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Harada T, Numata M, Izukawa S, Atsumi Y, Kazama K, Sawazaki S, Godai T, Mushiake H, Sugano N, Uchiyama M, Higuchi A, Tamagawa H, Suwa Y, Watanabe J, Sato T, Kunisaki C, Saito A. C-reactive protein-to-albumin ratio as a risk factor for anastomotic leakage after anterior resection for rectal cancer with intraoperative use of indocyanine green fluorescence imaging. Surg Endosc 2024; 38:4236-4244. [PMID: 38858251 DOI: 10.1007/s00464-024-10940-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/17/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Indocyanine green fluorescence imaging (ICG-FI) reduces anastomotic leakage (AL) in rectal cancer surgery. However, no studies investigating risk factors for anastomotic leakage specific to the group using ICG-FI have ever previously been conducted. The purpose of this retrospective multicenter study was to ascertain the risk factors for AL in the group using ICG-FI. METHODS A total of 638 patients who underwent laparoscopic or robotic anterior resection for rectal cancer between April 2018 and March 2023 were included in this study. Patients were divided into two groups: the ICG-FI group (n = 269) and the non-ICG-FI group (n = 369) for comparative analysis. The effects of clinicopathological and treatment-related factors on AL in the ICG-FI group were evaluated using both univariate and multivariate analyses. RESULTS The incidence of AL in the ICG-FI group was 4.8%. Although there was no significant difference in the incidence of AL between the two groups, it was observed to be lower in the ICG-FI group. A multivariate analysis revealed a preoperative C-reactive protein-to-albumin ratio (CAR) ≥ 0.049 (odds ratio, 3.73; 95% confidence interval, 1.01-13.70; p = 0.048) as an independent risk factor for AL in the ICG-FI group. CONCLUSIONS In this study, CAR was the only identified risk factor for AL in the ICG-FI group. It was suggested that CAR could be a criterion for early surgical intervention, prior to the escalation of risks, or for considering interventions such as diverting stoma creation.
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Affiliation(s)
- Tatsunosuke Harada
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Masakatsu Numata
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Shota Izukawa
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Yosuke Atsumi
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Sho Sawazaki
- Department of Surgery, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Teni Godai
- Department of Surgery, Fujisawa Shounandai Hospital, 2345, Takakura, Fujisawa, Kanagawa, 252-0802, Japan
| | - Hiroyuki Mushiake
- Department of Surgery, Saiseikai Yokohamashi Nanbu Hospital, 3-2-10, Konandai, Konan-ku, Yokohama, Kanagawa, 234-0054, Japan
| | - Nobuhiro Sugano
- Department of Surgery, Hiratuka Kyosai Hospital, 9-11, Oiwake, Hiratuka, Kanagawa, 254-8502, Japan
| | - Mamoru Uchiyama
- Department of Surgery, Ashigarakami Hospital, 866-1, Matsudasouryou, Matsuda-town, Ashigarakami-gun, Kanagawa, 258-0003, Japan
| | - Akio Higuchi
- Department of Surgery, Yokohama Minami Kyosai Hospital, 21-1, Mutsuurahigashi, Kawazawa-ku, Yokohama, Kanagawa, 236-0037, Japan
| | - Hiroshi Tamagawa
- Department of Surgery, Yokohama Minami Kyosai Hospital, 21-1, Mutsuurahigashi, Kawazawa-ku, Yokohama, Kanagawa, 236-0037, Japan
| | - Yusuke Suwa
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Jun Watanabe
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Tsutomu Sato
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Chikara Kunisaki
- Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Town, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Aya Saito
- Department of Surgery, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
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Yuan J, Yang S, Zhuang Y, Lin G. New technique for laparoscopic removal of the dog-ear area to reduce anastomotic leakage after double stapling anastomosis. Asian J Surg 2024:S1015-9584(24)01357-5. [PMID: 38987153 DOI: 10.1016/j.asjsur.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024] Open
Affiliation(s)
- Jinpeng Yuan
- Department of Gastrointestinal Surgery, Cancer Hospital of Shantou University Medical College Shantou, Guangdong, China
| | - Shaoli Yang
- Department of Medical Oncology, Cancer Hospital of Shantou University Medical College Shantou, Guangdong, China
| | - Yezhong Zhuang
- Department of Gastrointestinal Surgery, Cancer Hospital of Shantou University Medical College Shantou, Guangdong, China.
| | - Guixing Lin
- Department of Gastrointestinal Surgery, Cancer Hospital of Shantou University Medical College Shantou, Guangdong, China.
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Ding R, He M, Cen H, Chen Z, Su Y. Clinical risk factors and Risk assessment model for Anastomotic leakage after Rectal cancer resection. Indian J Cancer 2024; 61:244-252. [PMID: 38155439 DOI: 10.4103/ijc.ijc_903_21] [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: 07/25/2021] [Accepted: 05/15/2021] [Indexed: 12/30/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is the most serious complication after rectal cancer surgery. Risk factors associated with AL have been documented in previous studies; however, the consensus is still lacking. In this retrospective study, we aimed to identify risk factors for AL after rectal cancer resection and to create an accurate and effective tool for predicting the risk of this complication. METHODS The study cohort comprised of 276 patients with rectal cancer who had undergone anterior resection between 2015 and 2020. Twenty-four selected variables were assessed by univariate and multivariate logistic regression analyses to identify independent risk factors of AL. A risk assessment model for predicting the risk of AL was established on the basis of the regression coefficients of each identified independent risk factor. RESULTS Anastomotic leakage occurred in 20 patients (7.2%, 20/276). Multivariate analysis identified the following variables as independent risk or protective factors of AL: perioperative ileus ( P < 0.001, odds ratio [OR] = 14.699), tumor size ≥5 cm ( P = 0.025, OR = 3.925), distance between tumor and anal verge <7.5 cm ( P = 0.045, OR = 3.512), obesity ( P = 0.032, OR = 7.256), and diverting stoma ( P = 0.008, OR = 0.143). A risk assessment model was constructed and patients were allocated to high-, medium-, and low-risk groups on the basis of risk model scores of 5-7, 2-4, and 0-1, respectively. The incidences of AL in these three groups were 61.5%, 11.9%, and 2.0%, respectively ( P < 0.001). CONCLUSIONS Our risk assessment model accurately and effectively identified patients at high risk of AL and could be useful in aiding decision-making aimed at minimizing adverse outcomes associated with leakage.
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Affiliation(s)
- Rui Ding
- Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
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Shen Y, Huang LB, Lu A, Yang T, Chen HN, Wang Z. Prediction of symptomatic anastomotic leak after rectal cancer surgery: A machine learning approach. J Surg Oncol 2024; 129:264-272. [PMID: 37795583 DOI: 10.1002/jso.27470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/31/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Anastomotic leakage (AL) remains the most dreaded and unpredictable major complication after low anterior resection for mid-low rectal cancer. The aim of this study is to identify patients with high risk for AL based on the machine learning method. METHODS Patients with mid-low rectal cancer undergoing low anterior resection were enrolled from West China Hospital between January 2008 and October 2019 and were split by time into training cohort and validation cohort. The least absolute shrinkage and selection operator (LASSO) method and stepwise method were applied for variable selection and predictive model building in the training cohort. The area under the receiver operating characteristic curve (AUC) and calibration curves were used to evaluate the performance of the models. RESULTS The rate of AL was 5.8% (38/652) and 7.2% (15/208) in the training cohort and validation cohort, respectively. The LASSO-logistic model selected almost the same variables (hypertension, operating time, cT4, tumor location, intraoperative blood loss) compared to the stepwise logistic model except for tumor size (the LASSO-logistic model) and American Society of Anesthesiologists score (the stepwise logistic model). The predictive performance of the LASSO-logistics model was better than the stepwise-logistics model (AUC: 0.790 vs. 0.759). Calibration curves showed mean absolute error of 0.006 and 0.013 for the LASSO-logistics model and stepwise-logistics model, respectively. CONCLUSION Our study developed a feasible predictive model with a machine-learning algorithm to classify patients with a high risk of AL, which would assist surgical decision-making and reduce unnecessary stoma diversion. The involved machine learning algorithms provide clinicians with an innovative alternative to enhance clinical management.
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Affiliation(s)
- Yu Shen
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Li-Bin Huang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Anqing Lu
- Department of Transportation Central, West China Hospital, West China Medical School, West China School of Nursing, Sichuan University, Chengdu, China
| | - Tinghan Yang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hai-Ning Chen
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ziqiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Wang S, Zhang Y, Tao S, Liu Y, Shi Y, Guan J, Liu M. Efficacy of reinforcing sutures for prevention of anastomotic leakage after low anterior resection for rectal cancer: A systematic review and meta-analysis. Cancer Rep (Hoboken) 2024; 7:e1941. [PMID: 38174618 PMCID: PMC10849930 DOI: 10.1002/cnr2.1941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/31/2023] [Accepted: 11/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Anastomotic leakage is a serious complication following surgery for cancer of the rectum. It is not clear whether reinforcing sutures could prevent anastomotic leakage. Therefore, this study aims at evaluating the efficacy of reinforcing sutures on anastomotic leakage. METHODS We searched PubMed, Embase, and the Cochrane Library databases from inception to January 31, 2023. We included studies comparing anastomosis with reinforcing sutures to anastomosis without reinforcing sutures after low anterior resection. Risk of bias was assessed by the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies. The overall quality of evidence for primary outcome was assessed using Grading of Recommendations Assessment, Development, and Evaluations methodology. RESULTS Two RCTs (345 patients) and four observational studies (783 patients) were included. Anastomotic leakage occurred in 4.4% (24 of 548) of patients with reinforcing sutures and 11.9% (69 of 580) of patients without reinforcing sutures. Meta-analysis showed a lower incidence of anastomotic leakage (RR, 0.41; 95% CI 0.25 to 0.66, low certainty) in patients with reinforcing sutures. Operative time (WMD, -3.66; 95% CI -18.58 to 11.25) and reoperation for anastomotic leakage (RR, 0.69; 95% CI 0.23 to 2.08) were similar between patients with reinforcing sutures and those without reinforcing sutures. CONCLUSIONS While observational data suggest that, there is a clear benefit in terms of reducing the risk of anastomotic leakage with the use of reinforcing sutures, RCT data are less clear. Further large, prospective studies are warranted to determine whether a true clinically important benefit exists with this technique.
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Affiliation(s)
- Shuanhu Wang
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Yi Zhang
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Song Tao
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Yakui Liu
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Yi Shi
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Jiajia Guan
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
| | - Mulin Liu
- Department of Gastrointestinal surgeryThe First Affiliated Hospital of Bengbu Medical CollegeBengbuAnhuiChina
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Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going? Curr Oncol 2023; 30:3111-3137. [PMID: 36975449 PMCID: PMC10047700 DOI: 10.3390/curroncol30030236] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.
