Laparoscopic Ultralow Anterior Resection with Colonic J-pouch-Anal Anastomosis

Purpose  Optimal treatment of mid to distal rectal cancers includes total mesorectal excision for oncologic clearance and, where reanastomosis is feasible, a colonic J-pouch-anal anastomosis improves bowel function. There is recent interest in performing an ultralow anterior resection laparoscopically.1–3 A technique is described that includes specimen extraction through the eventual routine defunctioning colostomy or ileostomy site. Methods  Consecutive unselected patients who underwent laparoscopic ultralow anterior resection were recruited. Patients with adenocarcinoma underwent preoperative endorectal ultrasound to individualize for neoadjuvant chemoradiotherapy, based on local extent and lymph nodes seen. The operative procedures were as shown in the video. Posterior dissection along the “total mesorectal excision plane” included incision of Waldeyer’s fascia. Bowel continuity was restored by an intracoporeal double-cross stapled colonic J-pouch-anal anastomosis, but where not possible a coloplasty with pull-through handsewn coloanal anastomosis was performed. Results  Laparoscopic ultralow anterior resection was performed on 55 patients (35 men; median age, 63 (range, 33–90) years) from March 2004 to October 2006. The median body mass index was 26.3 (19–38); 14 patients (25 percent) had a body mass index >30. Ten patients (18 percent) had an American Society of Anesthesiologists’ classification of III. The indications were adenocarcinoma (n = 51), squamous-cell carcinoma of rectum (n = 1), dermoid tumor of mesorectum (n = 1), large villous adenoma (n = 1), and carcinoid with local lymph node metastases (n = 1). The adenocarcinomas were a median distance of 6 (3–12) cm from the anal verge. Neoadjuvant radiotherapy was given in 12 patients (24 percent) who had preoperative endoanal ultrasound findings of tumor extension beyond the muscularis propria and chemoradiotherapy in 7 (14 percent) of these patients where the tumor was more bulky and fixed. Laparoscopic ultralow anterior resection was completed at a median 180 (90–405) minutes, with 53.5 (2–2250) ml of blood loss, and the specimen was extracted through a 4.5 (3.5–11) cm wound. The latter included three cases (5 percent) that were converted. Significant adhesiolysis was required in 29 patients (52.7 percent) because of previous operations. The histologic grading or the adenocarcinoma patients were: Stage I, n = 14; Stage II, n = 23; Stage III, n = 11; Stage IV, n = 3. Of those who underwent curative resection (Stages I–III), the distal resection margin was 2.9 ± 0.7 cm (mean ± standard error) and the radial resection margins were at least 2 mm in all patients. The level of the coloanal anastomosis was a median 3.5 (0–4.5) cm from the anal verge; a coloanal pull-through anastomosis was required in one patient who had a distal cancer. The ileostomies functioned and patients tolerated free fluids at a median of two (1–9) days, and the median postoperative hospital stay was seven (3–22) days. At a median follow-up of 14 (2–33) months, none of the adenocarcinoma patients who had undergone curative resection had recurrences. Four patients (8 percent) had postoperative complications that required operative/invasive intervention (anatomotic leak n = 1, proximal bowel ischemia n = 1, port site hernia n = 1, pelvic collection n = 1). Four other patients had smaller pelvic collections that resolved with antibiotics; pelvic collections were associated with advanced stage of cancer (P = 0.047). Discharge was delayed by acute gastric distension in 11 patients; the latter was associated with poorer American Society of Anesthesiologists’ risk classification (P = 0.035). Erectile dysfunction occurred in ten men, and this was associated with adjuvant chemoradiotherapy (P = 0.042). One patient (2 percent) had persistent urinary retention that required catheterization at latest follow-up. The ileostomy had been closed in 50 patients, and at last follow-up, the median stool frequency was two (1–8) bowel movements per day. Conclusions  Laparoscopic ultralow anterior resection could be offered routinely and completed safely in Western populations, where obesity and adhesions from previous abdominal surgery is common. A laparoscopic technique readily allowed visual identification of the autonomic nerves in the abdomen over the aorta, which could then be followed down into the pelvis. If the pelvis was deep, inversion of the 30° laparoscope in the “upside down” position fascilited incision of Waldeyer’s fascia. This brought the rectum proximally and anteriorly, aiding with the laparoscopic stapler transection of the distal rectum, especially if the cancer was distal, the patient was obese, and the pelvis was narrow. Extraction of the specimen at the eventual defunctioning stoma site reduced the incisions required. Preoperative chemoradiotherapy may have a role in postoperative male sexual dysfunction. Further randomized, controlled studies that include assessing five-year cancer survival/recurrence, pelvic nerve dysfunction, and bowel function are needed before laparoscopic ultralow anterior resection becomes widely accepted. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Routine Mobilization of the Splenic Flexure is not Necessary During Anterior Resection for Rectal Cancer

