent from January 2005 to December 2017 were retrospectively analyzed. Short-term morbidity, long-term functional and oncological outcomes were compared between patients with SAL, AAL and without AL (WAL).ResultsOverall, 200 patients were included and AL was observed in 39 (19.5%) patients (10 AAL and 29 SAL) with a median follow-up of 38.5 months. Rectal cancer location and preoperative neoadjuvant treatment was similar between the three groups. Postoperative 30-day mortality rate was nil. The permanent stoma rate was higher in patients with SAL or AAL compared to WAL patients (44.8 and 30% vs 9.3%, p < 0.001). The mean wexner continence grading scale was significantly different between AAL (11,4 ± 3,8), SAL (10,3 ± 0,6) and WAL (6,4 ± 4,7) groups (p = 0.049). The 3 and 5-year overall and disease-free survival rates were similar between the 3 groups (86.6% /84% vs 100%/100% vs 76%/70 and 82.9%/77% vs 100%/100% vs 94.7%/88.3% for patients with SAL, AAL, and WAL, p = 0.480 and p = 0.527).ConclusionThe permanent stoma rate was significant higher in patients with SAL or AAL compared to WAL patients. AL did not impair long-term oncological outcome.

Assessment of the risk of permanent stoma after low anterior resection in rectal cancer patients

BackgroundOne of the most severe complications of low anterior rectal resection is anastomotic leakage (AL). The creation of a loop ileostomy (LI) reduces the prevalence of AL requiring surgical intervention. However, up to one-third of temporary stomas may never be closed.The first aim of the study was to perform a retrospective assessment of the impact of LI on the risk of permanent stoma (PS) and symptomatic AL. The second aim of the study was to assess preoperative PS risk factors in patients with LI.MethodsA total of 286 consecutive patients who underwent low anterior rectal resection were subjected to retrospective analysis. In 101 (35.3%) patients, diverting LI was performed due to low anastomosis, while in the remaining 185 (64.7%) patients, no ileostomy was performed. LIs were reversed after adjuvant treatment. Analyses of the effect of LI on symptomatic AL and PS were performed. Among the potential risk factors for PS, clinical factors and the values of selected peripheral blood parameters were analysed.ResultsPS occurred in 37.6% and 21.1% of the patients with LI and without LI, respectively (p < 0.01). Symptomatic ALs were significantly more common in patients without LI. In this group, symptomatic ALs occurred in 23.8% of patients, while in the LI group, they occurred in 5% of patients (p < 0.001). In the LI group, the only significant risk factor for PS in the multivariate analysis was preoperative plasma fibrinogen concentration (OR = 1.007, 97.5% CI 1.002–1.013, p = 0.013).ConclusionsAlthough protective LI may reduce the incidence of symptomatic AL, it can be related to a higher risk of PS in this group of patients. The preoperative plasma fibrinogen concentration can be a risk factor for PS in LI patients and may be a useful variable in decision-making models.

Effectiveness of a Transanal Drainage Tube for the Prevention of Anastomotic Leakage after Laparoscopic Low Anterior Resection for Rectal Cancer.

Background and Objective:Anastomotic leakage is one of the most serious complications after laparoscopic low anterior resection Low Anterior Resection (LAR) for rectal cancers. The purpose of this study was to evaluate the effectiveness of a transanal drainage tube placed for the prevention of anastomotic leakage after laparoscopic LAR. Methods:The clinical data of 220 patients with rectal cancer who underwent laparoscopic LAR using the double stapling technique Double Stapling Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Technique (DST) from Jun 2017 to Dec 2018 were analyzed retrospectively at our institution. A transanal drainage tube was placed after anastomosis in 120 patients (TDT group). Another 100 patients were operated on without a transanal drainage tube (NTDT group). Clinicopathological and surgical factors, the frequencies of anastomotic leakage and re-operation after leakage were compared between the two groups. Results:Patient age, gender, body mass index, American Society of Anesthesiologists (ASA) score, previous abdominal surgery, intraoperative blood loss, tumor size, tumor stage, specimen length, distance of tumor from the anal verge, and operative time were comparable between the two groups. Overall rate of leakage was 4.5% (10/220). The frequency of leakage was 3.3% (4/120) in TDT group and was 6.0% (6/100) in NTDT group. The rate of leakage was significantly lower in TDT group (p<0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 50.0% (2/4) in TDT group, while in contrast it was 83.3% (5/6) in NTDT group. The rate of re-operation was lower in TDT group than NTDT group (p<0.05). Conclusions:The use of a transanal drainage tube in laparoscopic LAR for rectal cancer is a simple and effective method for prevention of anastomotic leakage and decreases the rate of re-operation after symptomatic leakage.