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Simillis C, Charalambides M, Mavrou A, Afxentiou T, Powar MP, Wheeler J, Davies RJ, Fearnhead NS. Operative blood loss adversely affects short and long-term outcomes after colorectal cancer surgery: results of a systematic review and meta-analysis. Tech Coloproctol 2023; 27:189-208. [PMID: 36138307 DOI: 10.1007/s10151-022-02701-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery. METHODS A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion. RESULTS Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02). CONCLUSIONS Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.
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Affiliation(s)
- C Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
| | - M Charalambides
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - A Mavrou
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - T Afxentiou
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - M P Powar
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - J Wheeler
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - R J Davies
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - N S Fearnhead
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
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Tyler R, Foss H, Phelan L, Radley S, Geh I, Karandikar S. Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Colorectal Dis 2023; 25:253-260. [PMID: 36222737 DOI: 10.1111/codi.16368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 02/08/2023]
Abstract
AIM The impact of surgeon volume on 18-month unclosed ileostomy rates after rectal cancer surgery has not been fully explored. The aim of this study was to describe the effect of surgeon volume and evaluate factors predictive of an unclosed ileostomy. METHOD Patients undergoing anterior resection with a diverting ileostomy for rectal cancer from March 2004 to October 2018 were identified from a prospectively maintained database. The unclosed ileostomy rate was determined by those with an unclosed ileostomy at 18 months. High- and low-volume surgeons (HVS and LVS, respectively) were classed as those performing five or more or fewer than five rectal cancer resections per year, respectively. Data on sex, age, American Society of Anesthesiologists grade, neoadjuvant chemoradiotherapy (CRT), tumour height, T-stage, anastomotic leak, surgical approach and adjuvant chemotherapy were also collected. Factors predictive of an unclosed ileostomy at 18 months were explored using a multivariate binary logistic regression analysis. RESULTS A total of 415 patients (62.4% male) with a median age of 67 were eligible for analysis. Of these, 115 (27.7%) had an unclosed ileostomy at 18 months. HVS had an unclosed ileostomy rate of 24.6% (72/292) compared with 34.9% (43/123) for LVS. Volume was associated with an unclosed ileostomy in univariable analysis (p = 0.032) but not in multivariate analysis (OR 1.75, 95% CI 0.92-3.32, p = 0.08). Independent factors predictive of an unclosed ileostomy were anastomotic leak (OR 10.41, 3.95-27.0, p < 0.01), adjuvant chemotherapy (OR 2.23, 1.24-3.96, p < 0.01) and neoadjuvant CRT (OR 2.16, 1.15-5.75, p = 0.01). CONCLUSION LVS were associated with a higher unclosed ileostomy at 18 months compared with HVS. This study adds further weight to the call for adoption of a minimum annual case threshold in rectal cancer surgery.
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Affiliation(s)
| | - Helen Foss
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Liam Phelan
- Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Dias VE, Castro PASVDE, Padilha HT, Pillar LV, Godinho LBR, Tinoco ACDEA, Amil RDAC, Soares AN, Cruz GMGDA, Bezerra JMT, Silva TAMDA. Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis. Rev Col Bras Cir 2022; 49:e20223363. [PMID: 36449942 PMCID: PMC10578842 DOI: 10.1590/0100-6991e-20223363-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy. METHODS the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05. RESULTS cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35). CONCLUSIONS important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.
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Affiliation(s)
- Vinícius Evangelista Dias
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
- - Universidade Iguaçu - Itaperuna - RJ - Brasil
- - Faculdade Metropolitana São Carlos - Bom Jesus do Itabapoana - RJ - Brasil
| | | | | | | | | | | | - Rodrigo DA Costa Amil
- - Hospital São José do Avaí, Departamento de Cirurgia Geral - Itaperuna - RJ - Brasil
| | - Aleida Nazareth Soares
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
| | - Geraldo Magela Gomes DA Cruz
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
| | - Juliana Maria Trindade Bezerra
- - Faculdade de Medicina da Universidade Federal de Minas Gerais - Belo Horizonte - MG - Brasil
- - Universidade Estadual do Maranhão, Centro de Estudos Superiores de Lago da Pedra - Lago da Pedra - MA - Brasil
- - Universidade Estadual do Maranhão, Programa de Pós-Graduação em Ciência Animal - São Luís - MA - Brasil
| | - Thais Almeida Marques DA Silva
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
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Tschann P, Weigl MP, Szeverinski P, Lechner D, Brock T, Rauch S, Rossner J, Eiter H, Girotti PNC, Jäger T, Presl J, Emmanuel K, De Vries A, Königsrainer I, Clemens P. Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study. Langenbecks Arch Surg 2022; 407:2945-2957. [PMID: 35849193 DOI: 10.1007/s00423-022-02609-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy. METHODS A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage -). RESULTS A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172-309] vs. 93 days [50-182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08-7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01-4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors. CONCLUSION We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.
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Affiliation(s)
- Peter Tschann
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria.
| | - Markus P Weigl
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Philipp Szeverinski
- Institute of Medical Physics, Academic Teaching Hospital, Feldkirch, Austria
| | - Daniel Lechner
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Thomas Brock
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Stephanie Rauch
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Jana Rossner
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Helmut Eiter
- Department of Radio-Oncology, Academic Teaching Hospital, Feldkirch, Austria
| | - Paolo N C Girotti
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Tarkan Jäger
- Department of Surgery, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Salzburg, Austria
| | - Jaroslav Presl
- Department of Surgery, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Salzburg, Austria
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University/Salzburger Landeskliniken (SALK), Salzburg, Austria
| | - Alexander De Vries
- Institute of Medical Physics, Academic Teaching Hospital, Feldkirch, Austria
| | - Ingmar Königsrainer
- Department of General and Thoracic Surgery, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Patrick Clemens
- Department of Radio-Oncology, Academic Teaching Hospital, Feldkirch, Austria
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Degiuli M, Elmore U, De Luca R, De Nardi P, Tomatis M, Biondi A, Persiani R, Solaini L, Rizzo G, Soriero D, Cianflocca D, Milone M, Turri G, Rega D, Delrio P, Pedrazzani C, De Palma GD, Borghi F, Scabini S, Coco C, Cavaliere D, Simone M, Rosati R, Reddavid R. Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group. Colorectal Dis 2022; 24:264-276. [PMID: 34816571 PMCID: PMC9300066 DOI: 10.1111/codi.15997] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/07/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022]
Abstract
AIM Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage. METHODS The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured. RESULTS A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection. CONCLUSIONS While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.
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Affiliation(s)
- Maurizio Degiuli
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
| | - Ugo Elmore
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | - Raffaele De Luca
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Paola De Nardi
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | | | - Alberto Biondi
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Roberto Persiani
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Leonardo Solaini
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Gianluca Rizzo
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusRomeItaly
| | - Domenico Soriero
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | | | - Marco Milone
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Giulia Turri
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Daniela Rega
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Paolo Delrio
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Giovanni D. De Palma
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Felice Borghi
- Department of SurgeryS. Croce e Carle HospitalCuneoItaly
| | - Stefano Scabini
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | - Claudio Coco
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusUniversità Cattolica del Sacro CuoreRomeItaly
| | - Davide Cavaliere
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Michele Simone
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Riccardo Rosati
- Division of Gastrointestinal SurgerySan Raffaele HospitalVita Salute UniversityMilanItaly
| | - Rossella Reddavid
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
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DIAS VINÍCIUSEVANGELISTA, CASTRO PEDROALVESSOARESVAZDE, PADILHA HOMEROTERRA, PILLAR LARAVICENTE, GODINHO LAURABOTELHORAMOS, TINOCO AUGUSTOCLAUDIODEALMEIDA, AMIL RODRIGODACOSTA, SOARES ALEIDANAZARETH, CRUZ GERALDOMAGELAGOMESDA, BEZERRA JULIANAMARIATRINDADE, SILVA THAISALMEIDAMARQUESDA. Fatores de risco pré-operatórios associados à fístula anastomótica após colectomia para câncer colorretal: revisão sistemática e metanálise. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RESUMO Objetivo: fístula anastomótica (FA) após colectomia para câncer colorretal (CCR) é complicação grave. Esta revisão sistemática e meta-análise avaliou os fatores de risco pré-operatórios para FA em pacientes submetidos à colectomia. Métodos: a pesquisa bibliográfica abrangeu 15 anos e 9 meses (1 de janeiro de 2005 - 19 de outubro de 2020), sendo utilizadas as plataformas PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC e Web of Science. O critério de inclusão foram estudos transversais, coorte e caso-controle em fatores de risco pré-operatórios para FA (desfecho). A escala Newcastle-Ottawa foi usada para avaliação de viés dos estudos. A metanálise envolveu o cálculo dos efeitos de tratamento para cada estudo individualmente incluindo odds ratio (OR), risco relativo (RR) e intervalo de confiança de 95% (IC95%) com construção de modelo de efeitos aleatórios, para avaliar o impacto de cada variável (p<0,05). Resultados: foram selecionados 39 estudos transversais, 21 coortes e quatro casos-controle. A metanálise identificou 14 fatores de risco para FA em pacientes com CCR após colectomia, que são sexo masculino (RR=1,56; IC 95%=1,40-1,75), tabagismo (RR=1,48; IC 95%=1,30-1,69), alcoolismo (RR=1,35; IC 95%=1,21-1,52), diabetes mellitus (RR=1,97; IC 95%=1,44-2,70), doenças pulmonares (RR=2,14; IC 95%=1,21-3,78), doença pulmonar obstrutiva crônica (RR=1,10; IC 95%=1,04-1,16), doença coronariana (RR=1,61; IC 95%=1,07-2,41), doença renal crônica (RR=1,34; IC 95%=1,22-1,47), altas notas na escala ASA (RR=1,70; IC 95%=1,37-2,09), cirurgia abdominal prévia (RR=1,30; IC 95%=1,04-1,64), cirurgia de emergência (RR=1,61; IC 95%=1,26-2,07), quimioterapia neoadjuvante (RR=2,16; IC 95%=1,17-4,02), radioterapia (RR=2,36; IC 95%=1,33-4,19) e quimiorradioterapia (RR=1,58; IC 95%=1,06-2,35). Conclusões: importantes fatores de risco pré-operatórios para FA colorretais em pacientes com CCR foram identificados com base nas melhores pesquisas baseadas em evidências e esse conhecimento deve influenciar decisões relacionadas ao tratamento.
