Treatment of anastomotic leakage following low anterior colon resection

Four hundred five consecutive cases of low anterior colon resection were studied to determine the best treatment of anastomotic leak. The triad of fever, leukocytosis, and pelvic pain was present in 15 of the 16 cases with leaks. Four (25%) of the 16 patients died. Eleven were managed by proximal decompression and drainage; four died (36%). Three patients underwent takedown of the anastomosis, end colostomy, and distal closure or exteriorization; none died. Neither of the two patients who had drainage alone died. Anastomotic leakage accounted for two thirds of the deaths in this series. Recognition of the clinical triad of fever, leukocytosis, and pelvic pain could lead to earlier diagnosis and improved outcome. Our data suggest that a procedure that includes takedown of the anastomosis, end colostomy, and closure of the rectum is the most efficacious treatment of anastomotic leakage after low anterior colon resection.     

Intraoperative testing of anastomotic integrity after stapled anterior resection for cancer

Sixty consecutive patients undergoing anterior restorative resection of the rectum for cancer were studied. After full mechanical bowel preparation and intravenous antibiotic prophylaxis, colorectal anastomosis was performed with the EEA (Autosuture) staple gun. The median height of the anastomosis above the anal verge was 9 cm (range 3-15 cm) and no patient had a protecting colostomy fashioned. All 'doughnuts' were checked and following instillation of saline into the pelvis the anastomosis was tested by air insufflation through the rectum. There was a statistically significant association between an incomplete 'doughnut' and peroperative anastomotic leakage (P less than 0.001); however, of the 11 patients shown to have a leak, only seven had deficient 'doughnuts'. All 11 patients had repair of the defect identified by escape of air and none of these patients developed a clinical leak.     

Factors affecting anastomotic complications following anterior resection in rectal cancer

OBJECTIVE: Anastomotic complications following sphincter saving rectal surgery remains a significant clinical problem in rectal cancer surgery. Preoperative combined modality therapy followed by anterior resection with total mesorectal excision (TME) has become the preferred treatment paradigm for locally advanced rectal cancer. However, its impact on anastomotic complications has not been adequately evaluated. This study aimed to assess the relationship between the response of the primary tumour to neo-adjuvant therapy with anastomotic complications and to evaluate the effect of other clinico-pathological factors previously implicated, in this patient cohort. METHOD: A total of 119 consecutive patients with primary rectal cancer were assessed of which there were 87 anterior resections. A prospectively collected database was queried to determine the incidence of anastomotic complications, association with response to neo-adjuvant therapy and other clinico-pathological factors. Data were analysed with SPSS 14.0. RESULTS: Anterior resection was performed in 87/111 (78.4%) patients of which 46/84 (56%) were low resections, with an abdominoperineal excision of rectum rate of 11/111 (9.9%). Anastomotic complications were seen as clinical leaks in 10/87 (11.5%) and late colo-visceral fistulae in 2/87 (2.2%) patients. Subclinical/ radiological 'leaks' were quantified as 4/87 (4.5%). A good pathological response to neo-adjuvant therapy was found to be strongly associated with anastomotic complications (P = 0.006). Presence of a perioperative cardiac event was the only other clinical factor associated with anastomotic complications (P = 0.004) in our study. CONCLUSION: Rectal cancer treated with neo-adjuvant therapy and radical resection with TME for better local control may be associated with greater anastomotic complications particularly when a good pathological response is seen.     

