OBJECTIVETo assess the effect of preoperative long course radiotherapy (RT) on anastomotic leakage (AL) after low anterior resection(LAR) for rectal cancer.

METHODSMedline, EMBASE, China National Knowledge Infrastructure,the Cochrane Library databases and other databases were searched for relevant studies. Correlation between preoperative long course RT and AL after LAR for rectal cancer was examined. Review Manager 5.2 software was used to pool raw data and test the heterogeneity of existing studies and to calculate the incorporated odds ratio (OR) and 95% confidence interval (95%CI). Finally, forest plots and funnel plots were created to allow for visual comparison of the results or the effect of publication bias.

RESULTSA total of 881 studies were identified and 10 studies (n=7829) were eligible for the meta-analysis, including 2581 cases of preoperative RT, and 5248 cases of surgery alone without RT. There was no significant difference in anastomotic leakage rate between the two groups (OR:1.17, 95%CI:0.98-1.39, P=0.09).

CONCLUSIONSPreoperative long course RT did not increase the risk of postoperative AL after LAR in patients with rectal cancer.

Anastomotic Leak ; etiology ; Humans ; Postoperative Complications ; etiology ; Preoperative Care ; Radiography ; Rectal Neoplasms ; diagnostic imaging ; surgery

In order to prevent and reduce the severity of anastomotic leakage after low rectal cancer surgery, prophylactic ileostomy is often performed by the clinician simultaneously. There are many controversies about prophylactic ileostomy in medicine, such as ileostomy indications, ileostomy complications, ileostomy reversal time, ileostomy reversal method and technique. Based on relevant literature and our own experience, we discussed the timing, method and complications of ileostomy reversal in this article to improve the diagnosis and treatment of ileostomy reversal as well as the life quality of the patients after ileostomy reversal.
Humans ; Ileostomy/methods* ; Anastomosis, Surgical/adverse effects* ; Anastomotic Leak/etiology* ; Rectal Neoplasms/complications* ; Rectum/surgery*

OBJECTIVETo explore the association between the score of preoperative Nutritional Risk Screening 2002 (NRS 2002) and anastomotic leakage following anterior resection for the rectal cancer.

METHODSClinical data of 641 patients with rectal cancer undergoing anterior resection in Nanfang Hospital, Southern Medical University between January 2003 and July 2012 were analyzed retrospectively. Preoperative nutritional status was evaluated using NRS 2002. Association of clinicopathologic characteristics with postoperative anastomotic leakage was examined using univariate χ(2) and Logistic regression model.

RESULTSAmong the 641 patients, postoperative anastomotic leakage occurred in 26 (4.1%) cases. The proportion of anastomotic leakage in patients with the NRS 2002 score ≥3 was significantly higher than that in patients with the score <3 (6.9% vs. 2.1%, P=0.002). After the adjustment of factors as age, distance of anastomosis above the anal margin, and pathological staging, NRS 2002 score ≥3 was identified as an independent risk factor for anastomotic leakage following anterior resection for rectal cancer (OR=3.198, 95%CI:1.324-7.722, P=0.010).

CONCLUSIONThe use of the NRS 2002 for preoperative evaluation on patient's nutritional status may help to predict the occurrence of anastomotic leakage following anterior resection for rectal cancer, which may be involved in the indication of protecting ileostomy in clinical practice.

Anastomotic Leak ; etiology ; Female ; Humans ; Male ; Middle Aged ; Nutritional Status ; Rectal Neoplasms ; surgery ; Retrospective Studies ; Risk Factors

OBJECTIVETo evaluate the necessity of defunctioning stoma in low anterior resection for rectal cancer below peritoneal reflection.

METHODSThe databases of Medline, Embase, Cochrane Library, Wanfang and CNKI were searched. The eligible studies were identified for pooled analyses.