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Affiliation(s)
- VINÍCIUS EVANGELISTA DIAS
- Faculdade Santa Casa BH, Brasil; Universidade Iguaçu, Brazil; Faculdade Metropolitana São Carlos, Brazil
| | | | | | | | | | | | | | | | | | - JULIANA MARIA TRINDADE BEZERRA
- Universidade Federal de Minas Gerais, Brazil; Universidade Estadual do Maranhão, Brazil; Universidade Estadual do Maranhão, Brazil
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A systematic review of the literature assessing operative blood loss and postoperative outcomes after colorectal surgery. Int J Colorectal Dis 2022; 37:47-69. [PMID: 34697662 DOI: 10.1007/s00384-021-04015-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery. METHODS A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery. RESULTS The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss. CONCLUSION The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.
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Favuzza J. Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains. Clin Colon Rectal Surg 2021; 34:366-370. [PMID: 34853556 DOI: 10.1055/s-0041-1735266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.
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Affiliation(s)
- Joanne Favuzza
- Division of Colon and Rectal Surgery, Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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15
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Hernandez PT, Paspulati RM, Shanmugan S. Diagnosis of Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:391-399. [PMID: 34853560 DOI: 10.1055/s-0041-1735270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.
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Affiliation(s)
- Paul T Hernandez
- Division of Colorectal Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Raj M Paspulati
- Department of Radiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Skandan Shanmugan
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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16
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Ju HE, Lee CS, Bae JH, Lee HJ, Yoon MR, Al-Sawat A, Lee DS, Lee IK, Lee YS, Song IH, Han SR. High incidence rate of late anastomosis leakage in patients for rectal cancer after neoadjuvant chemoradiotherapy: A comparative study. Asian J Surg 2021; 45:1832-1842. [PMID: 34815142 DOI: 10.1016/j.asjsur.2021.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 11/02/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the clinical features and risk factors of late anastomotic leakage (AL) in a homogeneous cohort with elective sphincter-sparing surgery (SSS) with ileostomy after neoadjuvant chemoradiotherapy (nCRT) for rectal cancer. METHODS Data from a total of 359 patients who underwent elective rectal cancer surgery between Jan 2017 and May 2020 were retrospectively reviewed. Patients were classified into early and late AL groups, referring to onset of AL occurring within or after 30 post-operative days, respectively. We analyzed clinical, pathological, and inflammatory features of both AL and risk factors of stoma reversal failure and late AL. RESULTS A total of 85 patients with SSS with ileostomy after nCRT were classified into 8 (9.4%) patients of early AL and 16 (18.8%) of late AL. Unlike early AL patients, late AL group showed lower neutrophil-lymphocyte ratio (NLR) (P < 0.001) and did not need an invasive intervention at the time of diagnosis. 50% (5/10) patients needed reformation of ileostomy. (P = 0.048) Failure of stoma reversal is associated with advanced stages, high NLR ratio (≥3), and inflammatory lesions seen around anastomosis in radiologic findings, which was confirmed as the risk factor of late AL. CONCLUSION Late AL, with different clinical features, showed a higher incidence than early AL in patients who underwent surgery after nCRT and also had a higher stoma reformation rate. Careful evaluation using laboratory and radiological findings before an ileostomy closure is performed to prevent late AL.
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Affiliation(s)
- Hui Eun Ju
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Seung Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Hoon Bae
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jin Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mi Ran Yoon
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Abdullah Al-Sawat
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea; Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
| | - Do Sang Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Hye Song
- Department of Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Rim Han
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Turgeon MK, Gamboa AC, Regenbogen SE, Holder-Murray J, Abdel-Misih SR, Hawkins AT, Silviera ML, Maithel SK, Balch GC. A US Rectal Cancer Consortium Study of Inferior Mesenteric Artery Versus Superior Rectal Artery Ligation: How High Do We Need to Go? Dis Colon Rectum 2021; 64:1198-1211. [PMID: 34192711 PMCID: PMC8573719 DOI: 10.1097/dcr.0000000000002052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal level of pedicle ligation during proctectomy for rectal cancer, either at the origin of the inferior mesenteric artery or the superior rectal artery, is still debated. OBJECTIVE The objective was to determine whether superior rectal artery ligation portends equivalent technical or oncologic outcomes. DESIGN This was a retrospective analysis of a rectal cancer database (2007-2017). SETTINGS The study was conducted at 6 tertiary referral centers in the United States (Emory University, University of Michigan, University of Pittsburgh Medical Center, The Ohio State University Wexner Medical Center, Vanderbilt University Medical Center, and Washington University School of Medicine in St. Louis). PATIENTS Patients with primary, nonmetastatic rectal cancer who underwent low anterior resection or abdominoperineal resection were included. MAIN OUTCOME MEASURES Anastomotic leak, lymph node harvest, locoregional recurrence-free survival, recurrence-free survival, and overall survival were measured. RESULTS Of 877 patients, 86% (n = 755) received an inferior mesenteric artery ligation, whereas 14% (n = 122) received a superior rectal artery ligation. A total of 12%, 33%, 24%, and 31% were pathologic stage 0, I, II, and III. Median follow-up was 31 months. Superior rectal artery ligation was associated with a similar anastomotic leak rate compared with inferior mesenteric artery ligation (9% vs 8%; p = 1.0). The median number of lymph nodes removed was identical (15 vs 15; p = 0.38). On multivariable analysis accounting for relevant clinicopathologic factors, superior rectal artery ligation was not associated with increased anastomotic leak rate, worse lymph node harvest, or worse locoregional recurrence-free survival, recurrence-free survival, or overall survival (all p values >0.1). LIMITATIONS This was a retrospective design. CONCLUSIONS Compared with inferior mesenteric artery ligation, superior rectal artery ligation is not associated with either worse technical or oncologic outcomes. Given the potential risks of inadequate blood flow to the proximal limb of the anastomosis and autonomic nerve injury, we advocate for increased use of superior rectal artery ligation. See Video Abstract at http://links.lww.com/DCR/B646. ESTUDIO DEL CONSORCIO DE CNCER DE RECTO DE ESTADOS UNIDOS DE LIGADURA BAJA DE LA ARTERIA MESENTRICA INFERIOR CONTRA LIGADURA ALTA DE LA ARTERIA MESENTRICA INFERIOR QU TAN ALTO DEBEMOS EXTENDERNOS ANTECEDENTES:el nivel óptimo de la ligadura del pedículo en la proctectomía para el cáncer de recto, ya sea en el origen de la arteria mesentérica inferior o en la arteria rectal superior aún no esta definido.OBJETIVO:El objetivo era determinar si la ligadura de la arteria rectal superior pronostica resultados técnicos u oncológicos similares.DISEÑO:Análisis retrospectivo de una base de datos de cáncer de recto (2007-2017).ESCENARIO:el estudio se realizó en seis centros de referencia de tercer nivel en los Estados Unidos (Universidad de Emory, Universidad de Michigan, Centro médico de la Universidad de Pittsburgh, Centro médico Wexner de la Universidad Estatal de Ohio, Centro médico de la Universidad de Vanderbilt y Escuela de Medicina de la Universidad de Washington en St. Louis).PACIENTES:Se incluyeron pacientes con cáncer de recto primario no metastásico que se sometieron a resección anterior baja o resección abdominoperineal.PRINCIPALES VARIABLES ANALIZADAS:Se midió la fuga anastomótica, los ganglios linfáticos recuperados, la sobrevida sin recidiva locorregional, la sobrevida sin recidiva y la sobrevida global.RESULTADOS:De 877 pacientes, en el 86% (n = 755) se realizó una ligadura de la arteria mesentérica inferior, y en el 14% (n = 122) se realizó una ligadura de la arteria rectal superior. El 12%, 33%, 24% y 31% estaban en estadio patológico 0, I, II y III respectivamente. La mediana de seguimiento fue de 31 meses. La ligadura de la arteria rectal superior se asoció con una tasa de fuga anastomótica similar a la ligadura de la arteria mesentérica inferior (9 vs 8%, p = 1,0). La mediana del número de ganglios linfáticos extirpados fue idéntica (15 contra 15, p = 0,38). En el análisis multivariado que tiene en cuenta los factores clínico-patológicos relevantes, la ligadura de la arteria rectal superior no se asoció con una mayor tasa de fuga anastomótica, una peor cosecha de ganglios linfáticos o una peor sobrevida libre de recurrencia locorregional, sobrevida libre de recurrencia o sobrevida global (todos p> 0,1).LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:En comparación con la ligadura de la arteria mesentérica inferior, la ligadura de la arteria rectal superior no se asocia a peores resultados técnicos ni oncológicos. Debido a los riesgos potenciales de un flujo sanguíneo inadecuado del muñon proximal de la anastomosis y la lesión de los nervios autonómicos, proponemos una mayor realización de la ligadura de la arteria rectal superior. Consulte Video Resumen en http://links.lww.com/DCR/B646.
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Affiliation(s)
- Michael K. Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Scott E. Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sherif R.Z. Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander T. Hawkins
- Section of Colon and Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew L. Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Shishir K. Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Glen C. Balch
- Division of Colon and Rectal Surgery, Department of Surgery, Emory University, Atlanta, Georgia
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Han Z, Chen D, Li Y, Zhou G, Wang M, Zhang C. Development of a Risk Scoring System for Predicting Anastomotic Leakage Following Laparoscopic Rectal Cancer Surgery. Ther Clin Risk Manag 2021; 17:145-153. [PMID: 33628027 PMCID: PMC7898229 DOI: 10.2147/tcrm.s297278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/02/2021] [Indexed: 01/22/2023] Open
Abstract
Purpose To develop a risk scoring system that can predict the incidence of anastomotic leakage after laparoscopic rectal cancer surgery. Patients and Methods The clinical data of 387 patients with rectal cancer who underwent laparoscopic low anterior resection were retrospectively collected. Univariable and multivariable logistic regression analyses were used to evaluate independent risk factors for postoperative anastomotic leakage. A simplified points system was then developed based on the corresponding regression coefficient β of each risk factor. Receiver operating characteristic (ROC) analysis was used to evaluate the performance and the optimal cut-off value in predicting anastomotic leakage. The performance of the points system was then externally validated in an independent cohort of 192 patients based in another institution. Results Anastomotic leakage occurred in 36 of 387 patients with rectal cancer (9.30%). Logistic multivariable regression analysis showed that males, maximum tumor diameter (≥5cm), operation time (≥180min), preoperative chemoradiation, intraoperative blood transfusion and the anastomosis level from the anal verge (≤5cm) were independent risk factors for the incidence of anastomotic leakage. According to the scoring standard, the risk points of each patient were calculated. ROC analysis based on the risk points showed that the area under the curve (AUC) was 0.795 (95% CI:0.752-0.834) and the optimal cut-off value was 6, yielding a sensitivity of 88.89% and a specificity of 62.96%. Using this risk points system, the AUC of another cohort of 192 patients from another institution who underwent laparoscopic low anterior resection for rectal cancer was 0.853 (95% CI:0.794-0.900, p<0.001) and patients with risk points ≥6 had a 21.05% chance of developing anastomotic leakage. Conclusion This risk points system for predicting anastomotic leakage following laparoscopic rectal cancer surgery may be useful for surgeons in their decisions to perform intraoperative diversion stoma, which can reduce the incidence of postoperative anastomotic leakage.
