Aim
Anastomotic leakage is a major complication after right hemicolectomy leading to increased morbidity, mortality, length of stay and hospital costs. Previous studies have shown that the type of ...anastomosis (handsewn or stapled) is a major risk factor for anastomotic leakage. The purpose of this study was to evaluate the clinical impact of anastomotic leakage depending on the type of anastomotic technique (handsewn vs stapled).
Method
This was an observational, retrospective, cross‐sectional study. Data were collected at two major hospitals in Spain from January 2010 to December 2016. Patients had elective right colectomy for cancer with handsewn or stapled ileocolic anastomosis. The main outcome was the grading of postoperative treatments needed to manage anastomotic leakage according to two major classification systems. The other outcomes were demographics, time of hospitalization and death rate.
Results
Patients (n = 961) underwent elective surgery for neoplasia of the right colon. Anastomotic leakage was diagnosed in 116 patients (12.07%). Patients with handsewn anastomosis had more Type IIIA surgical complications and received milder treatments than patients with stapled anastomosis (SA) who had more Type IIIB complications and more re‐laparotomies (P = 0.004). The clinical impact of anastomotic leakage was significantly more severe (Grade C) in patients with SA than in patients with a handsewn anastomosis (P = 0.007). No differences were found for hospital stay of patients with anastomotic leakage depending on the type of anastomosis (P = 0.275). Death due to anastomotic leakage was similar in both groups.
Conclusions
The clinical impact of anastomotic leakage in patients with handsewn anastomosis is lower than in patients with SA.
Aim
The aim was to assess factors independently associated with low anterior resection syndrome (LARS) following resection for rectal cancer.
Method
This was a cross‐sectional study carried out in ...two acute‐care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter‐preserving low anterior resection with curative intent with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self‐administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses.
Results
The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis total mesorectal excision (OR 2.18, 95% CI: 1.02–4.65), preoperative radiotherapy (OR 4.33, 95% CI: 2.03–9.27) and postoperative radiotherapy (OR 9.52, 95% CI: 1.74–52.24) were independent risk factors for major LARS.
Conclusions
In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy.
The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports of the combination of ...pre-operative chemoradiotherapy (CRT) and transanal endoscopic microsurgery (TEM) have shown reductions in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of local recurrence and the improvement in morbidity achieved with CRT-TEM compared with TME. Here we describe morbidity rates and pathological outcomes.
This was a prospective, multicentre, randomised controlled non-inferiority trial including patients with rectal adenocarcinoma staged as T2-T3ab,N0,M0. Patients were randomised to the CRT-TEM or the TME group. Patients included, tolerance of CRT and its adverse effects, surgical complications (Clavien–Dindo and Comprehensive Complication Index classifications) and pathological results (complete response in the CRT-TEM group) were recorded in both groups. Patients attended follow-up controls for local and systemic relapse. Trial registration: NCT01308190.
From July 2010 to October 2021, 173 patients from 17 Spanish hospitals were included (CRT-TEM: 86, TME: 87). Eleven were excluded after randomisation (CRT-TEM: 5, TME: 6). Modified intention-to-treat analysis thus included 81 patients in each group. There was no mortality after CRT. In the CRT-TEM group, one patient abandoned CRT, 1/81 (1.2%). The CRT-related morbidity rate was 29.6% (24/81). Post-operative morbidity was 17/82 (20.7%) in the CRT-TEM group and 41/81 (50.6%) in the TME group (P < 0.001, 95% confidence interval 42.9% to 16.7%). One patient died in each group (1.2%). Of the 81 patients in the CRT-TEM group who received the allocated treatment, 67 (82.7%) underwent organ preservation. Pathological complete response in the CRT-TEM group was 44.3% (35/79). In the TME group, pN1 were found in 17/81 (21%).
CRT-TEM treatment obtains high pathological complete response rates (44.3%) and a high CRT compliance rate (98.8%). Post-operative complications and hospitalisation rates were significantly lower than those in the TME group. We await the results of the follow-up regarding cancer outcomes and quality of life.
•CRT-TEM treatment achieves high rates of pathological complete response (44.3%).•CRT-TEM treatment achieves a high CRT compliance rate (98.8%).•Post-operative complications and hospitalisation rates were significantly lower than those in the TME group.•The accuracy of the endorectal ultrasound, rectal magnetic resonance imaging in the CRT-TEM group was not as high as expected.
Aim
Although the oncological adequacy of laparoscopic rectal resection (LR) appears equivalent to open resection (OR), its benefit is controversial in the elderly. The aim of this study was to ...investigate the influence of LR on morbidity and mortality in octogenarians.
