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Wang G, Tang H, Huang Y, Guo Y. Efficacy of transanal drainage tubes in postoperative anastomotic leakage in patients with laparoscopic anterior rectal resection without diverting stoma. Sci Rep 2025; 15:18834. [PMID: 40442271 PMCID: PMC12122800 DOI: 10.1038/s41598-025-03440-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2024] [Accepted: 05/20/2025] [Indexed: 06/02/2025] Open
Abstract
To assess whether transanal drainage tubes (TDT) protect against anastomotic leakage (AL) in patients without diverting stomas (DS) after laparoscopic anterior rectal resection (LAR). In the TDT group, after anastomosis of the sigmoid colon to the rectum, a 32F silicone tube was inserted through the anus with the tip of the tube exceeding the anastomosis by more than 5 cm. The tube was secured around the anus with a skin suture and a drainage bag was attached. It was left in place for 3-5 days postoperatively in the TDT group. In the No-TDT group, no transanal silicone tube drainage was used after the anastomosis. A total of 927 patients (620 in the no-TDT group and 307 in the TDT group) were included in the analysis, and a total of 50 (5.4%) patients were observed to develop AL. After using propensity score matching (PSM) to reduce baseline feature imbalances between the two groups, there were 287 patients in both groups, and the mean retention time of TDT was (4.7 ± 1.2) d. The incidence of AL in the TDT group was significantly lower than that in the no-TDT group (3.8% vs. 8.0%, with a the incidence of AL in the TDT group was significantly lower than that in the non-TDT group (3.8% vs. 8.0%, P = 0.034), but the incidence of AL classification was similar (P = 0.709). There were no significant differences between the two groups in terms of postoperative complications and postoperative recovery. Multivariate logistic regression analysis revealed that TDT was found to be an independent protective factor for postoperative AL (OR 0.437, 95% CI 0.207-0.923, P = 0.030). The elective use of TDT is a simple and effective protective measure for the prevention of AL in patients without stoma after LAR surgery, helping to reduce the probability of AL. This may be a potential alternative DS method for the appropriate population.
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Affiliation(s)
- Guancong Wang
- Department of Colorectal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
- Department of Colorectal and Anal Surgery, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, 363000, China
| | - Haiwen Tang
- Department of Colorectal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
- Department of General Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
| | - Yincong Guo
- Department of Colorectal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China.
- Department of Colorectal and Anal Surgery, Zhangzhou Municipal Hospital of Fujian Province, Zhangzhou, 363000, China.
- Department of Colorectal and Anal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000, China.
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Huang X, Zheng L, Wu H, Li X, Song C. The feasibility and safety of deeply inserted enema tubes for acute malignant left-hemicolon obstruction: an alternative solution in developing countries. Front Oncol 2025; 15:1522138. [PMID: 40270604 PMCID: PMC12014448 DOI: 10.3389/fonc.2025.1522138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 03/24/2025] [Indexed: 04/25/2025] Open
Abstract
Background and aims Disposable enema kits are commonly used for bowel preparation, with the anal tube typically positioned near the rectal ampulla. This study assesses the feasibility and safety of deeply inserting an enema tube in cases of acute malignant left-hemicolon obstruction. Methods A retrospective analysis was conducted on 42 patients who underwent emergency endoscopic decompression via a deeply inserted enema tube for acute malignant left-hemicolon obstruction from January 2021 to September 2024 at a single center, the Endoscopy Centre of the Affiliated Hospital of Putian University. This analysis covered intubation duration, the success rate of intubation, the obstruction relief rate, as well as associated adverse events. Results Thirty-six patients achieved successful tube placement, attaining a one-time success rate of 85.7% (36/42). Following successful intubation, the abdominal circumference decreased to a mean of (85.2 ± 3.0)% of the original value on the subsequent day (P < 0.01). Abdominal plain films depicted a significant reduction in both the quantity of gas-fluid levels and the maximal transverse diameter of the proximally obstructed colon [(4.5 ± 1.2) cm versus (7.4 ± 0.8) cm, P < 0.01]. Within 48 hours, C-reactive protein (CRP) levels plummeted by over 50%, and bowel sounds normalized within 2 - 5 days. During surgery, the bowel exhibited only slight or negligible dilation and edema, with no conspicuous fecal residues detected in the colonic cavity. Furthermore, no severe tube-related adverse events occurred either during or after intubation. Conclusion The application of deeply inserted enema tubes proves to be both feasible and safe in treating acute malignant left-hemicolon obstruction, thus presenting itself as a viable alternative approach in developing countries.