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Affiliation(s)
- Zhongbo Han
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Dawei Chen
- Department of General Surgery, Jiangyin People's Hospital, School of Medicine, Southeast University, Jiangyin, Jiangsu, People's Republic of China
| | - Yan Li
- Department of Quality and Safety Management, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Guangshuai Zhou
- Department of Quality and Safety Management, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Meng Wang
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
| | - Chao Zhang
- Department of Gastrointestinal Surgery, Zibo Central Hospital, Shandong University, Zibo, Shandong, People's Republic of China
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Teixeira Farinha H, Martin D, Ramó A, Hübner M, Demartines N, Hahnloser D. Proposition of a simple binary grading of estimated blood loss during colon surgery. Int J Colorectal Dis 2021; 36:2111-2117. [PMID: 33864102 PMCID: PMC8426219 DOI: 10.1007/s00384-021-03925-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Intraoperative estimated blood loss (EBL) is often reported in nearly all surgical papers; however, there is no consensus regarding its measurement. The aim of this study was to determine whether EBL (ml) is as reliable and reproducible in predicting complications as a simple binary grading of EBL. METHODS All consecutive patients undergoing colectomies between January 2015 and December 2018 were included. EBL was assessed prospectively by the surgeon and anaesthesiologist in ml and with a binary scale: bleeding "as usual" versus "more than usual" by the surgeon. Differences between pre- and post-operative haemoglobin levels (ΔHb g/dl) were correlated to EBL. Blood loss impact on 30-day postoperative morbidity was analysed. RESULTS A total of 270 patients were included, with a mean age of 65 years (SD 17). Mean EBL documented by surgeons correlated to EBL by anaesthesiologists (79.5 ml, SD 99 vs. 84.5 ml, SD 118, ϱ = 0.926, p < 0.001). Surgeons and anaesthesiologists' EBL correlated also with ΔHb (ϱ = - 0.273, p = 0.01 and ϱ = - 0.344, p = 0.01, respectively). Patient with surgeon EBL ≥ 250 ml or graded as "more than usual" bleeding had significantly more severe complications (8% vs. 20%, p = 0.02 and 8% vs. 27%, p = 0.001, respectively). CONCLUSION Anaesthesiologist and surgeon's EBL correlated with ΔHb. Simple grading of blood loss as "usual" and "more than usual" predicted severe complications and higher mortality rates. This simple binary grading of blood loss in colon surgery could be an alternative to the estimation of blood loss in ml as it is easy to apply but needs to be validated externally.
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Affiliation(s)
- Hugo Teixeira Farinha
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - David Martin
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Audrey Ramó
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Wang XT, Li L, Kong FB, Zhong XG, Mai W. Surgical-related risk factors associated with anastomotic leakage after resection for rectal cancer: a meta-analysis. Jpn J Clin Oncol 2020; 50:20-28. [PMID: 31665375 DOI: 10.1093/jjco/hyz139] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/13/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Anastomotic leakage (AL) after anterior resection always leads to longer hospital stays, decreased quality of life and even increased mortality. Despite extensive research, no consensus on the world well-concerned surgical-related risk factors exists. We therefore conducted a meta-analysis of the available published literature to identify the effects of surgical-related risk factors for AL after anterior resection for rectal cancer, hoping to provide more information and improved guidance for clinical workers managing patients with rectal cancer who are at a high risk for AL. METHODS In this study, the relevant articles were systematically searched from EMBASE, MEDLINE, PubMed, WangFang (Database of Chinese Ministry of Science & Technology), Chinese National Knowledge Infrastructure Database and China Biological Medicine Database. The pooled odds ratio (OR) with 95% confidence interval (95% CI) were calculated. Meta-analysis was performed using of RevMan 5.3 software. RESULTS A total of 26 studies met the inclusion criteria and comprised 34238 cases. Analysis of these 26 studies showed that no defunctioning stoma was highly correlated with AL (pooled OR = 1.28, 95%CI: 1.05-1.57, P = 0.01, random effect), and intraoperative blood transfusion was significantly associated with AL (pooled OR = 1.64, 95%CI: 1.34-2.02, P = 0.02, random effect). However, the AL was not associated with type of anastomosis, type of surgery, technique of anastomosis, level of inferior mesenteric artery ligation, operation time and splenic flexure mobilization. CONCLUSIONS Depend on this meta-analysis, no defunctioning stoma and intraoperative blood transfusion are the major surgical-related risk factors for AL after resection for rectal cancer. Because of the inherent limitations of the research, future prospective randomized controlled trials will need to confirm this conclusion.
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Affiliation(s)
- Xiao-Tong Wang
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Lei Li
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Fan-Biao Kong
- Departments of Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Xiao-Gang Zhong
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
| | - Wei Mai
- Departments of Gastrointestinal and Peripheral Vascular Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, People's Republic of China
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Wiseman JT, Kimbrough C, Beal EW, Zaidi MY, Staley CA, Grotz T, Leiting J, Fournier K, Lee AJ, Dineen S, Powers B, Veerapong J, Baumgartner JM, Clarke C, Patel SH, Dhar V, Hendrix RJ, Lambert L, Abbott DE, Pokrzywa C, Raoof M, Lee B, Fackche N, Greer J, Pawlik TM, Abdel-Misih S, Cloyd JM. Predictors of Anastomotic Failure After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Technique Matter? Ann Surg Oncol 2020; 27:783-792. [PMID: 31659645 DOI: 10.1245/s10434-019-07964-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 08/30/2023]
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Anastomotic Leak Does Not Impact Oncologic Outcomes After Preoperative Chemoradiotherapy and Resection for Rectal Cancer. Ann Surg 2020; 269:678-685. [PMID: 29112004 DOI: 10.1097/sla.0000000000002582] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the relationship of anastomotic leakage, local recurrence, and overall survival in rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection. BACKGROUND Little is known about the association between anastomotic leakage and oncologic outcomes after preoperative CRT. METHODS A total of 698 consecutive primary rectal cancer patients after preoperative CRT between April 19, 2000, and December 27, 2013, were retrospectively reviewed. Forty-seven patients who had anastomotic leakage were compared with 651 patients who had no anastomotic leakage. RESULTS Of 698 patients, 47 (6.7%) patients had anastomotic leakage. Among these 47 patients, 39 (83.0%) had grade C leak that required urgent operation, while 8 (17.0%) had grade B leak that was managed expectantly or by percutaneous drainage. The median follow-up period was 47.6 months (range, 27.1 to 68.9 months). One hundred twenty (17.2%) recurrences were identified among all patients. The median overall disease-free survival was 43 months (range, 22.4 to 66.7 months). Five-year disease-free survival did not differ significantly between the 2 groups (80.5% vs 80.4%, P = 0.839). Five-year local recurrence-free survival did not differ significantly either between the 2 groups (93.7% vs 94.9%, P = 0.653). Five-year overall survival rates of patients with or without leakage were 90.9% and 86.3%, respectively (P = 0.242). Five-year cancer-specific survival rates of patients with or without leakage were 92.2% and 86.3%, respectively (P = 0.248). CONCLUSION After preoperative CRT, an anastomotic leak is not associated with a significant increase in local recurrence or long-term survival in rectal cancer.
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Klupp F, Schuler S, Kahlert C, Halama N, Franz C, Mayer P, Schmidt T, Ulrich A. Evaluation of the inflammatory markers CCL8, CXCL5, and LIF in patients with anastomotic leakage after colorectal cancer surgery. Int J Colorectal Dis 2020; 35:1221-1230. [PMID: 32307587 PMCID: PMC7320065 DOI: 10.1007/s00384-020-03582-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage constitutes a dreaded complication after colorectal surgery, leading to increased morbidity and mortality as well as prolonged hospitalization. Most leakages become clinically apparent about 8 days after surgery; however, early detection is quintessential to reduce complications and to improve patients' outcome. We therefore investigated the significance of specific protein expression profiles as putative biomarkers, indicating anastomotic leakage. METHODS In this single-center prospective cohort study serum and peritoneal fluid samples-from routinely intraoperatively inserted drainages-of colorectal cancer patients were collected 3 days after colorectal resection. Twenty patients without anastomotic leakage and 18 patients with an anastomotic leakage and without other complications were included. Protein expression of seven inflammatory markers in serum and peritoneal fluid was assessed by multiplex ELISA and correlated with patients' clinical data. RESULTS Monocyte chemoattractant protein 2 (CCL8/MCP-2), leukemia-inhibiting factor (LIF), and epithelial-derived neutrophil-activating protein (CXCL5/ENA-78) were significantly elevated in peritoneal fluid but not in serum samples from patients subsequently developing anastomotic leakage after colorectal surgery. No expressional differences could be found between grade B and grade C anastomotic leakages. CONCLUSION Measurement 3 days after surgery revealed altered protein expression patterns of the inflammatory markers CCL8/MCP2, LIF, and CXCL5/ENA-78 in peritoneal fluid from patients developing anastomotic leakage after colorectal surgery. Further studies with a larger patient cohort with inclusion of different variables are needed to evaluate their potential as predictive biomarkers for anastomotic leakage.