RESULTSSix randomized controlled trials with 648 cases(332 patients with defunctioning stoma and 316 without stoma) and 25 retrospective controlled trials with 10,722 cases(4,470 patients with defunctioning stoma and 6,252 without stoma) were included. Combined analyses showed that defunctioning stoma was effective for decreasing risk of postoperative anastomotic leakage (RR=0.33 and 95% CI:0.21-0.53 for RCTs, OR=0.60 and 95% CI:0.42-0.85 for retrospective studies), reoperation (RR=0.30, 95% CI:0.16-0.53 for RCTs, OR=0.26 and 95% CI:0.21-0.32 for retrospective studies) and mortality(OR=0.41, 95% CI:0.27-0.62 for retrospective studies).

CONCLUSIONDefunctioning stoma should be routinely performed in low anterior resection for high-risk patients.

Anastomotic Leak ; etiology ; prevention & control ; Enterostomy ; methods ; Humans ; Postoperative Complications ; prevention & control ; Randomized Controlled Trials as Topic ; Rectal Neoplasms ; surgery

OBJECTIVETo study the efficacy, safety and reliability of colonic sac duct for first-stage repair of colorectal anastomotic leakage.

METHODSAn animal model of colon anastomotic leakage was established in 30 Tibet miniature pigs, which were randomly divided into treatment group and control group (n=15). Colon anastomotic leakage in the treatment group was repaired using the colonic sac duct, while the control group received conventional surgical repair. At 7, 14, and 21 days after the surgery, the healing of the anastomotic leakage was evaluated by examining the bursting pressure, tissue microvessel density and hydroxyproline content at the anastomosis.

RESULTSUsing the colonic sac duct, the anastomotic leakage was successfully repaired without death of the pigs or the occurrence of intestinal stenosis or necrosis. At 7 and 14 days after the surgery, the bursting pressure, hydroxyproline contents, and microvessel density in the treatment groups were higher than those in the control group, but such difference was not found at 21 days.

CONCLUSIONColonic sac duct allows effective repair of colon anastomotic leakage, and is especially useful for leakage lasting for 48-72 h complicated by severe abdominal infection.

Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; etiology ; surgery ; Animals ; Colon ; surgery ; Female ; Male ; Rectum ; surgery ; Swine ; Swine, Miniature

Objective: To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Methods: Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging(M(IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7^th day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by U test or χ² test between groups. Results: The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) vs. 6.5%(45/689), χ²=2.027, P=0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days vs. 6(3) days, Z=-2.517, P=0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Conclusions: Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9^th day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.
Anastomosis, Surgical/adverse effects* ; Anastomotic Leak/etiology* ; Esophageal Neoplasms/surgery* ; Esophagectomy/methods* ; Female ; Humans ; Male ; Retrospective Studies ; Surgical Wound/surgery*