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Affiliation(s)
- Xinxiang Huang
- Gastrointestinal Endoscopy Center, The Affiliated Hospital of Putian University, Putian, Fujian, China
| | - Lijuan Zheng
- Gastrointestinal Endoscopy Center, The Affiliated Hospital of Putian University, Putian, Fujian, China
| | - Huifeng Wu
- Gastrointestinal Endoscopy Center, The Affiliated Hospital of Putian University, Putian, Fujian, China
| | - Xiaomei Li
- School of Basic Medicine, Putian University, Putian, Fujian, China
- Key Laboratory of Translational Tumor Medicine in Fujian Province, Putian University, Putian, Fujian, China
| | - Conghua Song
- Gastrointestinal Endoscopy Center, The Affiliated Hospital of Putian University, Putian, Fujian, China
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Jones M, Moran B, Heald RJ, Bunni J. Can the Heald anal stent help to reduce anastomotic or rectal stump leak in elective and emergency colorectal surgery? A single-center experience. Ann Coloproctol 2024; 40:82-85. [PMID: 38414124 PMCID: PMC10915531 DOI: 10.3393/ac.2023.00038.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 02/29/2024] Open
Abstract
Anastomotic and rectal stump leaks are feared complications of colorectal surgery. Diverting stomas are commonly used to protect low rectal anastomoses but can have adverse effects. Studies have reported favorable outcomes for transanal drainage devices instead of diverting stomas. We describe our use of the Heald anal stent and its potential impact in reducing anastomotic or rectal stump leak after elective or emergency colorectal surgery. We performed a single-center retrospective analysis of patients in whom a Heald anal stent had been used to "protect" a colorectal anastomosis or a rectal stump, in an elective or emergency context, for benign and malignant pathology. Intraoperative and postoperative outcomes were reviewed using clinical and radiological records. The Heald anal stent was used in 93 patients over 4 years. Forty-six cases (49%) had a colorectal anastomosis, and 47 (51%) had an end stoma with a rectal stump. No anastomotic or rectal stump leaks were recorded. We recommend the Heald anal stent as a simple and affordable adjunct that may decrease anastomotic and rectal stump leak by reducing intraluminal pressure through drainage of fluid and gas.
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Affiliation(s)
- Michael Jones
- Department of Colorectal Surgery, Royal United Hospital, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Brendan Moran
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Richard John Heald
- Pelican Cancer Foundation, Basingstoke, UK
- Colorectal Surgery, Champalimaud Foundation, Lisbon, Portugal
| | - John Bunni
- Department of Colorectal Surgery, Royal United Hospital, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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Sueda T, Tei M, Mori S, Nishida K, Yasuyama A, Nomura M, Yoshikawa Y, Tsujie M. Clinical Impact of Transanal Drainage Tube on Anastomosis Leakage Following Minimally Invasive Resection Without Diverting Stoma in Patients With Rectal Cancer: A Propensity Score-matched Analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:608-616. [PMID: 37852234 DOI: 10.1097/sle.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/09/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES As one of the most serious complications of rectal cancer (RC) surgery, preventing anastomotic leakage (AL) is crucial. Several studies have suggested a positive role of the transanal drainage tube (TaDT) in AL prevention. However, whether TaDT is beneficial for AL in patients with RC remains controversial. The present study aimed to evaluate the clinical impact of TaDT on AL following minimally invasive resection without diverting stoma (DS) in patients with RC. MATERIALS AND METHODS We retrospectively analyzed 392 consecutive patients with RC who had undergone minimally invasive resection without DS between 2010 and 2021. Propensity score matching (PSM) was performed to reduce selection bias. AL was classified as grade A, B, or C. RESULTS A TaDT was used in 214 patients overall. After PSM, we enrolled 316 patients (n=158 in each group). Before PSM, significant group-dependent differences were observed in terms of age, American Society of Anesthesiologists physical status, and the use of antiplatelet/anticoagulant agents. The frequency of AL was 7.3% in the overall cohort and was significantly lower in the TaDT group (3.7%) than in the non-TaDT group (11.8%). The rate of grade B AL was significantly lower in the TaDT group than in the non-TaDT group (before PSM, P <0.01; after PSM, P =0.02). However, no significant differences between groups were found for grade C AL. Moreover, multivariate analysis identified the lack of a TaDT as an independent risk factor for AL in the overall and matched cohorts [before PSM, odds ratio, 3.64, P <0.01; after PSM, odds ratio, 2.91, P =0.02]. CONCLUSION These results indicated that TaDT may play a beneficial role in preventing AL, particularly of grade B, for patients with RC undergoing minimally invasive resection without DS. However, further randomized controlled trials, including patient-reported outcomes, are still needed to understand better the role of TaDT in preventing ALs in patients with RC undergoing minimally invasive resection without DS.
