Anastomotic Leaks After Restorative Resections for Rectal Cancer Compromise Cancer Outcomes and Survival

Lu, Zheqin R; Rajendran, Nirooshun; Lynch, A. C.; Heriot, Alexander G.; Warrier, Satish

doi:10.1097/dcr.0000000000000554

Cited by 124 publications

(99 citation statements)

References 54 publications

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“…AL is a clinical problem because it may cause acute peritonitis and pelvic sepsis. It may also have an adverse effect on long‐term bowel function, quality of life, cancer‐specific survival, local recurrence and rate of permanent stoma. Previous studies reported that the incidence of major AL was reduced when CJP reconstruction was performed in patients with a stapled colorectal anastomosis.…”

Section: Discussionmentioning

confidence: 99%

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer

Pucciarelli

Bianco

Pace

et al. 2019

British Journal of Surgery

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Background Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. Methods This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. Results Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. Conclusion Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov/).

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Section: Discussionmentioning

confidence: 99%

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer

Pucciarelli

Bianco

Pace

et al. 2019

British Journal of Surgery

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“…Anastomotic leakage is a feared complication after anterior resection as it is associated with a 6-22 per cent increase in postoperative mortality and may result in worse oncological outcomes 1,2 . Anastomotic leakage is a feared complication after anterior resection as it is associated with a 6-22 per cent increase in postoperative mortality and may result in worse oncological outcomes 1,2 .…”

Section: Introductionmentioning

confidence: 99%

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

Keane

Park

Öberg

et al. 2019

British Journal of Surgery

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Background Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer. Methods Early closure (8–13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI). Results Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty‐two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma ( P = 0·054). Conclusion Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

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“…It is one of the leading causes of death following rectal cancer surgery, with around 20-30% of all 30-day mortality being directly attributed to AL [7,8]. In O232 Intra-operative fluorescence angiography to prevent anastomotic leak those patients who survive AL, it is a cause of long-term morbidity, associated with poor bowel function, reduced QoL, increased risk of cancer recurrence and high rates of permanent stoma [5,6,9,40].…”

Section: Discussionmentioning

confidence: 99%

“…It increases postoperative morbidity from~20% to~60% and mortality from < 5% to~20%, and extends in-patient stay by an additional 7 days on average [2][3][4]. Patients who survive AL suffer long-term consequences with reduced quality of life (QoL), high rates of wound complications, permanent stoma and increased risk of cancer recurrence [5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

IntAct: intra‐operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial

et al. 2018

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AimAnastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10–15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near‐infrared laparoscopy can minimize the rate of AL leak compared with conventional white‐light laparoscopy. Two mechanistic sub‐studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies.MethodIntAct is a prospective, unblinded, parallel‐group, multicentre, European, randomized controlled trial comparing surgery with intra‐operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end‐point is rate of clinical AL at 90 days following surgery. Secondary end‐points include all AL (clinical and radiological), change in planned anastomosis, complications and re‐interventions, use of stoma, cost‐effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days.DiscussionIntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning.

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Anastomotic Leaks After Restorative Resections for Rectal Cancer Compromise Cancer Outcomes and Survival

Abstract: Anastomotic leaks after restorative resections for rectal cancer adversely impact cancer-specific mortality and local recurrence.

Cited by 124 publications

References 54 publications

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

IntAct: intra‐operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial

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