Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

Peeters, Koen; Tollenaar, Rob A.E.M.; Marijnen, Corrie A.M.; Kranenbarg, E. Klein; Steup, W. H.; Wiggers, Theo; Rutten, H.J.T.; Velde, Cornelis J.H. van de

doi:10.1002/bjs.4806

Cited by 594 publications

(467 citation statements)

References 29 publications

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“…Anastomotic leakage may remain localized, causing perianastomotic inflammation or abscess formation, or may progress to generalised peritonitis. Several authors have demonstrated that a diverting stoma, placed in the proximal colon or ileum during the initial operation, prevents anastomotic leakage [9] and clearly reduces the incidence of generalised peritonitis and thus reoperations, intensive care unit (ICU) stay and mortality [10,11]. In pelvic anastomosis, drainage might reduce the consequences of anastomotic leakage [11], similar to oesophageal anastomosis within the thoracic cavity.…”

Section: Introductionmentioning

confidence: 99%

“…Several authors have demonstrated that a diverting stoma, placed in the proximal colon or ileum during the initial operation, prevents anastomotic leakage [9] and clearly reduces the incidence of generalised peritonitis and thus reoperations, intensive care unit (ICU) stay and mortality [10,11]. In pelvic anastomosis, drainage might reduce the consequences of anastomotic leakage [11], similar to oesophageal anastomosis within the thoracic cavity. Given these possibilities to reduce the major consequences of anastomotic leakage during the initial operation, the operating surgeon might thus decide to construct a diverting stoma in case of high risk for anastomotic leakage if determined by a reliable predictive test.…”

Section: Introductionmentioning

confidence: 99%

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Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

Karliczek

Harlaar

Zeebregts

et al. 2009

Int J Colorectal Dis

386

239

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Background The dramatic clinical consequences of anastomotic leakage in gastrointestinal surgery can be reduced by a diverting stoma or drainage of the peri-anastomotic area. Currently, the surgeons' clinical judgement is of major importance in decision making, but reliable data of the diagnostic accuracy are lacking. In this prospective clinical study, the surgeons' predictive accuracy for anastomotic leakage was evaluated. Materials and methods In 191 patients undergoing colorectal resection with anastomosis, the risk for anastomotic leakage was determined by the surgeon on the basis of a visual analogue scale (VAS). This risk assessment was compared to the actual occurrence of anastomotic leakage post-operatively. Results A total of 26 (13.6%) patients showed anastomotic leakage. The surgeons' median predicted leakage rate was 7.1% in anastomoses >15 cm from the anal verge and 9.5% ≤15 cm (sensitivity 38/62%, specificity 46/52%). Diagnostic accuracy was not influenced by the surgeons' training level (VAS score, surgeons 7.8% vs assistant surgeons 8.5%, p=0.96, sensitivity 41% vs 44%, specificity 59% vs 48%, p=0.20). Conclusion The surgeons' clinical risk assessment appeared to have a low predictive value for anastomotic leakage in gastrointestinal surgery. The low a priori risk of anastomotic leakage of 14% resulted in a low post-test odds (11%) of correct prediction of anastomotic leakage. This warrants the ongoing search for a better diagnostic test of anastomotic leakage to prevent morbidity and mortality.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

Karliczek

Harlaar

Zeebregts

et al. 2009

Int J Colorectal Dis

386

239

View full text Add to dashboard Cite

show abstract

“…Control of the anastomosis should always be performed by either endoscopy, methylene blue or instillation of air under saline solution. The presacral space should be drained [91] and a protective stoma created [92].…”

Section: (100% [Strong Consensus]; Gorb: 100% [Strong Consensus])mentioning

confidence: 99%

“…The specimen can be retrieved through a small Pfannenstiel incision or through the anus, and an end-to-side or J pouch anastomosis is performed [74,85,106,107]. The presacral space should be drained and a defunctioning loop ileostomy created to protect the anastomosis [91,92].…”

Section: 7% [Consensus]; Gor A: 857% [Consensus])mentioning

confidence: 99%

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

et al. 2011

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Background The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (midand low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not

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“…However, introduction of total mesorectal excision (TME) for rectal cancer surgery has prompted further concern with this issue because of the increased incidence of anastomotic leakage with 10 to 20% [11][12][13][14][15]. The Dutch TME trial [15] demonstrated some supportive data of using pelvic drainage in decreasing anastomotic failure rate and the need for surgical re-intervention.…”

Section: Introductionmentioning

confidence: 99%

Drain vs No Drain After Colorectal Surgery

Tsujinaka

Konishi

2011

Indian J Surg Oncol

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In colorectal surgery, drains are expected to prevent hematoma, fluid collection, or abscess formation, to act as an indicator of postoperative complication, or to minimize the severity of complication-related symptoms. Routine drainage has not been advocated by meta-analyses as they failed to demonstrate any benefit in reducing anastomotic leak rate, minimizing symptoms, or serving as a warning function. Moreover, some reports even showed that drain itself is an independent risk factor of anastomosis. The introduction of total mesorectal excision (TME) for rectal cancer surgery has given further concern to this controversial issue, that the use of drain decreased anastomotic failure rate and the need for surgical re-intervention. While controversy still remains, the choice of using drain is left to the individual surgeon's preference in daily practice. Therefore, surgeons should be well acquainted with purpose of drainage (prophylaxis, information, or treatment), characteristics (materials), clinical application of drain (type of drainage system, timing of removal), surgical outcomes after using drain (incidence of postoperative complication), and drain-related complications. If drains are used, careful observation with proper use is crucial for the management. It is important that the duration of drainage should not be inadequately extended. Any complications directly associated with the use of drain should be avoided. New concepts of drain have been proposed as diagnostic tool using biomarkers, and as preventive device against anastomotic leak. This article overviews the available, published data on the use of drain in colorectal surgery.

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Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

Abstract: Placement of one or more pelvic drains after TME may limit the consequences of anastomotic failure. The clinical decision to construct a defunctioning stoma is supported by this study.

Cited by 594 publications

References 29 publications

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

Drain vs No Drain After Colorectal Surgery

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