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Piozzi GN, Khobragade K, Aliyev V, Asoglu O, Bianchi PP, Butiurca VO, Chen WTL, Cheong JY, Choi GS, Coratti A, Denost Q, Fukunaga Y, Gorgun E, Guerra F, Ito M, Khan JS, Kim HJ, Kim JC, Kinugasa Y, Konishi T, Kuo LJ, Kuzu MA, Lefevre JH, Liang JT, Marks J, Molnar C, Panis Y, Rouanet P, Rullier E, Saklani A, Spinelli A, Tsarkov P, Tsukamoto S, Weiser M, Kim SH. International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome. Colorectal Dis 2023; 25:1896-1909. [PMID: 37563772 DOI: 10.1111/codi.16704] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023]
Abstract
AIM Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future. METHOD A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol. RESULTS Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements. CONCLUSION This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.
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Affiliation(s)
| | | | - Vusal Aliyev
- Bogazici Academy for Clinical Sciences, Istanbul, Turkey
| | - Oktar Asoglu
- Bogazici Academy for Clinical Sciences, Istanbul, Turkey
| | | | - Vlad-Olimpiu Butiurca
- University of Medicine, Pharmacy Science, and Technology 'G.E. Palade', Târgu-Mureș, Romania
| | | | | | - Gyu-Seog Choi
- Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Andrea Coratti
- Azienda USL Toscana Sud Est-Misericordia Hospital, Grosseto, Italy
| | | | - Yosuke Fukunaga
- Cancer Institution Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan
| | | | - Francesco Guerra
- Azienda USL Toscana Sud Est-Misericordia Hospital, Grosseto, Italy
| | - Masaaki Ito
- National Cancer Center Hospital East, Chiba, Japan
| | - Jim S Khan
- University of Portsmouth, Portsmouth, UK
| | - Hye Jin Kim
- Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Jin Cheon Kim
- University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | | | - Tsuyoshi Konishi
- M.D. Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Li-Jen Kuo
- Taipei Medical University Hospital, Taipei City, Taiwan
| | | | - Jeremie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Jin-Tung Liang
- National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | | | - Călin Molnar
- University of Medicine, Pharmacy Science, and Technology 'G.E. Palade', Târgu-Mureș, Romania
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly, Seine, France
| | | | - Eric Rullier
- Bordeaux University Hospital, Haut-Leveque Hospital, Pessac, France
| | | | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Petr Tsarkov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Martin Weiser
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Seon Hahn Kim
- Korea University Anam Hospital, Seoul, Korea
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Fujino S, Yasui M, Ohue M, Miyoshi N. Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis. World J Gastrointest Surg 2023; 15:1202-1210. [PMID: 37405086 PMCID: PMC10315128 DOI: 10.4240/wjgs.v15.i6.1202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/21/2023] [Accepted: 04/25/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) following rectal cancer surgery is an important cause of mortality and recurrence. Although transanal drainage tubes (TDTs) are expected to reduce the rate of AL, their preventive effects are controversial. AIM To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery. METHODS A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases. We included randomized controlled trials (RCTs) and prospective cohort studies (PCSs) in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated. The results of the studies were synthesized using the Mantel-Haenszel random-effects model, and a two-tailed P value > 0.05 was considered statistically significant. RESULTS Three RCTs and two PCSs were included in this study. Symptomatic AL was examined in all 1417 patients (712 with TDT), and TDTs did not reduce the symptomatic AL rate. In a subgroup analysis of 955 patients without a diverting stoma, TDT reduced the symptomatic AL rate (odds ratio = 0.50, 95% confidence interval: 0.29-0.86, P = 0.012). CONCLUSION TDT may not reduce AL overall among patients undergoing rectal cancer surgery. However, patients without a diverting stoma may benefit from TDT placement.