Purpose Splenic flexure mobilization is widely considered to be an essential component of anterior resection for rectal cancer. It was our hypothesis that selective splenic flexure mobilization would reduce operative times without increasing morbidity or affecting cure. Methods A total of 100 consecutive patients with rectal cancer (mean 8 (range, 4–15) cm from anal verge) who underwent anterior resection for cure between 1996 and 2002 had splenic flexure mobilization only as required to achieve a tension-free anastomosis. Operative time, postoperative morbidity, pathologic findings, and recurrence rates were recorded. Results There were no clinicopathologic differences between those who had splenic flexure mobilization (n = 26) and those who did not (n = 74). Mean operative time in the splenic flexure mobilization group was longer, 167 (range, 130–200) minutes vs. 120 (range, 95–180) minutes in the nonmobilized group (P = 0.023). Mean length of specimen resected was longer in the splenic flexure mobilization group: 36 vs. 18 cm (P = 0.008). Anastomotic complications (4 percent), local recurrence (7 percent, median follow-up, 38 months), perioperative morbidity (32 percent) and mortality (2 percent), and survival did not differ between the two groups. Conclusions Routine splenic flexure mobilization is not required for safe anterior resection in patients with rectal cancer. Avoiding splenic flexure mobilization results in shorter operative times and does not increase postoperative morbidity, anastomotic leakage, or local recurrence. Presented at the Freyer Surgical Meeting, Galway, Ireland, September 2 to 3, 2005.     

Neoadjuvant Therapy and Anastomotic Leak After Tumor-Specific Mesorectal Excision for Rectal Cancer

Purpose  This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery. Methods  A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model. Results  A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (≤4 cm from the verge; odds ratio, 5.28 (1.05, 26.6), P = 0.044) were independently associated with anastomotic leakage. Conclusions  Significant predictors of anastomotic leak include smoking, difficult anastomosis, and level of anastomosis (≤4 cm). Neoadjuvant chemoradiation therapy was not found to be significantly associated with leakage after tumor-specific mesorectal excision for rectal cancer. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Level of Arterial Ligation in Rectal Cancer Surgery: Low Tie Preferred over High Tie. A Review

Consensus does not exist on the level of arterial ligation in rectal cancer surgery. From oncologic considerations, many surgeons apply high tie arterial ligation (level of inferior mesenteric artery). Other strategies include ligation at the level of the superior rectal artery, just caudally to the origin of the left colic artery (low tie), and ligation at a level without any intraoperative definition of the inferior mesenteric or superior rectal arteries. Publications concerning the level of ligation in rectal cancer surgery were systematically reviewed. Twenty-three articles that evaluated oncologic outcome (n = 14), anastomotic circulation (n = 5), autonomous innervation (n = 5), and tension on the anastomosis/anastomotic leakage (n = 2) matched our selection criteria and were systematically reviewed. There is insufficient evidence to support high tie as the technique of choice. Furthermore, high tie has been proven to decrease perfusion and innervation of the proximal limb. It is concluded that neither the high tie strategy nor the low tie strategy is evidence based and that low tie is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. As a consequence, in rectal cancer surgery low tie should be the preferred method.     