Small bowel obstruction following low anterior resection: the impact of diversion ileostomy

Background The incidence of small bowel obstruction following rectal cancer surgery has not been well documented in the era of sphincter-preserving surgery. This report aimed to study the incidence, aetiologies and outcomes of small bowel obstruction in patients after low anterior resection for rectal cancer. The factors that might affect the incidences of small bowel obstruction were analysed.Methods Consecutive patients who had undergone low anterior resection for rectal cancer from August 1993 to March 1999 were studied. Patients with unplanned admissions, with the diagnosis of small bowel obstruction, were reviewed. The aetiologies and outcome of small bowel obstruction were documented.Results Two hundred and fourteen patients were included, with a median follow-up time of 39 months; 22 patients presented with 30 episodes of small bowel obstruction, and operations were necessary in nine patients (40.9%). Malignant obstruction occurred in two patients (10.3%). Obstruction within 6 weeks of surgery (including closure of stoma) occurred in 13 patients (6.1%). Early obstruction occurred at a higher incidence in those patients who had had an ileostomy than in those who did not (9.1% vs 2.9%, P=0.048).Conclusion Small bowel obstruction following rectal cancer surgery occurred in 10.3% of patients. The majority of the obstruction was benign in nature. The presence of diversion ileostomy was associated with an increased incidence of early obstruction, and the use of loop ileostomy for proximal diversion should be further assessed.     

Anorectal function following low anterior resection

Introduction Rectal function following rectal resection for carcinoma was studied in 43 patients. Methods Sixteen women and 27 men with a median age of 66 years (range 41–79 years) were included. Twenty‐three patients had a diverting ileostomy at the time of resection. Eight patients had a 6‐cm colonic J‐pouch. Ten patients had anastomotic leakage including two patients without diverting ileostomy. One patient had pre‐operative radiation with 25 Gy. The patients were studied at a median 12 months (range 3–30) after rectal resection. Distance from anal verge to the anastomosis was a median 7 cm (range 3–12 cm). Clinical data, anal manometry and rectal compliance were analysed. Results Stool frequency was 3 per day (range 1–10). Twenty‐two (51%) patients were continent, 11 (26%) were incontinent for flatus, and 10 (23%) were incontinent for faeces (three for liquid and seven for solid stool). Fourteen (33%) patients had constipation, two of whom also had incontinence for solid or liquid stool. The level of the anastomosis for patients with postoperative constipation was 5 cm (range 3–12 cm), while it was 7 cm (range 3–10 cm) for nonconstipated patients (NS). Anal manometry was normal. Rectal compliance was lower in patients with incontinence for liquid or solid faeces than in patients with flatus incontinence only (P < 0.01), and rectal volume tolerability was lower in incontinent patients compared with continent patients (P < 0.05). The rectoanal reflex was present in 31 (72%) patients. There was a negative correlation between maximal rectal volume and stool frequency and between level of the anastomosis and degree of incontinence. Age did not affect functional outcome. Conclusion Many patients had a poor functional result following low anterior resection. One in four suffered from incontinence to liquid or solid faeces and one third of the patients experienced constipation. A low level of anastomosis tended to increase stool frequency and carried a higher risk of incontinence. Patients with faecal incontinence tended to have lower rectal compliance and volume tolerability than patients who were continent, while there was no difference in anal pressures.     

直肠肛管内外双引流预防直肠低位吻合口瘘的发生

目的探讨直肠肛管内、外双引流在预防直肠低位吻合口瘘的作用。方法将235例行直肠低位前切除术的患者按不同时间段分成前期组（2003年3月至2004年8月）和后期组（2004年9月至2007年11月）。后期组患者的围手术期处理有所改进，特别是常规行直肠肛管内、外双引流。分别比较两组患者的吻合口瘘发生率和相关的临床病理资料。结果前期组89例患者中4例（4．5％）发生吻合口瘘，后期组146例患者中1例（0．7％）发生吻合口瘘。Logistic回归分析发现．是否行直肠肛管内、外双引流是影响吻合口瘘发生率的主要因素。结论直肠肛管内、外双引流能有效预防直肠低位吻合口瘘的发生。     