Method
This was a retrospective analysis of all patients who underwent rectal surgery for cancer between 2003 and 2013 in a teaching hospital. The primary aim of the study was to assess the influence of surgical approach on mortality and morbidity of rectal resection in patients ≥ 80 years old. Regression analysis was performed to control the effect of covariables on the clinical outcome.
Results
Of 408 patients 203 were in the LR group and 205 in the OR group including 303 (74.3%) less than 80 years and 105 (25.7%) over 80 years. The mortality was lower in the LR group compared with the OR group for patients under 80 years (0% vs 4.6%; P = 0.049) and no different in the over 80 group (11.5% vs 9.4%; P = 0.859). In younger patients, the OR group showed longer hospital stay (9 vs 7 days; P < 0.001) and more complications (44.1% vs 29.8%; P = 0.042). Medical complications were more frequent in LR group than OR group octogenarians (40.4% vs 20.8%; P = 0.009) as well as grade C anastomotic leakage (13.8 vs 10.7; P = 0.041).
Conclusion
LR for rectal cancer showed clinical advantages in patients under 80 years and was as safe as OR in patients over 80 years, although the advantages of laparoscopic surgery were lost in the elderly group due to a higher rate of medical complications. OR may be an option in elderly patients with important comorbidities.
Background
The influence of anastomotic leak on local recurrence and survival remains debated in rectal cancer.
Methods
This was a multicentre observational study using data from the Spanish Rectal ...Cancer Project database. Demographics, American Society of Anesthesiologists classification, tumour location, stage, use of defunctioning stoma, administration of neoadjuvant and adjuvant treatment, invasion of circumferential resection margin, quality of mesorectal excision and anastomotic leakage were recorded. Anastomotic leak was defined as an anastomotic event requiring surgical intervention or interventional radiology, including pelvic abscesses without radiological evidence of leakage and early rectovaginal fistulas. Variables associated with oncological outcome were assessed by multivariable Cox regression analysis.
Results
A total of 1181 consecutive patients were included. Rates of anastomotic leak and 30‐day postoperative mortality were 9·4 and 2·4 per cent respectively. Data from 1153 patients were analysed after a median follow‐up of 5 years. Cumulative rates of local recurrence, overall recurrence, overall survival and cancer‐specific survival were 4·9, 19·4, 77·5 and 84·7 per cent respectively. In the multivariable regression analysis, anastomotic leakage was not associated with local recurrence (hazard ratio (HR) 0·80, 95 per cent c.i. 0·28 to 2·26; P = 0·669), overall recurrence (HR 1·14, 0·70 to 1·85; P = 0·606), overall survival (HR 1·10, 0·73 to 1·65; P = 0·648) or cancer‐specific survival (HR 1·23, 0·75 to 2·02; P = 0·421).
Conclusion
Anastomotic leak after low anterior resection did not affect oncological outcomes in these patients.
No adverse effects on cancer parameters
Purpose
Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh ...during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia.
Methods
Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis.
Results
Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50 % of patients in the mesh group and in 93.8 % of patients in the control group (
P
= 0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (
P
= 0.004) and the optimal threshold 23 mm. Subcutaneous fat thickness ≥23 mm was a significant predictor of parastomal hernia (odds ratio 15.7,
P
= 0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06,
P
= 0.031).
Conclusions
Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ≥23 mm measured by CT was an independent predictor of parastomal hernia.
The standard treatment of rectal adenocarcinoma is total mesorectal excision (TME), in many cases requires a temporary or permanent stoma. TME is associated with high morbidity and genitourinary ...alterations. Transanal endoscopic microsurgery (TEM) allows access to tumors up to 20 cm from the anal verge, achieves minimal postoperative morbidity and mortality rates, and does not require an ostomy. The treatment of T2, N0, and M0 cancers remains controversial. Preoperative chemoradiotherapy (CRT) in association with TEM reduces local recurrence and increases survival. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with TEM compared with TME.
Prospective, multicenter, randomized controlled non-inferiority trial includes patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2 or T3-superficial N0-M0. Patients will be randomized to two areas: CRT plus TEM or radical surgery (TME). Postoperative morbidity and mortality will be recorded and patients will complete the quality of life questionnaires before the start of treatment, after CRT in the CRT/TEM arm, and 6 months after surgery in both arms. The estimated sample size for the study is 173 patients. Patients will attend follow-up controls for local and systemic relapse.
This study aims to demonstrate the preservation of the rectum after preoperative CRT and TEM in rectal cancer stages T2-3s, N0, M0 and to determine the ability of this strategy to avoid the need for radical surgery (TME).
ClinicalTrials.gov identifier: NCT01308190. Número de registro del Comité de Etica e Investigación Clínica (CEIC) del Hospital universitario Parc Taulí: TAU-TEM-2009-01.