Laparoscopic Resection of Rectal Cancer: A Comparison of Surgical and Oncologic Outcomes Between Extraperitoneal and Intraperitoneal Disease Locations

Purpose  The extraperitoneal rectum is anatomically and biologically different from the intraperitoneal rectum, therefore, the surgical outcomes may be different. This study was designed to assess operative outcomes of laparoscopic resection of extraperitoneal (≤7 cm from the anal verge) vs. intraperitoneal rectal cancer. Methods  Prospective data were collected from 312 patients with rectal cancer who underwent laparoscopic resection. Patients were divided into two groups: extraperitoneal (EP, n = 138) vs. intraperitoneal (IP, n = 174). Mean follow-up was 33 months. Results  Patients with pT3/pT4 accounted for 69.6 percent of EP and 74.1 percent of IP. Circumferential margin was positive in 8.7 percent of EP and 0.6 percent of IP (P = 0.0004). Anastomotic leakage developed in 9.7 percent of EP vs. 4.6 percent of IP (P = 0.1081, overall 6.4 percent). Local recurrence rate at three years was 7.6 percent in EP and 0.7 percent in IP (P = 0.0011, overall 4 percent). By multivariate analysis, extraperitoneal location was a risk factor for local recurrence. Conclusions  Laparoscopic resection of rectal cancer, regardless of EP or IP, provided acceptable operative outcomes. There was an increasing tendency for positive circumferential margin, leakage, and local recurrence in EP vs. IP. A multicenter, prospective study is ongoing to identify the high-risk group for local recurrence who may really benefit from neoadjuvant therapy in the era of laparoscopy. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

A Diverting Stoma Is Not Necessary when Performing a Handsewn Coloanal Anastomosis for Lower Rectal Cancer

Purpose Although a temporary diverting stoma is a frequent surgical procedure for the protection of anastomosis in a sphincter-preserving operation for lower rectal cancer, its impact on anastomotic leakage is not conclusive. This study was designed to evaluate anastomotic complications after ultralow anterior resection and handsewn coloanal anastomosis without a diverting stoma for lower rectal cancer patients. Methods Between January 1995 and December 2005, 96 patients were treated by ultralow anterior resection and handsewn coloanal anastomosis for lower rectal cancer. Fifty-one patients received preoperative concurrent chemoradiation, whereas 45 had no preoperative treatment. No diverting stoma was created in any of these cases. The anastomotic complications were evaluated between the groups. Results Six of 96 patients (6.1 percent) developed anastomotic complications: three anastomotic stenoses, one partial anastomotic dehiscence, one retrorectal abscess, and one rectovaginal fistula. All of the complications occurred in the preoperative radiation group, whereas none from the nonradiation group had an anastomotic complication (P = 0.017). The patients with stenosis and partial dehiscence were managed conservatively. The patient with retrorectal abscess was treated with debridement, irrigation and drainage, and seton procedure with a transanal approach. The patient with rectovaginal fistula underwent a second coloanal anastomosis. Conclusions The anastomotic complication rate was low even without a diverting stoma. This study suggests that a diverting stoma is not necessary when performing a handsewn coloanal anastomosis for lower rectal cancer however, an effort should be made for healthy anastomotic healing in patients with rectal cancer who are preoperatively radiated. Presented at the Congress of the International Society of University Colon and Rectal Surgeons, Istanbul, Turkey, June 25 to 28, 2006. Reprints are not available.     

Primary <Emphasis Type="Italic">vs</Emphasis>. Delayed Resection for Obstructive Left-Sided Colorectal Cancer: Impact of Surgery on Patient Outcome