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Affiliation(s)
- Shiki Fujino
- Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masayoshi Yasui
- Department of Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Norikatsu Miyoshi
- Innovative Oncology Research and Regenerative Medicine, Osaka International Cancer Institute, Osaka 541-8567, Japan
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Wang W, Zhang J, Cai J, Zhao X, Wang F. Transanal drainage tube for the prevention of anastomotic leakage in anterior resection for rectal cancer: a systematic review and meta-analysis. Expert Rev Anticancer Ther 2023; 23:431-442. [PMID: 36772974 DOI: 10.1080/14737140.2023.2179991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To evaluate the ability of the transanal drainage tube (TDT) to prevent anastomotic leakage (AL) and provide clinicians with the latest evidence in this area. MATERIALS AND METHODS We search for relevant studies according to a search strategy. Data extracted from the study were analyzed using RevMan 5.4 software. RESULTS Fourteen eligible studies were included in our meta-analysis. The results of this meta-analysis suggest that patients with TDT placement have a lower incidence of AL than those without TDT placement (6% vs. 9.1%) (RR = 0.58, 95% CI: 0.46, 0.73, P < 0.00001). However, pooled results from RCTs suggest that TDT does not appear to reduce the incidence of AL in patients (6.4% vs. 8%) (RR = 0.79, 95% CI 0.52, 1.18, P = 0.24). In addition, the results of the meta-analysis suggest that TDT appears to reduce patient reoperation rates (2.6% vs. 5.8%) (RR = 0.38, 95% CI 0.27, 0.54, P < 0.00001). CONCLUSIONS The results of the RCTs suggest that TDT placement does not reduce the AL rate in patients, however, it is undeniable that the placement of TDT does provide patients with some clinical benefits (such as reduced reoperation rates).
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Affiliation(s)
- Wei Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, Gansu, China
| | - Jianping Zhang
- Department of General Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, Gansu, China
| | - Jumei Cai
- Department of General Surgery, Wuwei Liangzhou Hospital, Wuwei Gansu, China
| | - Xinmin Zhao
- Department of General Surgery, Wuwei Liangzhou Hospital, Wuwei Gansu, China
| | - Fazhi Wang
- Department of General Surgery, Wuwei Liangzhou Hospital, Wuwei Gansu, China
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Toritani K, Kimura H, Goto K, Kunisaki R, Watanabe J, Ishibe A, Endo I. Curable leakage in stapled IPAA has little effect on the long-term pouch function. Int J Colorectal Dis 2023; 38:43. [PMID: 36790510 DOI: 10.1007/s00384-023-04339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
PURPOSE This study aimed to evaluate the frequency and grade of anastomotic leakage (AL) in stapled ileal pouch-anal anastomosis (IPAA) and its long-term impact on the pouch functions. METHODS A longitudinal cohort study was conducted on UC patients who underwent stapled IPAA at Yokohama City University Medical Center between 2007 and 2018. The diagnosis and grading of AL were performed in accordance with the recommendations of the International Study Group of Rectal Cancer. We assessed the functional pouch rate, late complication, pouch survival rate, bowel function (bowel movements per day, soiling, spotting, difficulty in distinguishing feces from flatus) and pouch inflammation (pouchitis disease activity index; PDAI) in the long-term period. RESULTS Two hundred seventy-six patients were analyzed. Twenty-three (8.3%; grade B/C; 13/10) patients were diagnosed with AL, but a functional pouch was achieved in all the twenty-three patients. Anastomotic stricture was significantly more common in patients with AL (AL group) than in patients without AL (non-AL group; AL/non-AL: 13.0/3.2%, p = 0.020). There were no differences in other late complications. Furthermore, the pouch survival rate did not differ between the AL and non-AL groups (100.0/97.9%/10 years, p = 0.494). There were no differences between the groups in bowel movements per day, spotting, soling, difficulty in distinguishing feces from flatus, or PDAI postoperatively. CONCLUSIONS Curable AL may not affect late complications (except anastomotic stricture), pouch survival, the bowel function, or pouch inflammation over the long term. Perioperative management to prevent the severity of AL is as important as preventing its occurrence.