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Affiliation(s)
- F. Klupp
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S. Schuler
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C. Kahlert
- grid.4488.00000 0001 2111 7257Department of Visceral, Thoracic and Vascular Surgery, University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - N. Halama
- grid.7700.00000 0001 2190 4373National Center for Tumor Diseases, Medical Oncology and Internal Medicine VI, Tissue Imaging and Analysis Center, Bioquant, University of Heidelberg, Im Neuenheimer Feld 267, 69120 Heidelberg, Germany
| | - C. Franz
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P. Mayer
- grid.5253.10000 0001 0328 4908Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T. Schmidt
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - A. Ulrich
- grid.7700.00000 0001 2190 4373Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany ,grid.416164.0Department of General and Visceral Surgery, Lukas Hospital Neuss, Preußenstr. 84, 41464 Neuss, Germany
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Shen Z, An Y, Shi Y, Yin M, Xie Q, Gao Z, Jiang K, Wang S, Ye Y. The Aortic Calcification Index is a risk factor associated with anastomotic leakage after anterior resection of rectal cancer. Colorectal Dis 2019; 21:1397-1404. [PMID: 31361381 DOI: 10.1111/codi.14795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 05/14/2019] [Indexed: 12/17/2022]
Abstract
AIM Anastomotic leakage (AL) is one of the most feared postoperative complications after anterior resection (AR) of rectal cancer. An adequate blood supply at the anastomotic site is regarded as a prerequisite for healing. We hypothesize that the Aortic Calcification Index (ACI) might reflect the severity of atherosclerosis in patients, and thereby be a risk factor for AL. METHOD AL was investigated retrospectively according to the definition of the International Study Group of Rectal Cancer in 423 rectal cancer patients who underwent anterior rectal resection. The ACI was measured by preoperative abdominal CT scan. The cross-section of the aorta was evenly divided into 12 sectors, the number of calcified sectors was counted as the calcification score of each slice. Lasso logistic regression and multivariate regression analysis were used to identify risk factors for AL. RESULTS The percentage of AL after AR was 7.8% (33/423); the mortality of patients who sustained a leak was 3.0% (1/33). Patients with a high ACI had a significantly higher percentage of AL than patients with low ACI (11.2% vs 5.6%, P = 0.04). Among patients with AL, a higher ACI was associated with greater severity of AL (the ACI of patients with grade A leakage, grade B leakage and grade C leakage was 0.5% ± 0.2%, 11.5% ± 9.2% and 24.2% ± 21.7%, respectively; P = 0.008). After risk adjustment, multivariate regression analysis showed that a higher ACI was an independent risk factor for AL (OR 2.391, P = 0.04). CONCLUSION A high ACI might be an important prognostic factor for AL after AR for rectal cancer. Confirmatory studies are required.
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Affiliation(s)
- Z Shen
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - Y An
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - Y Shi
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Beijing, China
| | - M Yin
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - Q Xie
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - Z Gao
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - K Jiang
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - S Wang
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
| | - Y Ye
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, China
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Knight KA, Horgan PG, McMillan DC, Roxburgh CSD, Park JH. The relationship between aortic calcification and anastomotic leak following gastrointestinal resection: A systematic review. Int J Surg 2019; 73:42-49. [PMID: 31765846 DOI: 10.1016/j.ijsu.2019.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/23/2019] [Accepted: 11/17/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a significant complication of gastrointestinal (GI) surgery. Impaired perfusion of the anastomosis is thought to play an important role. The degree of aortic calcification (AC) visible on preoperative CT imaging may be associated with an increased risk of AL following GI resection. This review assessed the relationship between AC and AL in patients undergoing GI resection. MATERIALS AND METHODS MEDLINE, EMBASE and the Cochrane library were systematically searched between 1946 and 2019. Relevant keywords were grouped to form a sensitive search strategy: surgical procedure (e.g. digestive system surgical procedure), calcification (e.g. vascular calcification, calcium score) and outcome (e.g. anastomotic leak). Studies assessing the degree of AC on preoperative imaging in relation to AL in adult patients requiring resection and anastomosis were included. The quality of each study was assessed using the Newcastle-Ottawa scale. Bias was assessed using the RevMan risk of bias tool. RESULTS Nine observational studies were included: four in patients undergoing oesophageal resection (n = 1446) and five in patients undergoing colorectal resection (n = 556). AL occurred in 20% of patients following oesophagectomy and 14% of patients following colorectal resection. Adjustment for relevant confounders was limited in most studies. Two studies reported a relationship between the degree of AC and AL in patients undergoing oesophagectomy, independent of age and comorbidity. One study reported an association between AC and AL following colorectal resection, while three studies reported higher calcium scores in the iliac arteries of patients who developed colorectal AL. Overall study quality was moderate to good using the Newcastle-Ottawa scale. Detection and reporting bias was evident in the studies examining AL following colorectal resection. CONCLUSION The current evidence suggests that the degree of AC may be associated with the development of AL, in particular in patients undergoing oesophagectomy. Further prospective data with adequate adjustment for confounders are required. PROSPERO REGISTRATION NUMBER CRD42018081128.
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Affiliation(s)
- K A Knight
- Academic Unit of Surgery, Glasgow Royal Infirmary, School of Medicine, University of Glasgow, UK.
| | - P G Horgan
- Academic Unit of Surgery, Glasgow Royal Infirmary, School of Medicine, University of Glasgow, UK
| | - D C McMillan
- Academic Unit of Surgery, Glasgow Royal Infirmary, School of Medicine, University of Glasgow, UK
| | - C S D Roxburgh
- Academic Unit of Surgery, Glasgow Royal Infirmary, School of Medicine, University of Glasgow, UK
| | - J H Park
- Academic Unit of Surgery, Glasgow Royal Infirmary, School of Medicine, University of Glasgow, UK
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Kang L, Chen YG, Zhang H, Zhang HY, Lin GL, Yang YC, Chen WH, Luo SL, Chen N, Tong WD, Shen ZL, Xiong DH, Xiao Y, Zhang ZT, Wang JP. Transanal total mesorectal excision for rectal cancer: a multicentric cohort study. Gastroenterol Rep (Oxf) 2019; 8:36-41. [PMID: 32104584 PMCID: PMC7034231 DOI: 10.1093/gastro/goz049] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 12/17/2022] Open
Abstract
Background Transanal total mesorectal excision (taTME) has recently emerged as a promising novel surgical procedure for rectal cancer. It is believed to hold the potential advantage of providing better access to mobilize the distal rectum and achieving better pathologic results. This study aimed to evaluate the feasibility of taTME for rectal cancer and summarize the preliminary experience in 10 Chinese hospitals. Methods A total of 211 patients were enrolled in this study. Variables for evaluation of safety, feasibility, and oncologic outcomes were retrospectively collected and analysed. Results The median distance between the tumor and the anal verge was 5.9 cm (range, 1.5–12 cm). The median operating time was 280 min (range, 70–600 min) and the median estimated intra-operative blood loss was 50 mL (range, 10–1,500 mL). The overall rate of complication was 27.9%. Among the 211 patients, 175 (82.9%) had complete TME and 33 (15.6%) had near complete TME. The circumferential resection margin was negative in 97.7% of patients. The patients were followed for a median of 35 months (range, 2–86 months). There was 7.6% (16) mortality, 6.2% (13) had local recurrence, and 12.8% (27) had systemic recurrence. Kaplan–Meier survival analysis showed that 1-, 2-, and 3-year disease-free survival rates were 94.8%, 89.3%, and 80.2%, respectively, and 1-, 2-, and 3-year OS rates were 97.4%, 95.7%, and 92.9%, respectively. Conclusions Although limited by its retrospective nature, taTME was safe and feasible in selected patients. Future work with rigorous data recording is warranted.
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Affiliation(s)
- Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, P. R. China
| | - Yuan-Guang Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P. R. China
| | - Hao Zhang
- Department of General Surgery, Dongguan Kanghua Hospital, Dongguan, Guangdong, P. R. China
| | - Hong-Yu Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Ying-Chi Yang
- Department of General Surgery, Beijing Friendship Hospital, Beijing, P. R. China
| | - Wen-Hao Chen
- Department of Colorectal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Shuang-Ling Luo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, P. R. China
| | - Ning Chen
- Department of General Surgery, Peking University Third Hospital, Beijing, P. R. China
| | - Wei-Dong Tong
- Department of Gastrointestinal Surgery, Daping Hospital, Third Military Medical University, Chongqing, P. R. China
| | - Zhan-Long Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, P. R. China
| | - De-Hai Xiong
- Department of General Surgery, Chongqing Three Gorges Center Hospital, Chongqing, P. R. China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P. R. China
| | - Zhong-Tao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Beijing, P. R. China
| | - Jian-Ping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, P. R. China
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Xiao C, Zhou M, Yang X, Xiao F, Liu X, Guo Y, Li X, Cao H, Luo J. Novel nomogram with microvascular density in the surgical margins can accurately predict the risk for anastomotic leakage after anterior resection for rectal cancer. J Surg Oncol 2019; 120:1412-1419. [PMID: 31621086 DOI: 10.1002/jso.25730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a serious complication after anterior resection. The purpose of this study was to determine the role of microvascular density (MVD) in AL and to develop a nomogram to accurately predict AL. METHODS This study retrospectively enrolled 477 consecutive patients who underwent anterior resection for rectal cancer from January 2011 to January 2019. Tissue samples of the resection margins were assessed for MVD. Univariate and multivariate regression analyses were used to identify the risk factors for AL. RESULTS The incidence of clinical AL was 6.7%. MVD in the distal margin was associated with AL (P < .001). Univariate and multivariate regression analysis identified the following variables as independent risk factors for AL: preoperative albumin ≤35 g/L (odds ratio [OR] = 2.511), neoadjuvant treatment (OR = 3.560), location of tumor ≤7 cm (OR = 3.381), blood loss ≥100 mL (OR = 2.717), and MVD in the distal margin ≤20 (OR = 4.265). Then, a nomogram including these predictors was developed. The nomogram showed good discrimination (AUC = 0.816) and calibration (concordance index = 0.816). The decision curve analysis demonstrated that the nomogram was clinically useful. CONCLUSIONS MVD in the distal margin is closely associated with AL. The nomogram can be used for individualized prediction of AL after anterior resection for patients with rectal cancer.
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Affiliation(s)
- Chanchan Xiao
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Meihua Zhou
- Department of Nursing, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Xihua Yang
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Fangtao Xiao
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Xiaofei Liu
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Yi Guo
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Xiaojie Li
- Department of Pathology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Huiqiu Cao
- Department of Pathology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
| | - Jihui Luo
- Department of Surgical Oncology, Chenzhou No. 1 People's Hospital, Chenzhou, Hunan, China
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Arezzo A, Migliore M, Chiaro P, Arolfo S, Filippini C, Di Cuonzo D, Cirocchi R, Morino M. The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery. Tech Coloproctol 2019; 23:649-663. [PMID: 31240416 DOI: 10.1007/s10151-019-02028-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/20/2019] [Indexed: 12/31/2022]
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Abstract
Objective: Anastomotic Leakage (AL) is one of the most common complications after resection of rectal cancer. Recognition of the incidence and risk factors related to AL is important. This study aimed develops a model that can predict anastomotic leakage after anterior rectal resection. Methods: Data from 188 patients undergoing anterior resection of rectal cancer were collected for retrospective analysis. Patients were randomly divided in the development set and validation set at a 1:1 ratio. We first included age, sex, preoperative chemoradiotherapy, tumor size, degree of tumor differentiation, stage, TNM stage, lymph vascular invasion, distance, anastomotic method, diabetes, intraoperative time, intraoperative bleeding and smoking as candidates for variable selection with a LASSO method. A ROC curve was constructed with the validation set to assess the accuracy of the prediction model. Results: AL occurred in 20 of 188 patients (10.6%). Preoperative chemoradiotherapy (p=0.04), medium degree of tumor differentiation (p=0.04), anastomotic method (p<0.01), intraoperative bleeding≥400ml (p<0.01), smoking (p<0.01), diabetes (p<0.01) were significantly related to AL. The area under the ROC curve of the prediction model is 0.952. Conclusions: This study developed a model that can predict anastomotic leakage after anterior rectal resection, which may aid the selection of preventive ileostomy and postoperative management.