骶前引流方式对直肠癌低位前切除术后吻合口漏愈合的影响

目的比较经会阴和经腹壁两种不同的骶前引流方式对直肠癌低位前切除术后吻合口漏愈合的影响。方法总结2010年1月至2015年12月间45例直肠癌低位前切除术后吻合口漏的临床资料。结果经会阴和经腹壁两种引流方式在病人年龄、性别、是否接受新辅助放化疗、平均手术时间、p TNM分期、术后发生漏的确定时间、初次手术后平均住院时间等方面差异均无统计学意义(P0.05)。但经会阴引流组的保护性造口率(16.7%)、腹膜炎发生率(8.3%)及再次手术率(16.7%)均明显低于经腹壁引流组(分别为75.8%、39.4%、93.9%,P0.05)。结论经会阴骶前引流可降低低位直肠吻合口漏的相关并发症,有助于吻合口漏的愈合。     

腹腔镜低位直肠前切除术后吻合口漏的原因及预防

【摘要】 目的 探讨腹腔镜下低位直肠前切除术后吻合口漏的原因和预防措施。方法 回顾性分析2014年5月至2015年6月253例低位直肠癌患者行腹腔镜低位直肠前切除术的临床资料。结果 253例患者手术均获成功,无一例死亡。其中15例患者(5.9%)发生了术后吻合口漏,1例因腹膜炎行腹腔镜再手术并行回肠末端造口,14例经腹膜外骶前引流、局部冲洗、抗感染及肠外营养支持等保守治疗后痊愈;其余患者恢复良好。腹腔镜低位直肠前切除术发生术后吻合口漏的原因主要与术后肠管血运不良、吻合口张力较大以及直肠双吻合技术缺陷有关。结论 腹膜外骶前置管引流是是治疗术后吻合口漏的有效措施。     

低位直肠癌前切除术后吻合口漏的临床特点分析

目的：回顾性分析低位直肠癌前切除术后吻合口漏发生的影响因素、临床特点、治疗方法和相关愈后。方法：回顾性分析本院674例低位直肠癌前切除术病人，根据不同性别、肿瘤大小、位置、Dukes分期、手术时机和方法对术后吻合口漏的发生进行了分析，并总结主要临床症状和处理方法。结果：674例低位直肠癌前切除术中共发生吻合口漏39例（5．8％），95％可信限区间（CI）为4．02％-7．54％，其中肿瘤下缘距肛缘〈6cm者吻合口漏发生率为6．2％，≥6cm者吻合口漏发生率5．5％。肿瘤直径≥3cm者吻合口漏发生率5．9％，〈3cm者吻合口漏发生率5．5％。Dukes B、C和D期肿瘤术后吻合口漏的发生率分别为2.4％、7．9％和7_4％。择期和急症手术吻合口漏的发生率为5．3％和26．7％。吻合口漏发生于术后7d或7d内为71．1％，发生于术后7d后为28．9％。经引流管局部冲洗引流及全胃肠外营养（TPN）治愈率为63．2％，横结肠失功性造瘘治愈率为36．8％。结论：低位直肠癌前切除术后吻合口漏的发生与肿瘤大小（P=0．962）和距肛门距离（P=0．798）无关，急症手术与择期手术吻合口漏发生率有显著差异（p=0．003），不同Dukes分期吻合口漏的发生率有显著差异（P=0．018）。间歇性或持续性发热、麻痹性肠梗阻、引流管中有粪质样液体是吻合口漏的主要表现，经引流管局部冲洗引流辅以TPN和横结肠失功性造漏是治疗吻合口漏的主要方法。     

低位直肠癌前切除术后吻合口瘘的原因及防治的研究

低位直肠癌行保肛手术,可以使患者的生活质量有很大的提高,但是术后吻合口瘘仍是其主要的并发症,其发生可导致围手术期病死率上升,住院时间延长,费用增加,给患者造成了极大的痛苦.本文就低位直肠癌术后吻合口瘘发生的原因及防治措施的研究现状做一综述.     