Purpose By comparing surgical outcomes between primary and delayed resection, we addressed whether and how surgical strategies impacted prognosis of patients with left-sided colorectal cancer underwent emergency curative resection. Methods Between January 1980 and December 2002, a total of 143 patients were identified who presented with obstructive left-sided colorectal cancer and received emergency curative resection in Taipei Veterans General Hospital. Patients were stratified according to the timing of tumor resection into two groups: primary resection and delayed resection. Demographic data of the patients, characteristics of the tumors, and short-term and long-term outcomes were analyzed and compared between the two groups. Results The demographic data and tumor characteristics did not differ between the two groups except for more rectal cancers in the delayed resection group (P = 0.021). Primary resection group had a higher anastomotic leakage rate (P = 0.017) and a trend toward a higher mortality rate, which did not reach statistical significance (P = 0.063). The median follow-up intervals were similar (60.4 vs. 58.3 months; P = 0.79). The median survival tended to be longer in delayed resection group (66 vs. 105 months; P = 0.088). Overall five-year and ten-year survival for primary resection were 43.7 and 31.9 percent, respectively, compared with 67.2 and 53.2 percent, respectively, for delayed resection. Conclusions Delayed resection seems to be a safer procedure and provided a better oncologic outcome compared with primary resection in obstructive left-sided colorectal cancer under emergency situations. Supported by the Taipei Veterans General Hospital Research Fund (VGH92-B262).     

Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection

Background We experienced some technical difficulty in dividing the middle and lower rectum through the right-lower quadrant intracorporeally. The aim of this study was to determine whether multiple stapler firings during rectal division are associated with anastomotic leakage after laparoscopic rectal resection. Methods Laparoscopic anterior resection with double-stapling technique anastomosis was performed in 180 consecutive rectal cancer patients. We often used vertical rectal division through a suprapubic site instead of the standard transverse rectal division for laparoscopic total mesorectal excision (LapTME). We attempted to determine whether there was an association between the number of stapler firings and procedures in rectal division. Moreover, we identified risk factors for anastomotic leakage after laparoscopic rectal resection by multivariate analysis. Results Anastomotic leakage occurred in 5% of the subjects of this study. Vertical rectal division through the suprapubic site after Lap TME required fewer staples than transverse division through the right-lower port and a smaller percentage of patients required three or more staples for vertical rectal division than for transverse division (15% vs. 45%, p = 0.03). In the multivariate analysis, TME and the number of staplers used for rectal division were the factors found to be associated with a significantly greater risk of subsequent leakage (odd’s ratio = 5.3; 95% CI 1.2–22.7 and odd’s ratio = 4.6; 95% CI 1.1–19.2). Conclusion TME and multiple stapler firings during distal rectal division were associated with anastomotic leakage after laparoscopic rectal resection. Vertical rectal division through a suprapubic site was a useful method of avoiding multiple stapler firings during laparoscopic TME.     

Fish Mouth and Parachute Surgical Technique for Hirschsprung’s Disease

Purpose  This study examined the long-term therapeutic effect of fish mouth and parachute technique anastomosis for Hirschsprung’s disease. Methods  From March 1992 to October 2002, we performed one-stage fish mouth and parachute technique anastomosis for 293 patients with Hirschsprung’s disease. Two hundred and fifty-four patients (79 percent) were followed up for three to five years. The operative outcome and postoperative complications were retrospectively analyzed. Results  Two hundred ninety-three patients were included in the study, the majority of patients were male (n = 205, 70 percent) and ages ranged between 8 months and five years. Early complications were low (n = 7, 2.3 percent) and included urine retention (n = 2), enteritis (n = 2), and intestinal obstruction (n = 3). No infection of the abdominal cavity or wound, anastomotic leakage, or death occurred in any patients. Late complications were present in 10 cases (3.4 percent). Conclusions  The fish mouth and parachute surgical technique procedure showed some practical benefits and fewer complications than traditional surgical techniques for the treatment of Hirschsprung’ s disease. Presented at the 12th Council Meeting of the World Federation of Association of Pediatric Surgeons (WOFAPS). Zagreb, Croatia, June 22 to 27, 2004.     