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Affiliation(s)
- Kenichiro Toritani
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.,Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
| | - Koki Goto
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Atsushi Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Brisinda G, Chiarello MM, Pepe G, Cariati M, Fico V, Mirco P, Bianchi V. Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors. World J Clin Cases 2022; 10:13321-13336. [PMID: 36683625 PMCID: PMC9850997 DOI: 10.12998/wjcc.v10.i36.13321] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality. AIM To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study. METHODS To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated. RESULTS The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did. CONCLUSION Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
| | | | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Paolo Mirco
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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10
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Zhao S, Hu K, Tian Y, Xu Y, Tong W. Role of transanal drainage tubes in preventing anastomotic leakage after low anterior resection: a meta-analysis of randomized controlled trials. Tech Coloproctol 2022; 26:931-939. [PMID: 35915290 DOI: 10.1007/s10151-022-02665-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND The transanal drainage tube (TDT) is thought to reduce the incidence of anastomotic leakage (AL) in patients with low anterior resection (LAR). However, results from different clinical trials are inconsistent, although nearly all meta-analyses agree on the efficacy. In contrast to results of many previous studies, 2 recent independent randomized controlled trials (RCTs) suggest that the use of TDT does not prevent AL. We performed a meta-analysis including only RCTs to compare patients with TDTs vs. those without TDTs in terms of AL rate. METHODS A systematic literature search was performed in the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov and WHO/ICTRP from inception until February 14, 2022. RCTs that evaluated the role of TDTs in AL prevention in patients who underwent LAR for rectal cancer were included. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by two authors independently, and random-effects models were implemented. The main outcome was AL, and the secondary outcome was the grade of AL. RESULTS Three RCTs were included involving a total of 1115 participants (559 patients in the TDT group and 556 in the non-TDT group). No significant difference in the AL rate was detected (RR = 0.69, 95% confidence interval (CI) 0.42-1.15, p = 0.15, I2 = 21%, very low certainty evidence). The incidence of grade C AL was possibly lower in the TDT group (RR = 0.33, 95% CI 0.11-1.01, p = 0.05, very low certainty evidence), while the rate of grade B AL was similar between the two groups (RR = 1.17, 95% CI 0.66-2.08, p = 0.59, very low certainty evidence). CONCLUSIONS The present meta-analysis suggests that TDTs are not effective in reducing the overall incidence of AL, but possibly have a potential benefit in reducing the occurrence of grade C AL in patients with LAR. Based on the current limited data and existing heterogeneity, the inclusion of larger populations and the identification of more uniform indications for TDT need to be addressed in future studies.
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Affiliation(s)
- S Zhao
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, No. 10, Changjiangzhilu, Daping, Yuzhong District,, Chongqing, 400042, China
| | - K Hu
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, No. 10, Changjiangzhilu, Daping, Yuzhong District,, Chongqing, 400042, China
| | - Y Tian
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, No. 10, Changjiangzhilu, Daping, Yuzhong District,, Chongqing, 400042, China
| | - Y Xu
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, No. 10, Changjiangzhilu, Daping, Yuzhong District,, Chongqing, 400042, China
| | - W Tong
- Gastric and Colorectal Surgery Division, Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, No. 10, Changjiangzhilu, Daping, Yuzhong District,, Chongqing, 400042, China.
