Increased Local Recurrence and Reduced Survival From Colorectal Cancer Following Anastomotic Leak Systematic Review and Meta-Analysis
ABSTRACT To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival.
Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival.
Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I and publication bias assessed with funnel plots and Egger's test.
Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51-2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78-4.71; P < 0.001). The OR of developing a distant recurrence after AL was 1.38 (95% CI = 0.96-1.99; P = 0.083). Long term cancer specific mortality was significantly higher after AL with an OR of 1.75 (95% CI = 1.47-2.1; P = 0.0001).
AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found.
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ABSTRACT: Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colocolic or colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery, as faecal diversion in low colorectal anastomosis. Now we report our experience with the TPI in protecting colocolic and colorectal anastomosis in urgency in elderly. From January 2012 to June 2014, 45 patients underwent urgent surgical procedures for acute abdomen with colonic and/or rectal resections and colocolic or colorectal anastomosis with faecal diversion by TPI. Nineteen out of 45 patients were older than 70. Four low colorectal anastomoses, 10 intra-peritoneal colorectal anastomosis and 4 colocolic anastomosis were performed. Neither intra-operative complications nor post-operative deaths were observed. None of the 19 patients treated had evidence of clinical or radiological leakage of the anastomosis. Post-operative complications occurred in 7 patients and nobody required re-intervention. No intestinal obstruction was reported in the early (30 days) post-operative period. The TPI seems to be a valid alternative to standard ileostomy, ensuring an optimal faecal diversion both in elective surgery and in urgency. The TPI also ensures less patient discomfort and it can be easily removed without surgery, unlike the CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of this new technique, especially in elderly.International Journal of Surgery 08/2014; DOI:10.1016/j.ijsu.2014.08.361 · 1.65 Impact Factor
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ABSTRACT: Purpose: Anastomotic leakage (AL) is associated with high morbidity and mortality, high reoperation rates, and increased hospital length of stay. Here we investigated the risk factors for AL after anterior resection for rectal cancer with a double stapling technique. Patients and Methods: Data for 460 patients who underwent primary anterior resection with a double stapling technique for rectal carcinoma at a single institution from 2003 to 2007 were prospectively collected. All patients experienced a total mesorectal excision (TME) operation. Clinical AL was defined as the presence of leakage signs and confirmed by diagnostic work-up according to ICD-9 codes 997.4, 567.22 (abdominopelvic abscess), and 569.81 (fistula of the intestine). Univariate and logistic regression analyses of 20 variables were undertaken to determine risk factors for AL. Survival was analysed using the Cox regression method. Results: AL was noted in 35 (7.6%) of 460 patients with rectal cancer. Median age of the patients was 65 (50-74) and 161 (35%) were male. The diagnosis of AL was made between the 6th and 12th postoperative day (POD; mean 8th POD). After univariate and multivariate analysis, age (p=0.004), gender (p=0.007), tumor site (p<0.001), preoperative body mass index (BMI) (p<0.001), the reduction of TSGF on 5th POD less than 10U/ml (p=0.044) and the pH value of pelvic dranage less than or equal to 6.978 on 3rd POD (p<0.001) were selected as 6 independent risk factors for AL. It was shown that significant differences in survival of the patients were AL-related (p<0.001), high ASA score related (p=0.036), high-level BMI related (p=0.007) and advanced TNM stage related (p<0.001). Conclusions: AL after anterior resection for rectal carcinoma is related to advanced age, low tumor site, male sex, high preoperative BMI, low pH value of pelvic drainage on POD 3 and a significant reduction of TSGF on POD 5. In addition to their high risk of immediate postoperative morbidity and mortality, AL, worse physical status, severe obesity and advanced TNM stage have similarly negative impact on survival.Asian Pacific journal of cancer prevention: APJCP 01/2014; 15(2):707-12. DOI:10.7314/APJCP.2014.15.2.707 · 2.51 Impact Factor
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ABSTRACT: Aim-Background Postoperative anastomotic leakage is a devastating complication of rectal surgery. A number of factors can influence the dehiscence rate, but the association between the levels of the tumour has been corroborated in numerous studies. Although not uniformly accepted, there are many reports demonstrating that anastomotic leakage can influence the oncologic outcome of surgery and predispose to stricture formation. The purpose of this review is to evaluate the relevance of the level of primary lesion and subsequent level of anastomosis from the anal verge, with the rate of dehiscence, anastomotic stricture and local recurrence during anterior resection for rectal cancer. Methods English language literature, mainly of the last 15 years, was identified and reviewed by searching the following databases: pubmed, medline and scopus. Results Our search yielded 27 retrospective studies, 6 prospective studies, 10 reviews, and 2 metanalyses. Reports concerning postoperative strictures are limited and hence insufficient to demonstrate comparative results. Conclusion Many risk factors are responsible for anastomotic leaks reflecting technical and anatomical issues. The level of <6cm above the anal verge is considered by most authors as high risk for anastomotic leakage. In an attempt to tackle this problem, most surgeons propose the creation of a defunctioning stoma, if anastomosis is below 6cm from the anal verge. Benign anastomotic strictures can develop due to anastomotic leaks, vascular compromise and technical pitfalls, and dehiscence is considered as an independent risk factor for stricture formation. Well-organised studies evaluating anastomotic strictures with adequate follow-up are scant in the literature. As for the oncologic outcome, it is debatable whether or not the level of tumour and postoperative anastomotic leakage are independent risk factors for local recurrence.Hellēnikē cheirourgikē. Acta chirurgica Hellenica 10/2012; 83(5). DOI:10.1007/s13126-011-0052-z