Use of Intracolonic Bypass Secured by a Biodegradable Anastomotic Ring to Protect the Low Rectal Anastomosis

Purpose Because of the relatively high morbidity and mortality of anastomotic leakage in patients with low rectal cancer who receive an anterior resection, many fecal diverting methods have been introduced. This study was designed to assess the efficacy and safety of the Valtrac™-secured intracolonic bypass in protecting low rectal anastomosis and to compare the efficacy and complications of Valtrac™-secured intracolonic bypass with those of loop ileostomy. Methods From January 2002 to April 2006, 83 patients with rectal cancer who underwent elective low anterior resection received intracolonic bypass or ileostomy. Demographics, clinical features, and operative data were recorded. Results Forty-four patients (53 percent) received a Valtrac™-secured intracolonic bypass and 39 patients (47 percent) a loop ileostomy. The demographics and clinical features of the groups were similar. None of the patients developed clinical anastomotic leakage. Longer overall postoperative hospital stay (21.3 ± 5.8 days) and higher costs incurred (3.1 ± 0.9 × $1,000 U.S. dollars) were observed in the ileostomy group than in the intracolonic bypass group (12.5 ± 6.3 days, 4.4 ± 1.2 × $1,000 U.S. dollars; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (12.8 percent), bleeding (2.6 percent), and intestinal obstruction after stoma closure (5.1 percent). No complications were observed in the intracolonic bypass group except for the Valtrac™ ring discharging en bloc, which compromised fecal evacuation in two cases (4.5 percent). Conclusions The Valtrac™-secured intracolonic bypass procedure is a safe, effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis. Valtrac™-secured intracolonic bypass, in contrast to loop ileostomy, avoids stoma-related complications or readmission for closure and is associated with decreased hospital time and cost. Presented at the First National Conference on Colorectal Surgery, Zhu Hai, Guang Dong, China, November 2 to 5, 2006. Reprints are not available.     

Laparoscopic- <Emphasis Type="Italic">vs.</Emphasis> Hand-Assisted Ultralow Anterior Resection: A Prospective Study

Purpose A standard laparoscopic-assisted operation can be conducted with colorectal anastomosis performed after extraction of specimen and insertion of a pursestring via a small left iliac fossa or suprapubic incision, or completed via hand-assisted laparoscopic technique with a 7-cm to 8-cm suprapubic incision. This study compares the short-term outcomes of either technique. Methods Sixty-three consecutive patients undergoing laparoscopic-assisted ultralow anterior resection or total mesorectal excision for rectal cancer were examined. The laparoscopic-assisted group (n = 31) had standard laparoscopic-assisted resection, whereas the hand-assisted laparoscopic group (n = 32) had a 7-cm to 8-cm suprapubic incision to allow an open colorectal anastomosis. In patients who were obese or have had multiple abdominal surgeries, the hand-assisted approach was generally favored. All patients had a diverting ileostomy. Results There was no conversion in either group. Mean operating time was significantly longer in the laparoscopic-assisted group (188.2 vs. 169.8 minutes; P < 0.0001). Mean duration for narcotic analgesia (1.65 vs. 3.38 days, P < 0.0001), mean time to flatus (1.97 vs. 3.19 days, P < 0.0001), and mean duration of intravenous hydration (2.45 vs. 3.88 days, P < 0.0001) were longer in the hand-assisted laparoscopic group. However, the mean length of hospital stay (5.8 vs. 5.9 days, P = 0.379) was similar. There was no major surgical complication in either group; chest infection, wound infection, and thrombophlebitis were similar between the laparoscopic-assisted group and the hand-assisted laparoscopic group. Adequacy of specimen harvest (distal tumor margins, P = 0.995; circumferential resection margin, P = 0.946; number of lymph nodes, P = 0.845) was similar. Conclusions Although both laparoscopic-assisted and hand-assisted laparoscopic surgeries are safe and feasible for ultralow anterior resection, the hand-assisted technique significantly shortens operating time. †Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Obstructive Complications of Laparoscopically Created Defunctioning Ileostomy

Purpose  The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. Methods  A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. Results  In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. Conclusions  Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided.     