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11
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Guo C, Fu Z, Qing X, Deng M. Prophylactic transanal drainage tube placement for preventing anastomotic leakage after anterior resection for rectal cancer: A meta-analysis. Colorectal Dis 2022; 24:1273-1284. [PMID: 35735261 DOI: 10.1111/codi.16231] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/23/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
AIM The aim was to evaluate the efficacy of transanal drainage tube (TDT) placement for preventing anastomotic leakage after low anterior resection for rectal cancer. METHOD PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to October 2021. Studies comparing outcomes following low anterior resection with or without TDT were included. The primary outcomes measured were anastomotic leakage rate, reoperation rate and anastomotic bleed rate. RESULTS Three randomized controlled trials (RCTs) and 16 observational studies (prospective or retrospective) involving 4560 patients satisfied the basic inclusion criteria. In RCTs, a TDT was associated with no statistically significant differences in anastomotic leakage (OR = 0.67, 95% CI 0.42-1.05, P = 0.08), reduction in reoperation (OR = 0.11, 95% CI 0.03-0.51, P = 0.004) and increased anastomotic bleeding rate (OR = 2.36, 95% CI 1.11-5.01, P = 0.03). In observational studies, a TDT was associated with significant reduction in anastomotic leak (OR = 0.44, 95% CI 0.30-0.64, P < 0.0001) and reoperation (OR = 0.47, 95% CI 0.33-0.69, P < 0.0001), with no statistically significant differences in anastomotic bleeding (OR = 1.30, 95% CI 0.20-8.30, P = 0.78). CONCLUSION In RCTs, a TDT for rectal cancer was correlated with no detectable differences in anastomotic leakage and with an increased risk of anastomotic bleeding. In observational studies, a TDT was correlated with reduction in anastomotic leakage and no detectable differences in anastomotic bleeding. Both RCTs and observational studies demonstrated a comparable reduction in reoperation rate with TDT. These data in aggregate indicated that TDTs may not show superiority but emphasized differences between RCT and observational data.
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Affiliation(s)
- Chenchen Guo
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Zhiwen Fu
- School of Medicine, Southeast University, Nanjing, China
| | - Xin Qing
- School of Medicine, Southeast University, Nanjing, China
| | - Mengen Deng
- School of Medicine, Southeast University, Nanjing, China
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12
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Xu F, Zhang Y, Yan J, Xu B, Wu G, Yang Z, Sun L, Zhang X, Yao H, Zhang Z. The taTME learning curve for mid-low rectal cancer: a single-center experience in China. World J Surg Oncol 2022; 20:305. [PMID: 36138427 PMCID: PMC9502600 DOI: 10.1186/s12957-022-02763-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose As transanal total mesorectal excision (taTME) is performed worldwide, the optimization of existing training and guidance programs to enhance new taTME learners’ competence in performing this procedure is warranted. This study aimed to evaluate the taTME learning curve in patients with mid-low rectal cancer. Methods Patients who underwent taTME for mid-low rectal cancer between October 2015 and August 2021 at a single center were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. The learning curve was analyzed using risk-adjusted CUSUM analysis, with postoperative complications and anastomotic leakage (AL) as outcomes. Results In total, 104 consecutive patients were included in this study. The CUSUM learning curve for total operative time started declining after 42 cases (309.1 ± 84.4 vs. 220.2 ± 46.4, P < 0.001). The risk-adjusted CUSUM (RA-CUSUM) learning curve for postoperative complications fluctuated in cases 44–75 and declined significantly after case 75. The RA-CUSUM learning curve for AL declined after 68 cases. Conclusions taTME had learning curves of 42, 75, and 68 cases for total operative time, postoperative complications, and AL, respectively. A surgeon may require 42 and 75 cases to achieve “proficiency” and “mastery” in taTME procedures, respectively. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02763-3.