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Affiliation(s)
- Shubang Cheng
- Dr. Shubang Cheng, MD, Department of Gastrointestinal, People's Hospital of Longhua District, Affiliated Hospital of Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Bolin He
- Dr. Bolin He, MD, Department of Gastrointestinal, People's Hospital of Longhua District, Affiliated Hospital of Guangdong Medical University, Shenzhen, Guangdong Province, China
| | - Xueyi Zeng
- Dr. Xueyi Zeng, MD, Department of Gastrointestinal, People's Hospital of Longhua District, Affiliated Hospital of Guangdong Medical University, Shenzhen, Guangdong Province, China
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Different clinical features according to the anastomotic leakage subtypes after rectal cancer surgeries: contained vs. free leakages. PLoS One 2018; 13:e0208572. [PMID: 30540826 PMCID: PMC6291156 DOI: 10.1371/journal.pone.0208572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/20/2018] [Indexed: 12/18/2022] Open
Abstract
Background Anastomotic leakage can be classified by free and contained leakage according to clinical manifestations. The risk factors and their comparison between these leakage subtypes are uncertain. This study aims to evaluate anastomotic leakage patterns and to compare clinical features between free and contained leakages after low anterior resection for rectal cancer. Materials and methods Between January 2005 and December 2012, a total of 2035 consecutive patients who underwent low anterior resection for primary rectal cancer were evaluated retrospectively at two-tertiary referral centers. The primary end points of this study were to assess detailed clinical features among leakage subtypes. The secondary end point was to compare risk factors between free and contained leakages. Results Patients were subdivided into a no leakage group (n = 1890), free leakage group (n = 73), and contained leakage group (n = 72). Free leakage occurred more frequently in laparoscopic and robotic surgeries than open surgery (p = 0.015). On the other hand, contained leakage was developed in a higher rate of patients who received preoperative chemoradiotherapy (p<0.001). The mean development time was 4.6 days in the free leakage group, and 23.6 days in the contained leakage group. Patients with free leakage had a lower rate of a defunctioning stoma than contained leakage (5.5% vs. 29.2%, p<0.001). Risk factors for free leakage were smoking, tumor location, and laparoscopic surgery. However, tumor location and preoperative chemoradiotherapy increased the risk for contained leakage. Conclusions Contained leakage in rectal cancer surgery showed different clinical manifestations and risk factors compared to free leakage. It is necessary to pay more attention to patients with particular risk factors for anastomotic leakage subtypes.
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Woo IT, Park JS, Choi GS, Park SY, Kim HJ, Park IK. Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis. Ann Coloproctol 2018; 34:259-265. [PMID: 30419724 PMCID: PMC6238803 DOI: 10.3393/ac.2018.05.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/04/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. Methods Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. Results A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). Conclusion In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.
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Affiliation(s)
- In Teak Woo
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Kyu Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
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Klose J, Tarantino I, von Fournier A, Stowitzki MJ, Kulu Y, Bruckner T, Volz C, Schmidt T, Schneider M, Büchler MW, Ulrich A. A Nomogram to Predict Anastomotic Leakage in Open Rectal Surgery-Hope or Hype? J Gastrointest Surg 2018; 22:1619-1630. [PMID: 29777457 DOI: 10.1007/s11605-018-3782-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leakage is the most dreaded complication after rectal resection and total mesorectal excision, leading to increased morbidity and mortality. Formation of a diverting ileostomy is generally performed to protect anastomotic healing. Identification of variables predicting anastomotic leakage might help to select patients who are under increased risk for the development of anastomotic leakage prior to surgery. The objective of this study was to assess the applicability of a nomogram as prognostic model for the occurrence of anastomotic leakage after rectal resection in a cohort of rectal cancer patients. METHODS Nine hundred seventy-two consecutive patients who underwent surgery for rectal cancer were retrospectively analyzed. Univariate and multivariable Cox regression analyses were used to determine independent risk factors associated with anastomotic leakage. Receiver operating characteristics (ROC) curve analysis was performed to calculate the sensitivity, specificity, and overall model correctness of a recently published nomogram and an adopted risk score based on the variables identified in this study as a predictive model. RESULTS Male sex (p = 0.042), obesity (p = 0.017), smoking (p = 0.012), postoperative bleeding (p = 0.024), and total protein level ≤ 5.6 g/dl (p = 0.007) were identified as independent risk factors for anastomotic leakage. The investigated nomogram and the adopted risk score failed to reach relevant areas under the ROC curve greater than 0.700 for the prediction of anastomotic leakage. CONCLUSIONS The proposed nomogram and the adopted risk score failed to reliably predict the occurrence of anastomotic leakage after rectal resection. Risk scores as prognostic models for the prediction of anastomotic leakage, independently of the study population, still need to be identified.
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Affiliation(s)
- Johannes Klose
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Ignazio Tarantino
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Armin von Fournier
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Moritz J Stowitzki
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Claudia Volz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Cikot M, Kasapoglu P, Isiksacan N, Binboga S, Kones O, Gemici E, Kartal B, Alis H. The importance of presepsin value in detection of gastrointestinal anastomotic leak: a pilot study. J Surg Res 2018; 228:100-106. [DOI: 10.1016/j.jss.2018.02.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/14/2018] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
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Elevated risk of stoma outlet obstruction following colorectal surgery in patients undergoing ileal pouch–anal anastomosis: a retrospective cohort study. Surg Today 2018; 48:1060-1067. [DOI: 10.1007/s00595-018-1698-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/01/2018] [Indexed: 12/22/2022]
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Multicenter analysis of risk factors for anastomotic leakage after middle and low rectal cancer resection without diverting stoma: a retrospective study of 319 consecutive patients. Int J Colorectal Dis 2017; 32:1431-1437. [PMID: 28766076 DOI: 10.1007/s00384-017-2875-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the risk factors for anastomotic leakage (AL) after anterior resection for middle and low rectal cancer in order to help surgeons to decide which patients could benefit from a diverting stoma. METHODS Data on 319 patients having a middle and low rectal cancer resection with anastomosis between May 2011 and October 2015 from two hospitals were included in the study. The analysis included the following variables: patient-related variables (gender, age, diabetes mellitus, ASA score, preoperative radiochemotherapy, body mass index, blood hemoglobin, and serum albumin level), tumor-related variables (K-ras status, distance of tumor from the anal verge, histopathologic grade, pathological T stage, pathological N stage, pathological M stage, TNM stage, and tumor size), and surgery-related variables (laparoscopic or open surgery, blood loss, and operative time). Univariate and multivariate regression analysis were carried out to identify risk factors for AL. RESULTS The AL rate was 11.91% (38/319). Male (OR 2.898, 95% CI 1.265-6.637, p = 0.012), diabetes mellitus (OR 2.482, 95% CI 1.004-6.134, p = 0.049), K-ras mutation (OR 2.544, 95% CI 1.210-5.348, p = 0.014), distance of tumor from the anal verge (OR 3.445, 95% CI 1.631-7.279, p = 0.001), and preoperative radiochemotherapy (OR 2.790, 95% CI 1.056-7.372, p = 0.039) were independent risk factors of AL. One (2.63%) in 38 patients with AL presented with no risk factor of AL, 6 (15.8%) in 38 patients with 1 risk factor, 16 (42.1%) in 38 patients with 2 risk factors, 9 (23.7%) in 38 patients with 3 risk factors, and 6 (15.7%) in 38 patients with 4 risk factors. No patient with 5 risk factors in our study. AL rate increased with the elevated number of risk factors clustering in individuals. CONCLUSIONS K-ras mutation is first reported to be an independent risk factor for AL after sphincter-preserving surgery without diverting stoma. A diverting stoma should be performed in sphincter-preserving surgery for middle and low rectal cancer patients with 2 or more risk factors identified in this analysis.
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Nomogram Prediction of Anastomotic Leakage and Determination of an Effective Surgical Strategy for Reducing Anastomotic Leakage after Laparoscopic Rectal Cancer Surgery. Gastroenterol Res Pract 2017; 2017:4510561. [PMID: 28592967 PMCID: PMC5448048 DOI: 10.1155/2017/4510561] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/13/2022] Open
Abstract
Background Although many surgical strategies have been used to reduce the anastomotic leak (AL) rate after laparoscopic rectal cancer surgery, limited data are available on the risk factors for AL and the effective strategy to reduce AL. Methods The present study enrolled 736 consecutive patients who underwent laparoscopic resection without a diverting stoma for rectal adenocarcinoma. A nomogram was constructed to predict AL. Based on the nomogram, personalized risk was calculated and sequential surgical strategies were monitored using risk-adjusted cumulative sum (RA-CUSUM) analysis. Results Among the 736 patients, clinical AL occurred in 65 patients (8.8%). Sex, an American Society of Anesthesiologists score, operation time, blood transfusion, and tumor location were identified as significant predictive factors for AL. Based on these factors, a nomogram was created to predict AL, with a concordance index (C-index) of 0.753 (95% confidence interval, 0.690–0.816). A calibration plot showed good statistical performance on internal validation (bias-corrected C-index of 0.742). The RA-CUSUM curve showed that extended splenic flexure mobilization (SFM) could be the most influential strategy to reduce AL. Conclusions Our nomogram for predicting AL after laparoscopic rectal cancer surgery might be helpful to identify the individual risk of AL. Furthermore, extended SFM might be the most appropriate strategy for reducing AL.