Aim
The aim of this study was to develop and externally validate a clinically, practical and discriminative prediction model designed to estimate in‐hospital mortality of patients undergoing ...colorectal surgery.
Method
All consecutive patients who underwent elective or emergency colorectal surgery from 1990 to 2005, at the Zaandam Medical Centre, The Netherlands, were included in this study. Multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variables to the outcome variable in‐hospital mortality, and a simplified Identification of Risk in Colorectal Surgery (IRCS) score was constructed. The model was validated in a population of patients who underwent colorectal surgery from 2005 to 2011 in Barcelona, Spain. Predictive performance was estimated by calculating the area under the receiver operating characteristic curve.
Results
The strongest predictors of in‐hospital mortality were emergency surgery (OR = 6.7, 95% CI 4.7–9.5), tumour stage (OR = 3.2, 95% CI 2.8–4.6), age (OR = 13.1, 95% CI 6.6–26.0), pulmonary failure (OR = 4.9, 95% CI 3.3–7.1) and cardiac failure (OR = 3.7, 95% CI 2.6–5.3). These parameters were included in the prediction model and simplified scoring system. The IRCS model predicted in‐hospital mortality and demonstrated a predictive performance of 0.83 (95% CI 0.79–0.87) in the validation population. In this population the predictive performance of the CR‐POSSUM score was 0.76 (95% CI 0.71–0.81).
Conclusions
The results of this study have shown that the IRCS score is a good predictor of in‐hospital mortality after colorectal surgery despite the relatively low number of model parameters.
Aims:
To assess outcome in patients with locally advanced rectal cancer undergoing multivisceral resection.
Methods:
Retrospective study of 30 consecutive patients (mean age 67.8 years) with primary ...locally advanced rectal cancer undergoing en bloc multivisceral resection of the organs involved with curative intent between 1998 and 2010. Overall survival, local and distal recurrence, and disease-free survival were analyzed by the Kaplan–Meier method. Risk factors for clinical outcome were obtained using a Cox multivariate model.
Results:
Postoperative complications occurred in 76.7% of patients and the in-hospital mortality rate was 10%. The median follow-up was 28.8 months. A total of 19 patients died at follow-up. Of the 11 patients who were alive, 7 were free of disease. In the multivariate analysis, lymph node involvement, stage II, and lymph vascular invasion were significantly associated with survival, and stage III showed a strong trend towards significance. Suture dehiscence (peritonitis and intra-abdominal abscess) showed a significant trend towards a higher local recurrence. Lymph vascular invasion was associated with a higher distant recurrence.
Conclusion:
Lymph node involvement was associated with worse survival, whereas stage II and absence of lymph vascular invasion were associated with a better survival. Lymph vascular invasion was associated with a higher distant recurrence.
Abstract
Background
Medical treatment is still the first approach on Crohn’s disease (CD) in most of the cases. Patients on remission after medical and/or surgical treatment show significant ...improvement on their quality of life (QoL). However, there is scarce bibliography evaluating the patients point of view regarding their surgery and the timing on performing this. The aim of this study was to evaluate how confident are patients with the timing of their surgery and how the surgery changed their QoL.
Methods
A questionnaire was sent to 274 patients operated, as a first surgery, between 1989 to 2018 due to CD at a single institution. The questionnaire included 12 questions: evaluating if they would have preferred their surgery (with or without stoma) to have been carried out sooner, later or at the same time as it was done and about their changes in quality of life. Clavien Dindo’s classification was used to evaluate postoperative complications. A consent form was obtained from all patients participating on the study. The study was accepted by our Ethics Committee.
Results
In total, 98 (36%) patients complete the questionnaire. Seventy-two of 98 had a CD location type L1, 14/98 L2 and 12/98 L3. The behaviour of CD was 5 B1; 56 B2; and 37 B3. A stoma was done in 16 patients. Twenty-five patients needed a reintervention due to a relapse of the disease. Eighty of 98 reported a significant improvement in their QoL after their first surgery; 11/98 did not experience any change, and 7/98 explained a drop on it. Analysing the group of patients that needed a stoma as a treatment: 12/16 (75%) reported an improvement in their QoL; 2/16 (12%) did not experience changes and 2 more explain a worsen on it. Regarding the timing on surgery: 30/98 preferred their operation to have been done earlier (8/30 (26%) experienced some postoperative complication); and 6/98 thought it should have been done later. Ninety-three of 98 patient will accept a new surgery if the disease would reappear, and of them 33/93 (35%) had postoperative complications after surgery.
Conclusions
Surgery for CD improves patients QoL in a high proportion of patients even on those that need a stoma. One on every three patients in this series preferred their operation to have been done earlier. More studies should be done to consider if earlier surgery should be offered as an alternative to medical treatment rather than as an option when medical treatment fails.