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Affiliation(s)
- Fengming Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Yiqiao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Jiafu Yan
- Department of Cardiovascular Medicine, Beijing Anzhen Hospital, Capital Medical University, 2 An-zhen Rd, Chao-Yang District, Beijing, 100029, China
| | - Bowen Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Guocong Wu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Zhengyang Yang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Liting Sun
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Xiao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China
| | - Hongwei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China. .,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China.
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Rd, Xi-Cheng District, Beijing, 100050, China. .,National Clinical Research Center for Digestive Diseases, 95 Yong-an Rd, Xi-Cheng District, 100050, Beijing, China.
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13
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KIROV KG, IVANOV TM, IVANOVA NS. Successful colorectal anastomotic leakage management: a two oncological centres' 12-year experience. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05306-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Cheng SL, Xie L, Wu HW, Zhang XF, Lou LL, Shen HZ. Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report. World J Clin Cases 2022; 10:8406-8416. [PMID: 36159539 PMCID: PMC9403701 DOI: 10.12998/wjcc.v10.i23.8406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/18/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.
CASE SUMMARY A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).
CONCLUSION For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.
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Affiliation(s)
- Si-Le Cheng
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Lu Xie
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Hao-Wei Wu
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Li-Lan Lou
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Hong-Zhang Shen
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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15
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Deng SY, Xing JD, Liu MX, Xu K, Tan F, Yao ZD, Zhang N, Yang H, Zhang CH, Cui M, Su XQ. Effect of the transanal drainage tube on preventing anastomotic leakage after laparoscopic surgery for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:1739-1750. [PMID: 35789424 DOI: 10.1007/s00384-022-04201-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, and transanal drainage tube (TDT) efficacy is still contentious. This study aimed to evaluate the TDT effect on AL prevention. METHODS All relevant papers were searched by using a predefined search strategy (two randomized controlled trials (RCTs), one prospective study, and four retrospective studies). Meta-analysis was conducted to estimate AL and re-operation pooled rates. RESULTS A total of 7 studies (1556 patients) were included: No significant statistic difference was found between two groups on AL rate (odds ratio (OR) 0.61, P = 0.11) and re-operation rate (OR 0.52, P = 0.10). For subgroup analysis, significant statistic difference was found between two groups on AL rate (OR 0.29, P = 0.002) and re-operation rate (OR 0.15, P = 0.04) in patients without neoadjuvant therapy. As for patients without diverting stoma, the AL rate (OR 0.35, P = 0.002) was significantly lower than that in patients without TDT. CONCLUSIONS TDT may reduce AL morbidity and re-operation rate for patients without high risk of AL, but may be useless for those in high-risk situations.
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Affiliation(s)
- Shun-Yu Deng
- Peking University Health Science Center, Beijing, 100038, China
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Jia-Di Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Mao-Xing Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Zhen-Dan Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Cheng-Hai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China
| | - Xiang-Qian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, Haidian District, No. 52 Fucheng Road, Beijing, 100142, China.
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16
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Chiarello MM, Bianchi V, Fransvea P, Brisinda G. Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery. World J Gastroenterol 2022; 28:3747-3752. [PMID: 36161042 PMCID: PMC9372806 DOI: 10.3748/wjg.v28.i28.3747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/13/2022] [Accepted: 06/22/2022] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient's presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.
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Affiliation(s)
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Giuseppe Brisinda
- Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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17
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Kawada K, Wada T, Yamamoto T, Itatani Y, Hida K, Obama K. Correlation between Colon Perfusion and Postoperative Fecal Output through a Transanal Drainage Tube during Laparoscopic Low Anterior Resection. Cancers (Basel) 2022; 14:cancers14092328. [PMID: 35565456 PMCID: PMC9101401 DOI: 10.3390/cancers14092328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 12/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
- Correspondence: ; Tel.: +81-75-366-7595
| | - Toshiaki Wada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka 589-8511, Japan
| | - Takehito Yamamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
- Department of Gastroenterological Surgery and Oncology, Kitano Hospital Medical Research Institute, Osaka 530-8480, Japan
| | - Yoshiro Itatani
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (T.W.); (T.Y.); (Y.I.); (K.H.); (K.O.)