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Bakker IS, Morks AN, ten Cate Hoedemaker HO, Burgerhof JGM, Leuvenink HG, van Praagh JB, Ploeg RJ, Havenga K, Bakker IS, Morks AN, ten Cate Hoedemaker HO, Leuvenink HG, Ploeg RJ, Havenga K, van Etten B, Lange JFM, Hemmer PHJ, Burgerhof JGM, Sonneveld DJA, Tanis PJ, Wegdam JA, Jonk A, Lutke Holzik MF, Bosker RJI, Lamme B, Spillenaar Bilgen EJ, Bremers AJ, van der Mijle HC, Hoff C, de Vries DP, Logeman F, Sietses C, Lesanka Versluijs-Ossewaarde FN, Leijtens JW, Tobon Morales RE, Neijenhuis PA, Kloppenberg FW, Schasfoort R, Bleeker WA, Hess D, Rosman C, Wit F, Ton van Engelenburg KC, Pronk A, Bonsing BA, Dekker JW, Consten EC, Patijn GA, Bogdan Rajcs S, Csapó Z, Bálint A, Harsányi L, István G, Horisberger K, Bader F, Kutup A, Mariette C, Cebrián F. Randomized clinical trial of biodegradeable intraluminal sheath to prevent anastomotic leak after stapled colorectal anastomosis. Br J Surg 2017; 104:1010-1019. [DOI: 10.1002/bjs.10534] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/09/2016] [Accepted: 02/08/2017] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Anastomotic leakage is a potential major complication after colorectal surgery. The C-seal was developed to help reduce the clinical leakage rate. It is an intraluminal sheath that is stapled proximal to a colorectal anastomosis, covering it intraluminally and thus preventing intestinal leakage in case of anastomotic dehiscence. The C-seal trial was initiated to evaluate the efficacy of the C-seal in reducing anastomotic leakage in stapled colorectal anastomoses.
Methods
This RCT was performed in 41 hospitals in the Netherlands, Germany, France, Hungary and Spain. Patients undergoing elective surgery with a stapled colorectal anastomosis less than 15 cm from the anal verge were eligible. Included patients were randomized to the C-seal and control groups, stratified for centre, anastomotic height and intention to create a defunctioning stoma. Primary outcome was anastomotic leakage requiring invasive treatment.
Results
Between December 2011 and December 2013, 402 patients were included in the trial, 202 in the C-seal group and 200 in the control group. Anastomotic leakage was diagnosed in 31 patients (7·7 per cent), with a 10·4 per cent leak rate in the C-seal group and 5·0 per cent in the control group (P = 0·060). Male sex showed a trend towards a higher leak rate (P = 0·055). Construction of a defunctioning stoma led to a lower leakage rate, although this was not significant (P = 0·095).
Conclusion
C-seal application in stapled colorectal anastomoses does not reduce anastomotic leakage. Registration number: NTR3080 (http://www.trialregister.nl/trialreg/index.asp).
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Affiliation(s)
- I S Bakker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A N Morks
- Department of Surgery, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - H O ten Cate Hoedemaker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J G M Burgerhof
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H G Leuvenink
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J B van Praagh
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - R J Ploeg
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - K Havenga
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - I S Bakker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A N Morks
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H O ten Cate Hoedemaker
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - H G Leuvenink
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - R J Ploeg
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K Havenga
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - B van Etten
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J F M Lange
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - P H J Hemmer
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J G M Burgerhof
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | | | - P J Tanis
- Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Wegdam
- Elkerliek Ziekenhuis, Helmond, The Netherlands
| | - A Jonk
- Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands
| | | | | | - B Lamme
- Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - A J Bremers
- Radboud University, Nijmegen Medical Centre, The Netherlands
| | | | - C Hoff
- Medical Centre, Leeuwarden, The Netherlands
| | - D P de Vries
- Ommelander Ziekenhuis Group, Winschoten, The Netherlands
| | - F Logeman
- Beatrix Hospital, Gorinchem, The Netherlands
| | - C Sietses
- Gelderse Vallei Hospital, Ede, The Netherlands
| | | | | | | | | | | | | | | | - D Hess
- Antonius Hospital, Sneek, The Netherlands
| | - C Rosman
- Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - F Wit
- Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - A Pronk
- Diakonessenhuis, Utrecht, The Netherlands
| | - B A Bonsing
- Leiden University Medical Centre, The Netherlands
| | - J W Dekker
- Reinier de Graaf Hospital, Delft, The Netherlands
| | - E C Consten
- Meander Medical Centre, Amersfoort, The Netherlands
| | | | - S Bogdan Rajcs
- Szabolcs-Szatmár-Bereg County Hospitals, Jósa András University Teaching Hospital, Nyíregyháza, Hungary
| | - Z Csapó
- Flór Ferenc Hospital of County Pest, Kistarcsa, Hungary
| | - A Bálint
- Szent Imre Hospital, Budapest, Hungary
| | - L Harsányi
- Semmelweis University, First Department of surgery, Budapest, Hungary
| | - G István
- Semmelweis University, Second Department of Surgery, Budapest, Hungary
| | - K Horisberger
- University Medical Centre Mannheim, University of Heidelberg, Germany
| | - F Bader
- Klinikum Rechts der Isar, Technische Universität München, Germany
| | - A Kutup
- University Medical Centre Hamburg–Eppendorf, Germany
| | - C Mariette
- Claude Huriez University Hospital, Lille, France
| | - F Cebrián
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Banasiewicz T, Dziki A, Lampe P, Lorenc Z, Szczepkowski M, Zieliński J, Wallner G. Anastomotic leaks in gastrointestinal surgery and their prevention. POLISH JOURNAL OF SURGERY 2017; 89:49-56. [PMID: 28537563 DOI: 10.5604/01.3001.0009.8979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.
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Affiliation(s)
- Tomasz Banasiewicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej Uniwersytetu Medycznego im. K. Marcinkowskiego w Poznaniu
| | - Adam Dziki
- Klinika Chirurgii Ogólnej i Kolorektalnej UM w Łodzi
| | - Paweł Lampe
- Katedra i Klinika Chirurgii Przewodu Pokarmowego Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Zbigniew Lorenc
- Katedra i Oddział Kliniczny Chirurgii Ogólnej, Kolorektalnej i Urazów Wielonarządowych w Sosnowcu; Wydział Nauk o Zdrowiu Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Marek Szczepkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej Centrum Medycznego Kształcenia Podyplomowego w Warszawie
| | | | - Grzegorz Wallner
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego Uniwersytetu Medycznego w Lublinie
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Jannasch O, Klinge T, Otto R, Chiapponi C, Udelnow A, Lippert H, Bruns CJ, Mroczkowski P. Risk factors, short and long term outcome of anastomotic leaks in rectal cancer. Oncotarget 2017; 6:36884-93. [PMID: 26392333 PMCID: PMC4742217 DOI: 10.18632/oncotarget.5170] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/04/2015] [Indexed: 12/12/2022] Open
Abstract
Background An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery. Methods From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage. Results In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL. Conclusion In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.
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Affiliation(s)
- Olof Jannasch
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany.,Department for General and Abdominal Surgery, AMEOS Hospital, Haldensleben, Germany
| | - Tim Klinge
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Ronny Otto
- Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
| | - Costanza Chiapponi
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Andrej Udelnow
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Hans Lippert
- Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
| | - Christiane J Bruns
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Pawel Mroczkowski
- Department for General, Visceral and Vascular Surgery, Otto-von-Guericke-University, Magdeburg, Germany.,Institute for Quality Assurance in Operative Medicine, Otto-von-Guericke-University, Magdeburg, Germany
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40
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Boland MR, Reynolds I, McCawley N, Galvin E, El-Masry S, Deasy J, McNamara DA. Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery. Ann R Coll Surg Engl 2017; 99:113-116. [PMID: 27659363 PMCID: PMC5392825 DOI: 10.1308/rcsann.2016.0280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2016] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.
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Affiliation(s)
- M R Boland
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - I Reynolds
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - N McCawley
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - E Galvin
- Department of Anaesthesia, Beaumont Hospital , Dublin 9 , Ireland
| | - S El-Masry
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - J Deasy
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
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Watanabe T, Miyata H, Konno H, Kawai K, Ishihara S, Sunami E, Hirahara N, Wakabayashi G, Gotoh M, Mori M. Prediction model for complications after low anterior resection based on data from 33,411 Japanese patients included in the National Clinical Database. Surgery 2017; 161:1597-1608. [PMID: 28153378 DOI: 10.1016/j.surg.2016.12.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 12/02/2016] [Accepted: 12/06/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential. METHODS Data from the National Clinical Database on patients who had undergone low anterior resection in 2011 and 2012 were retrospectively analyzed. Multiple logistic regression analyses were performed to generate predictive models of postoperative complications. Receiver-operator characteristic curves were generated, and the concordance index was used to assess the model's discriminatory ability. RESULTS The number of patients who had undergone low anterior resection was 33,411. Seven complications, namely, overall operative site infections except for leakage, anastomotic leakage, urinary tract infection, pneumonia, renal failure, systemic sepsis, and cardiac events, were selected to construct statistical risk models. The concordance indices for the first 2 complications, which were dependent on the operative procedure, were relatively low (0.593-0.625), and the other 5, unrelated to operative procedures, showed high concordance indices (0.643-0.799). CONCLUSION This study created the world's second risk calculator to predict the complications of low anterior resection as a model based on mass nationwide data. In particular, this model is the first to predict anastomotic leakage.
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Affiliation(s)
- Toshiaki Watanabe
- Japanese Society of Gastroenterological Surgery, Database Committee Working Group, Tokyo, Japan.
| | - Hiroaki Miyata
- Japanese Society of Gastroenterological Surgery, Database Committee Working Group, Tokyo, Japan; National Clinical Database, Tokyo, Japan
| | - Hiroyuki Konno
- Japanese Society of Gastroenterological Surgery, Database Committee Working Group, Tokyo, Japan
| | - Kazushige Kawai
- Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | | | - Eiji Sunami
- Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | | | - Go Wakabayashi
- Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Mitsukazu Gotoh
- Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Masaki Mori
- National Clinical Database, Tokyo, Japan; Japanese Society of Gastroenterological Surgery, Tokyo, Japan
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42
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Yang Y, Shu Y, Su F, Xia L, Duan B, Wu X. Prophylactic transanal decompression tube versus non-prophylactic transanal decompression tube for anastomotic leakage prevention in low anterior resection for rectal cancer: a meta-analysis. Surg Endosc 2016; 31:1513-1523. [PMID: 27620910 DOI: 10.1007/s00464-016-5193-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 08/17/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transanal decompression tube (TDT), an alternative intervention believed to have potential equivalent efficacy in reducing anastomotic leakage after rectal cancer surgery and lower complication rates compared to protective stoma, was sporadically applied in some medical centers during recent decade. The objective of this meta-analysis was to evaluate the effect of the TDT in preventing the anastomotic leakage after low anterior resection for rectal cancer. METHODS The studies comparing TDT and non-TDT in rectal cancer were researched up to March 22, 2016 without language preference, in databases of PubMed, Web of Science, Cochrane library, International Clinical Trials Registry Platform, and National Clinical Trials Registry. The rates of anastomotic leakage, bleeding, and re-operation were separately calculated and compared between TDT and non-TDT groups using RevMan 5.3. Funnel plots, and Egger's tests were used to evaluate the publication biases of the studies. RESULTS Two prospective randomized controlled trial studies and five observational cohort studies with 833 participants in TDT group and 939 participants in non-TDT group were finally included in this meta-analysis. The results indicated that the TDT group had lower anastomotic leakage rate than non-TDT group with significant RR (RR 0.44; 95 % CI 0.29-0.66; P < 0.0001) and heterogeneity (I 2 = 33 %; P = 0.18). So did the re-operation rate, with RR (RR 0.16; 95 % CI 0.07-0.37; P < 0.0001) and heterogeneity among the studies (I 2 = 0 %; P = 0.80). There was no significant difference in anastomotic bleeding rates (RR 1.48; 95 % CI 0.79-2.77; P = 0.22) (I 2 = 58 %; P = 0.09). No publication bias was found by Egger's test (anastomotic leakage rate, Pr > |z| = 0.224; re-operation rate, Pr > |z| = 0.425). CONCLUSIONS TDT might be an efficient and economic intervention in preventing anastomotic leakage after rectal cancer surgery.