Objective: To summarize short-term postoperative complications of transanal total mesorectal excision (taTME) in the treatment of middle-low rectal cancer. Methods: A descriptive case series of cases was constructed. Clinical data of consecutive 83 patients with mid-low rectal cancer who received taTME treatment from November 2016 to April 2021 at Department of General Surgery of Beijing Friendship Hospital, Capital Medical University were collected. Among 83 patients, 58 (69.9%) were males, with a mean age of (61.4±11.8) years; 42 (50.6%) were low rectal cancer, 41 (49.4%) were middle rectal cancer. Short-term postoperative complication was defined as complication occurring within 30 days after operation. The complication was graded according to the Clavien-Dindo classification. At the same time, the morbidity of short-term postoperative complication in the first 40 patients and that in the last 43 patients were compared to understand the differences before and after passing the taTME learning curve. Results: Two patients (2.5%) were converted to laparotomy ; 78 (94.0%) completed anastomosis.While 5 (6.0%) underwent permanent stoma. The total operation time of transabdominal+ transanal procedure was (246.9±85.0) minutes, and the median intraoperative blood loss was 100 (IQR: 100) ml. Seventy-five cases (75 /78, 96.2%) underwent defunctioning stoma, including 74 cases of diverting ileostomy, 1 case of diverting transverse colostomy and 3 cases without stoma. The morbidity of complication within 30 days after operation was 38.6% (32/83), and the morbidity of complication after discharge was 8.4% (7/83). Minor complications accounted for 31.3% (26/83) and major complications accounted for 7.2% (6/83). No patient died within 30 days after operation. The incidence of anastomotic leakage was 15.4% (12/78). Eight patients (9.6%) were hospitalized again due to complications after discharge. The median postoperative hospital stay was 7 (IQR: 3) days. All the patients with minor (I-II) complications received conservative treatment. One patient with grade C anastomotic leakage was transferred to intensive care unit and received a second operation due to sepsis and multiple organ dysfunction. Two patients with paralytic ileus (Clavien-Dindo IIIa) underwent endoscopic ileus catheter placement. There were 3 patients with Clavien-Dindo III or above respiratory complications, including 1 patient with pleural effusion and ultrasound-guided puncture, 2 patients with respiratory failure who were improved and discharged after anti-infection and symptomatic treatment. One patient underwent emergency ureteral stent implantation due to urinary infection (Clavien-Dindo IIIb). The morbidity of postoperative complication in the first 40 cases was 50.0% (20/40), and that in the latter 43 cases decreased significantly (27.9%, 12/43), whose difference was statistically significant (χ(2)=4.270, P=0.039). Conclusions: The procedure of taTME has an acceptable morbidity of short-term postoperative complication in the treatment of mid-low rectal cancer. The accumulation of surgical experience plays an important role in reducing the morbidity of postoperative complication.
Aged ; Anal Canal/surgery* ; Anastomotic Leak/etiology* ; Female ; Humans ; Male ; Middle Aged ; Operative Time ; Proctectomy/methods* ; Rectal Neoplasms/surgery*

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

Anastomotic leakage (AL) has always been a persistent issue for colorectal surgeons. It is still difficult to reduce the incidence of AL despite the advances in technology and equipment. With the development of evidence-based medicine, increasing high-risk factors for AL have been identified. How to efficiently and systematically combine and quantify these isolated risk factors to provide a scientific early warning of AL in clinical practices and help surgeons in choosing the optimal prophylactic strategies, is of great significance for reducing the incidence of AL. There are generally two types of AL prediction models in colorectal surgery, including prognostic models (for preoperative and intraoperative AL prediction) and diagnostic models (for early warning and improving the early diagnosis rate of AL). Prophylactic strategies for AL include stabilizing the underlying diseases, improving anemia and hypoalbuminemia, choosing an appropriate operative time window, and emphasizing and improving anastomotic techniques (including choosing an appropriate size of stapler). However, a prophylactic ostomy is still the most common method for surgeons. However, how to reduce the morbidity of complications following prophylactic ostomy and how to avoid the conversion of the prophylactic stoma to permanent stoma need further study.
Humans ; Anastomotic Leak/etiology* ; Colorectal Surgery/adverse effects* ; Digestive System Surgical Procedures/adverse effects* ; Anastomosis, Surgical/methods* ; Risk Factors

The rate of sphincter-preserving surgery for mid-low rectal cancer is increasing, but anastomotic leakage remains to be one of the common serious complications after operation. How to reduce the morbility and mortality of anastomotic leakage is always a hot and difficult point in colorectal surgery. Protective ostomy is a common method to deal with the above problems in clinical practice. However, some problems such as inappropriate stoma and stoma-related complications etc. become the current clinical challenges. The purpose of this consensus focusing on indication of ostomy, clinical value, ostomy skills, prevention of stoma complications, reversion of stoma and stoma nursing aims to provide guidance for the clinical practice of protective ostomy in the operation of mid-low rectal cancer in China.
Anastomosis, Surgical/adverse effects* ; Anastomotic Leak/etiology* ; Consensus ; Humans ; Ostomy/adverse effects* ; Rectal Neoplasms/surgery* ; Risk Factors ; Surgical Stomas