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18
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Nakanishi R, Fujimoto Y, Sugiyama M, Hisamatsu Y, Nakanoko T, Ando K, Ota M, Kimura Y, Oki E, Yoshizumi T. Clinical impact of the triple-layered circular stapler for reducing the anastomotic leakage in rectal cancer surgery: Porcine model and multicenter retrospective cohort analysis. Ann Gastroenterol Surg 2022; 6:256-264. [PMID: 35261951 PMCID: PMC8889859 DOI: 10.1002/ags3.12516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022] Open
Abstract
Aim To investigate the impact of the triple-layered circular stapler compared with the double-layered circular stapler on anastomotic leakage after rectal cancer surgery. Methods The bursting pressure was compared between porcine ileocolic anastomoses created using a double- or triple-layered stapler. We also retrospectively analyzed the incidence of severe anastomotic leakage in 194 patients who underwent colorectal anastomosis using a double- or triple-layered circular stapler during rectal cancer resection performed in two cancer centers between January 2015 and April 2021. Results In the porcine model, the bursting pressure was higher in anastomoses created using the triple-layered stapler than the double-layered stapler (end-to-end anastomosis: 26.4 ± 6.2 mm Hg vs 14.5 ± 4.3 mm Hg, P = .0031; side-to-side anastomosis: 27.7 ± 5.0 mm Hg vs 18.0 ± 2.9 mm Hg, P = .0275). Intersectional leakage occurred in 41% and 83% of anastomoses created using the triple- or double-layered stapler, respectively (P = .0821). In the clinical cohort, the double- and triple-layered stapler was used in 153 and 41 patients, respectively. The incidence of anastomotic leakage was lower for anastomoses created using the triple-layered stapler vs the double-layered stapler (0.0% vs 5.8%, P = .0362). In multivariate analysis, the factors independently associated with a lower incidence of anastomotic leakage were female sex (odds ratio: 0.16, 95% confidence interval: 0.01-0.90, P = .0354) and triple-layered stapler usage (odds ratio: 0.00, 95% confidence interval: 0.00-0.96, P = .0465). Conclusion Anastomoses created using a triple-layered circular stapler had high bursting pressure, which might contribute to a lower incidence of anastomotic leakage after rectal cancer surgery.
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Affiliation(s)
- Ryota Nakanishi
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Yoshiaki Fujimoto
- Department of Gastroenterological SurgeryNational Hospital Organization Kyushu Cancer CenterFukuokaJapan
| | - Masahiko Sugiyama
- Department of Gastroenterological SurgeryNational Hospital Organization Kyushu Cancer CenterFukuokaJapan
| | - Yuichi Hisamatsu
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tomonori Nakanoko
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Koji Ando
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Mitsuhiko Ota
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Yasue Kimura
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Eiji Oki
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Tomoharu Yoshizumi
- Department of Surgery and ScienceGraduate School of Medical SciencesKyushu UniversityFukuokaJapan
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Zhao Y, Li B, Sun Y, Liu Q, Cao Q, Li T, Li J. Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer. Technol Cancer Res Treat 2022; 21:15330338221118983. [PMID: 36172641 PMCID: PMC9523838 DOI: 10.1177/15330338221118983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.
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Affiliation(s)
- Yongqing Zhao
- 154454Department of General Surgery, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Bo Li
- 74569Department of Rehabilitation Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yao Sun
- 154454Department of General Surgery, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Qi Liu
- 154454Department of General Surgery, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Qian Cao
- 154454Department of Education, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Tao Li
- 154454Department of General Surgery, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Jiannan Li
- 154454Department of General Surgery, The Second Hospital of Jilin University, Changchun, Jilin, China
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20
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Varela C, Kim NK. Surgical Treatment of Low-Lying Rectal Cancer: Updates. Ann Coloproctol 2021; 37:395-424. [PMID: 34961303 PMCID: PMC8717072 DOI: 10.3393/ac.2021.00927.0132] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023] Open
Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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