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Affiliation(s)
- Yun Yang
- Department of Gastrointestinal Surgery, West China School of Medicine, Sichuan University/West China Hospital, Chengdu Shangjin Nanfu, Chengdu, 610041, Sichuan Province, China
| | - Ye Shu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Lane, Chengdu, 610041, Sichuan Province, China
| | - Fangyu Su
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | - Lin Xia
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Lane, Chengdu, 610041, Sichuan Province, China
| | - Baofeng Duan
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xiaoting Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Lane, Chengdu, 610041, Sichuan Province, China.
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Wei D. Surgical treatment of low rectal cancer: Current status and future prospects. Shijie Huaren Xiaohua Zazhi 2016; 24:3238-3247. [DOI: 10.11569/wcjd.v24.i21.3238] [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] [Indexed: 02/07/2023] Open
Abstract
Rectal cancer is a common type of malignant tumor in China, and its incidence rate is rising year by year. Middle and low rectal cancer accounts for 70%-80% of all rectal cancer cases. The treatment concept requires not only radical resection of tumor, but also preservation of the anal and urogenital function, in order to improve the quality of life. Improved surgical technique requires laparoscopic minimally invasive surgery, to reduce trauma and shorten hospital stay. To improve the 5-year disease-free survival rate, correct treatment of distant metastases, especially liver metastases, is required. By improving the accuracy of preoperative staging of rectal cancer, applying neoadjuvant therapy, and following the principle of total mesorectal excision, patients can benefit in terms of increased resection rate, decreased operation complication incidence, increased sphincter preservation, decreased local recurrence and increased overall survival rate. With the development of medical technology, minimally invasive surgery for low rectal cancer has been developed rapidly. Surgical resection is the only curative method in the therapy of rectal cancer and liver metastases. However, there are still some doubts concerning what to resect first in cases of synchronous rectal cancer and liver metastases in order to achieve the best results. In this paper, we discuss new progress in the surgical treatment of low rectal cancer and rectal cancer liver metastases.
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Ma L, Cai XJ, Wang HH, Yu YL, Huang DY, Ge GJ, Hu HY, Yu SC. Laparoscopic colonic anastomosis using a degradable stent in a porcine model. World J Gastroenterol 2016; 22:4707-4715. [PMID: 27217702 PMCID: PMC4870077 DOI: 10.3748/wjg.v22.i19.4707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/02/2016] [Accepted: 03/14/2016] [Indexed: 02/07/2023] Open
Abstract
AIM: To explore the feasibility and safety of laparoscopic colonic anastomosis using a degradable stent in a porcine model.
METHODS: Twenty Bama mini-pigs were randomly assigned to a stent group (n = 10) and control group (hand-sewn anastomosis, n = 10). The anastomotic completion and operation times were recorded, along with histological examination, postoperative general condition, complications, mortality, bursting pressure, and the average anastomotic circumference (AC).
RESULTS: All pigs survived postoperatively except for one in the stent group that died from ileus at 11 wk postoperatively. The operation and anastomotic completion times of the stent group were significantly shorter than those of the control group (P = 0.004 and P = 0.001, respectively). There were no significant differences in bursting pressure between the groups (P = 0.751). No obvious difference was found between the AC and normal circumference in the stent group, but AC was significantly less than normal circumference in the control group (P = 0.047, P < 0.05). No intestinal leakage and luminal stenosis occurred in the stent group. Histological examination revealed that the stent group presented with lower general inflammation and better healing.
CONCLUSION: Laparoscopic colonic anastomosis with a degradable stent is a simple, rapid, and safe procedure in this porcine model.
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Park IJ, Yu CS, Lim SB, Lee JL, Kim CW, Yoon YS, Park SH, Kim JC. Is Preoperative Chemoradiotherapy Beneficial for Sphincter Preservation in Low-Lying Rectal Cancer Patients? Medicine (Baltimore) 2016; 95:e3463. [PMID: 27149445 PMCID: PMC4863762 DOI: 10.1097/md.0000000000003463] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The present study explored the benefit of preoperative chemoradiotherapy (PCRT) for sphincter preservation in locally advanced low-lying rectal cancer patients who underwent stapled anastomosis, especially in those with deep and narrow pelvises determined by magnetic resonance imaging.Patients with locally advanced low-lying rectal cancer (≤5 cm from the anal verge) who underwent stapled anastomosis were included. Patients were categorized into two groups (PCRT+ vs. PCRT-) according to PCRT application. Patients in the PCRT+ group were matched to those in the PCRT- group according to potential confounding factors (age, gender, clinical stage, and body mass index) for sphincter preservation. Sphincter preservation, permanent stoma, and anastomosis-related complications were compared between the groups. Pelvic magnetic resonance imaging was used to measure 12 dimensions representing pelvic cavity depth and width with which deep and narrow pelvis was defined. The impact of PCRT on sphincter preservation and permanent stoma in pelvic dimensions defined as deep and narrow pelvis was evaluated, and factors associated with sphincter preservation and permanent stoma were analyzed.One hundred sixty-six patients were one-to-one matched between the PCRT+ and PCRT- groups. Overall, sphincter-saving surgery was performed in 66.3% and the rates were not different between the 2 groups. Anastomotic complications and permanent stoma occurred nonsignificantly more frequently in the PCRT+ group. PCRT was not associated with higher rate of sphincter preservation in all pelvic dimensions defined as deep and narrow pelvis, while PCRT was related to higher rate of permanent stoma in shorter transverse diameter and interspinous distance. On logistic regression analysis, PCRT was not shown to influence both sphincter preservation and permanent stoma, while longer transverse diameter and interspinous distance were associated with lower rate of permanent stoma.PCRT had no beneficial effect on sphincter preservation in patients with locally advanced low-lying rectal cancer who had undergone stapled anastomosis. In patients with deep and narrow pelvis, PCRT had no impact on sphincter preservation but was associated with higher rate of permanent stoma.
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Affiliation(s)
- In Ja Park
- From the Department of Colon and Rectal Surgery (IJP, CSY, S-BL, JLL, CWK, YSY, JCK); and Department of Radiology (SHP), University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Ukegjini K, Zadnikar M, Warschkow R, Müller S, Schmied BM, Marti L. Baseline mortality-adjusted survival in colon cancer patients. Langenbecks Arch Surg 2016; 401:633-41. [PMID: 27102323 DOI: 10.1007/s00423-016-1432-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 04/11/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND This investigation assessed the baseline mortality-adjusted survival after colon cancer resection. MATERIAL AND METHODS In total, 523 patients with adenocarcinoma of the colon who underwent primary colon resection at Kantonsspital St. Gallen, Switzerland, between 1996 and 2008 were included. RESULTS The median follow-up was 25 months for all patients and 39 months for those who survived until the end of the follow-up. The 5-year relative survival rate was 63.2 % (95 % CI 57.3-69.6 %), and the overall survival rate was 52 % (95 % CI 47.6-57.7 %). After curative resection of stage I-III colon cancer, 40 % of the observed deaths were cancer-related and 60 % reflected the baseline mortality. In stage I, the 5-year relative survival was 103.2 % (95 % CI 91.4-116.5 %) and was not different from a matched population (p = 0.820). In multivariate analysis, good general health and less advanced cancer stages were associated with better relative and overall survival rates. A more advanced age was associated with better relative survival, but worse overall survival. CONCLUSIONS The analysis of relative survival of patients exclusively with colon cancer revealed that prognosis of patients suffering from stage I colon cancer does not differ significantly from that of the general population. In more advanced stages, a relevant fraction of deaths is not cancer-related. As the stage determines a patient's survival, early diagnosis is crucial for prognosis.
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Affiliation(s)
- Kristjan Ukegjini
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Marcel Zadnikar
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
- Institute of Medical Biometry and Informatics, University of Heidelberg, 69120, Heidelberg, Germany
| | - Sascha Müller
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Lukas Marti
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
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Anastomic leak in colorectal cancer surgery. Development of a diagnostic index (DIACOLE). Int J Surg 2016; 27:92-98. [DOI: 10.1016/j.ijsu.2016.01.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/15/2016] [Accepted: 01/23/2016] [Indexed: 02/07/2023]
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48
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Risk factors for permanent stoma after rectal cancer surgery with temporary ileostomy. Surgery 2016; 159:721-7. [DOI: 10.1016/j.surg.2015.09.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/21/2015] [Accepted: 09/11/2015] [Indexed: 01/11/2023]
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49
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Laparoscopic double-stapled colorectal anastomosis without "dog-ears". Tech Coloproctol 2016; 20:243-7. [PMID: 26902367 DOI: 10.1007/s10151-016-1437-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/05/2015] [Indexed: 02/06/2023]
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50
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Rojas-Machado SA, Romero-Simó M, Arroyo A, Rojas-Machado A, López J, Calpena R. Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors. Int J Colorectal Dis 2016; 31:197-210. [PMID: 26507962 DOI: 10.1007/s00384-015-2422-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage. METHODS The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution. RESULTS The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator. CONCLUSIONS The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.
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Affiliation(s)
- S A Rojas-Machado
- Coloproctology Unit, Department of Surgery, University Hospital of Alicante, Alicante, Spain.,Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain
| | - M Romero-Simó
- Coloproctology Unit, Department of Surgery, University Hospital of Alicante, Alicante, Spain.,Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain
| | - A Arroyo
- Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain. .,Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/ Camí de l'Almazara no. 11, 03203, Elche, Spain.
| | - A Rojas-Machado
- Coloproctology Unit, Department of Surgery, University Hospital of Alicante, Alicante, Spain.,Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain
| | - J López
- Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain
| | - R Calpena
- Department of Pathology and Surgery, School of Medicine, Miguel Hernandez University, Elche, Spain.,Coloproctology Unit, Department of Surgery, University Hospital of Elche, C/ Camí de l'Almazara no. 11, 03203, Elche, Spain
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