Reconstruction methods to achieve optimal postoperative bowel function following low anterior resection for rectal cancer

After low anterior resection for rectal cancer, approximately 50% of patients experience defecatory malfunction such as multiple evacuations, urgency, and soiling. Since the neorectum is constructed with the remaining colonic segment, it can only substitute for the rectum to a limited extent. A straight anastomosis is most frequently used when the rectal remnant is sufficient, such as in high anterior resection. When the height of anastomosis is close to the anal sphincter, a J-pouch, a side-to-end, or a transverse coloplasty pouch are constructed to achieve better postoperative bowel function. The advantage of J-pouch reconstruction is not only the increased volume but also may be decreased motility when compared with straight reconstruction. In terms of postoperative function, the side-to-end and transverse coloplasty pouch have both been reported to exhibit similar functional results to J-pouch reconstruction. To obtain optimal functional results, pouch reconstruction should be considered, especially when the height of anastomosis is at the levator plane.     

预防性横结肠造瘘对直肠低位前切除术吻合口瘘的影响

目的探讨预防性横结肠造瘘对直肠低位前切除术(LAR)吻合口瘘(AL)发生率的影响。方法回顾分析312例行直肠LAR的中下段直肠癌手术患者的临床资料,采用Fisher确切概率法对比分析行预防性横结肠造瘘对AL发生的影响。结果63例行预防性横结肠造瘘的直肠LAR发生AL有2例(3.2%),249例未行该造瘘的发生AL有21例(8.4%),两者无统计学差异(P0.05)。结论直肠LAR行预防性横结肠造瘘并不能有效地降低AL的发生率,且行预防性造瘘者,均需再次手术关瘘。     

Standardized pelvic drainage of anastomotic leaks following anterior resection without diversional stomas

Background

Anastomotic leakage is a serious complication in rectal cancer surgery. More than one third of rectal cancer patients with low anterior resection (LAR) will receive defunctional stomas during primary operation.

Methods

Six hundred thirty-nine consecutive rectal cancer patients, whose tumors were located 5 to 12 cm from the anal verge, were treated with LAR. A standardized pelvic drainage for all these patients and selective irrigation for patients with leakage were conducted, and defunctional stoma was used as a salvage modality. All the anastomoses were all extraperitonealized during primary operations.

Results

The anastomotic leakage rate was 7.04%. Male gender and location of tumor were found to be risk factors for leakage in patients with LAR. The overall stoma rate was 1.88%. Nearly 75% of leakage could be cured by irrigation-suction without surgical intervention. Severe complications, such as peritonitis, fistula, and obstruction, were strong predictors of irrigation failure.

Conclusions

Extraperitonealized anastomosis and pelvic drainage obtained a very low rate of defunctional stoma for LAR. Pelvic irrigation-suction was an effective modality to resolve anastomotic leakage.     

Colorectal anastomotic integrity after anterior resection: is there a role for intraoperative testing?

Two hundred and two consecutive patients having an anterior resection of the rectum were studied retrospectively to determine the usefulness of intraoperative anastomotic testing. Saline introduced via a rectal catheter was used to distend the rectum and any leaks demonstrated were oversewn. Of 119 stapled anastomoses there were two (1.7%) clinical leaks; in both cases intraoperative testing had been negative. Five patients (4.2%) had leaks demonstrated by intraluminal distension. These defects were rectified at the time of operation and no clinical sequelae followed, three patients having had a covering colostomy added. Eighty-three untested handsewn anastomoses were also reviewed; all had a postoperative recovery uncomplicated by a clinical leak. These results raise the question: does intraoperative anastomotic testing produce false positives and/or weaken the anastomosis? We believe that in the three patients who required the addition of a covering colostomy a clinical leak was avoided as a result of the intraoperative test. The technique is simple, effective and probably helps reduce leakage following colorectal anastomoses.     

低位直肠癌前切除术后吻合口漏的处理和预防（附183例报告）

目的探讨直肠癌低位前切除术后吻合口漏发生的原因及预防措施。方法回顾性分析183例下段直肠癌保肛术后发生吻合口漏的临床资料。结果在183例保肛术中,发生吻合口漏9例,占4.92%较国内平均水平为低。通过积极有效的处理均得到临床满意的治疗效果。结论吻合口漏是直肠癌保肛术后主要并发症之一,通过积极有效的预防措施,可完全将此并发症降至最低限度。