Transanal Endoscopic Microsurgery is more Effective than Traditional Transanal Excision for Resection of Rectal Masses

Purpose  Transanal endoscopic microsurgery, developed by Buess in the 1980s, has become increasingly popular in recent years. No large studies have compared the effectiveness of transanal endoscopic microsurgery with traditional transanal excision. Methods  Between 1990 and 2005, 171 patients underwent traditional transanal excision (n = 89) or transanal endoscopic microsurgery (n = 82) for rectal neoplasms. Medical records were reviewed to determine type of surgery, resection margins, specimen fragmentation, complications, recurrence, lesion type, stage, and size. Results  The groups were similar with respect to age, sex, lesion type, stage, and size. Mean follow-up was 37 months. There was no difference in the complication rate between the groups (transanal endoscopic microsurgery 15 percent vs. traditional transanal excision 17 percent, P = 0.69). Transanal endoscopic microsurgery was more likely to yield clear margins (90 vs. 71 percent, P = 0.001) and a nonfragmented specimen (94 vs. 65 percent, P < 0.001) compared with transanal excision. Recurrence was less frequent after transanal endoscopic microsurgery than after traditional transanal excision (5 vs. 27 percent, P = 0.004). Conclusions  Transanal endoscopic microsurgery is the technique of choice for local excision of rectal neoplasms. Dr. Cataldo is an instructor and an invited speaker for Richard Wolf Medical Instruments Company. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Incidence,consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study

Background Anastomotic dehiscence is the most severe surgical complication after large bowel resection. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with anastomotic leakage after colorectal surgery. Materials and methods All procedures involving anastomoses of the colon or the rectum, which were performed between November 2002 and February 2006 in a single institution, were prospectively entered into a computerized database. Results One thousand eighteen colorectal resections and 811 anastomoses were performed over this 40-month period. The most frequent procedures were sigmoid (276) and right colectomies (217). The overall anastomotic leak rate was 3.8%. The mortality rate associated with anastomotic leak was 12.9%. In univariate analysis, the following parameters were associated with an increased risk for anastomotic dehiscence: (1) ASA score ≥ 3 (p = 0.004), (2) prolonged (>3 h) operative time (p = 0.02), (3) rectal location of the disease (p < 0.001), (4) and a body mass index > 25 (p = 0.04). In multivariate analysis, ASA score ≥ 3 (OR = 2.5; 95% CI 1.5–4.3, p < 0.001), operative time > 3 h [OR = 3.0; 95% CI 1.1–8.0, p = 0.02), and rectal location of the disease (OR = 3.75; 95% CI 1.5–9.0 (vs left colon), p = 0.003; OR = 7.69; 95% CI 2.2–27.3 (vs right colon), p = 0.001] were factors significantly associated with a higher risk of anastomotic dehiscence. Conclusions Three risk factors for anastomotic leak have been identified, one is patient-related (ASA score), one is disease-related (rectal location), the third being surgery-related (prolonged operative time). These factors should be considered in perioperative decision-making regarding defunctioning stoma formation.     

Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

Purpose  The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival. Methods  Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses. Results  Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1–2 resection, and lack of chemotherapy. Conclusions  Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening. Financial support  Neither one of the authors nor the institutions from which the work originated have asked for, accepted, or received any direct or indirect financial support from a third party regarding the matter and materials discussed in this paper.     

Long-Term Survival in Patients with Locally Advanced Colon Cancer After <Emphasis Type="Italic">En Bloc</Emphasis> Pancreaticoduodenectomy and Colectomy

Purpose  Surgical indications for colon cancer directly invading the pancreas head are controversial. Methods  Between 1957 and 2007, a total of 12 patients (8 men) underwent pancreaticoduodenectomy combined with right hemicolectomy for colon cancer involving the pancreas head. Results  Mean age was 58 (range, 34–77) years. Fistula formation was observed in five patients (41 percent) preoperatively. Tumor involvement was duodenum only (n = 4), duodenum/pancreas (n = 3), stomach/pancreas (n = 1), duodenum/stomach (n = 2), duodenum/liver (n = 1), and pancreas only (n = 1). Only one postoperative death was encountered. Histologic examination showed malignant invasion to the pancreas head in nine cases (75 percent). Overall one-year, three-year and, five-year survival rates after surgery were 75, 66, and 55 percent, respectively. Five patients (41 percent) survived for more than ten 10 years. Conclusions  Pancreaticoduodenectomy for advanced colon cancer invading the pancreas or duodenum provides favorable long-term survival. Supported by a Grant-in-Aid for Basic Research to Dr. Akio Saiura from the Ministry of Education, Culture, Sports, Science and Technology. Reprints are not available.     

