There are 41,000 patients diagnosed with colorectal cancer in the UK each year; approximately a third of these are rectal in origin [1]. As part of their treatment many of these patients will undergo surgical resection with formation of an anastomosis. In the intraoperative setting much focus is placed on techniques to ensure anastomotic integrity and avoid the well-established morbidity and mortality from an anastomotic leak.Further down the line patients can go to on develop a benign stricture at the level of the anastomosis. Rates have been shown to vary from 2% to 30% [2-4] but are often under-reported in the literature due to the need for long-term follow-up [5]. Neoadjuvant chemoradiotherapy and
Aim Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer‐related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought. Method A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990–2020. Additional papers were detected by scanning references of relevant papers. Results A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air‐leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra‐operatively provides the opportunity for either suture reinforcement or formal takedown with or without re‐do of the anastomosis and consideration of diversion. Suture repair alone of a positive air‐leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future. Conclusion Although over reliance on any assessment tool should be avoided, intra‐operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra‐operatively for mechanical failure, particularly distal anastomoses.
Aim Approximately a third of all colorectal cancers diagnosed in the UK each year are rectal in origin and will undergo surgical resection with formation of an anastomosis. Focus is placed on techniques to ensure anastomotic integrity however an anastomotic leak, pelvic sepsis, distance to the anal verge and stapler choice are all established risk factors for the formation of a benign anastomotic stricture. This review aimed to assess the use of endoscopic salvage techniques in an attempt to avoid surgical re-intervention. Method A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were detected by scanning the references of relevant papers. Results A total of 40 papers were included focusing upon balloon dilation, stent insertion, electroincision, stapler stricturoplasty and corticosteroid use. Endoscopic balloon dilatation remains the most commonly used technique in the management of anastomotic strictures, with a low complication rate despite the frequent requirement for repeated dilatations. Although established in the role for malignant obstruction, stent insertion is yet to gain an established role in the benign setting. Conclusions Benign anastomotic strictures can be a significant problem post-rectal resection, impacting upon quality of life and requiring repeated intervention. Endoscopic management should be utilised in the primary setting to avoid surgical re-intervention. Standardisation of these methods is imperative in establishing the best modality of treatment. For refractory strictures a low threshold of suspicion for malignant recurrence should be maintained.
Aim Post-operative pulmonary complications in perioperative SARS-CoV-2 infection are associated with significant morbidity and mortality. To maintain a safe cancer service, the Countess of Chester Hospital adopted “Cold-site” operating and maintained ERAS principles for patients undergoing elective colorectal cancer surgery during the pandemic. A comparative assessment of service was undertaken for benchmarking purposes. Method A comparative retrospective audit was undertaken of consecutive patients undergoing elective colorectal cancer surgery from June to November 2019 and compared to June to November 2020. The Somerset Cancer Registry and electronic medical case records were used to obtain the dataset. Outcomes measured were approach to surgery; stoma rate; length of stay; level of care required; post-operative complications (>Clavien-Dindo 2) and survival at 30 days. Mann-Whitney U test and Chi-squared were used for analysis. Results There were 33 and 24 elective colorectal cancer operations in 2019 and 2020 respectively. There was no difference in the median age (64:69; p = 0.3) or ASA grade (p = 0.9). The median length of stay was 5 and 4 days respectively (p = 0.3). There was a 32.2% reduction in laparoscopic approach to surgery in 2020 (69.7% vs 37.5%; p = 0.02). There was no difference in the stoma rate (p = 0.9), post-operative complication rate (p = 0.7), ITU admission rate (p = 0.3), length of ITU stay (p = 0.6) and 30-day mortality rates (p = 0.4). Conclusions “Cold-site” operating allows robust ERAS care to be adopted to ensure comparative outcomes for patients undergoing colorectal cancer surgery and was associated with a non-significant trend to shorter hospital stay during the COVID-19 pandemic.
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