Pelvic Nerve Stimulation Evokes Nitric Oxide Mediated Distal Rectal Relaxation in Pigs

Purpose  Pelvic nerve stimulation evokes a complex motility response in the pig rectum with a proximal decrease and a distal increase in cross-sectional area. This study investigated whether the distal increase in the cross-sectional area is because of smooth muscle relaxation mediated by nitric oxide. Methods  The pelvic nerves were stimulated with cuff electrodes in ten chloralose-anesthetized minipigs. Pressure, volume, and cross-sectional areas at five positions in the rectum were obtained during stimulation to examine the effect of N^G-nitro-L-arginine (an inhibitor of nitric oxide synthase) injection. Results  Stimulation evoked a median pressure decrease of 13 cm H₂O (range, 0–27; P < 0.05; n = 10) in the anal canal, a pressure increase of 6 cm H₂O (range,-15 to 30; P < 0.05; n = 10) in the rectum and a decrease of 39 mL (range, 30–63; P < 0.05; n = 6) in rectal volume. Rectal cross-sectional areas decreased 33 percent (range, 5–56; P < 0.02; n = 7) in the proximal part and increased 32 percent (range, 9–67; P < 0.02; n = 8) in the distal part. N^G-nitro-L-arginine eliminated the increase in the distal rectal cross-sectional area (n = 5) and the decrease in anal canal pressure (n = 9) in all tested animals. Conclusion  Pelvic nerve stimulation evokes distal rectal relaxation in pigs, sensitive to N^G-nitro-L-arginine, which suggests that this smooth muscle response is mediated by nitric oxide. This work was supported by grants from the Institute of Experimental Clinical Research, Aarhus University Hospital, Aarhus, Denmark Reprints are not available.     

Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer

Anastomotic leakage is a serious complication in colorectal surgery, especially in the treatment of adenocarcinoma located in the left-sided colon and rectum. It is controversial whether anastomotic leakage is a prognostic factor for local recurrence and/or survival in this disease. To evaluate the impact of anastomotic dehiscence on the outcome of surgery we reviewed data on 467 consecutive patients with adenocarcinoma of the left colon and rectum treated between 1985 and 1995 in our Department. Of these, 41 (8.8%) developed anastomotic leakage. The overall-survival differed nonsignificantly (P=0.57) between leakage and nonleakage groups. Of 331 patients with curative resection 29 showed an anastomotic leakage. There were 46 R0-resected patients who died under disease-related conditions: 7 patients in the leakage group (24.1%) and 39 in the nonleakage group (12.9%; P=0.045). In the curatively resected group 5 of 29 patients developed local recurrence in the leakage group (17.2%) but only 26 of 302 patients in the nonleakage group (8.6%; P = 0.0357). Multivariate analysis showed only the factors of age, stage of resection, staging of lymph nodes, and tumor staging as independent prognostic factors for overall survival. For local recurrence the multivariate analysis revealed tumor staging and anastomotic leakage as independently significant. Anastomotic leakage thus appears to be a prognostic factor for local tumor recurrence of colorectal cancer. In addition, disease-related survival is considerably decreased under leakage conditions. Anastomotic leakage was not shown in this study to be an independent prognostic factor for overall survival due to the lack of statistical significance. Accepted: 20 July 1998     

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

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.     

Long-Term Functional Outcome and Risk Factors for Recurrence After Surgical Treatment for Low and High Perianal Fistulas of Cryptoglandular Origin

Purpose  This study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated for cryptoglandular fistulas. Methods  Three hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires. Results  The median follow-up duration was 76 months (range, 7–134). The 3-year recurrence rate for low perianal fistulas treated by fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1–13 percent). In high transsphincteric fistulas treated by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9–33 percent). In both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant. Conclusions  Fistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of continence was good. However, a substantial amount of patients reported soiling. Poster presentation at the Annual General Meeting of the European Society of Coloproctology, Lisbon, Portugal, September 13 to 16, 2006. Reprints are not available.