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Rectal cancer surgery: Defunctioning stoma, anastomotic leakage and postoperative monitoring
Linköping University, Department of Clinical and Experimental Medicine, Surgery . Linköping University, Faculty of Health Sciences.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The understanding of the mesorectal spread in rectal cancer has lead to wide acceptance of total mesorectal excision (TME) as the surgical technique of choice for carcinoma in the lower and mid rectum. While oncological results and survival have improved with TME-surgery, morbidity and mortality remain important issues. The most feared complication is symptomatic anastomotic leakage. The aim of this thesis was to focus on the role of the defunctioning stoma, risk factors, and postoperative monitoring in regard to anastomotic leakage in sphincter saving resection of the rectum.

Intraoperative adverse events were analysed in a retrospective population based case-control study in which all patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days or during the initial hospital stay (n=140), were compared with patients chosen at random (n=423) who underwent the same operation during the same period, but survived the operation. Intraoperative adverse events were more frequent in those who died, and reconstruction of an anastomosis judged unsatisfactory by the surgeon improved the outcome.

In a population based retrospective case-control study, risk factors for symptomatic anastomotic leakage were investigated in randomly chosen sample of patients who underwent anterior resection in Sweden between 1987 and 1995 (n=432). Twelve per cent of the patients developed symptomatic leakage, and 25% of the patients with leakage ended up with a permanent stoma. In multivariate regression analysis, low anastomosis, preoperative radiotherapy, male gender and intraoperative adverse events were independent riskfactors for anastomotic leakage.

In a randomised multicentre trial patients operated with sphincter saving TME¨surgery for rectal cancer were randomised to a defunctioning stoma (n=116) or not (n=118). The overall rate symptomatic leakage was 19%. Patienst without a defunctioning stoma leaked in 28% and patients with a defunctioing stoma in 10%, a statistically significant difference (p<0.001) not previously demonstrated in any randomised trial of adequate size.

Postoperative monitoring with computed tomography scan (CT-scan) on postoperative day 2 and 7, and C-reactive protein (CRP) daily in 33 patients operated on with anterior resection of the rectum, demonstrated larger pelvic fluid collections in patients with leakage before the leakage was clinically diagnosed. CRP was increased from postoperative day 2 and onwards in patients in whom clinical leakage was diagnosed on median postoperative day 8.

In 23 patients who underwent anterior resection of the rectum, intraperitoneal metabolism was investigated using microdialysis technique measuring the carbohydrate metabolites lactate, pyruvate and glucose. Intraperitoneal cytokines IL-6, IL-10 and TNF-α were collected through a pelvic drain and analysed. In patients who developed leakage, the latate/pyruvate ratio was increased near the anastomosis on postoperative day 5 and 6, as well as IL-6 and IL-10 which were increased postoperatively day 1 and 2, while TNF-α was higher on day 1.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronci Press , 2006. , 72 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 940
Keyword [en]
Anterior resection of the rectum, total mesorectal excision, TME, anastomotic leakage, defunctioning stoma, risk factors, intraoperative adverse events, population based study, postoperative monitoring, CT-scan microdialysis, cytokines
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-7695ISBN: 91-85497-80-0 (print)OAI: oai:DiVA.org:liu-7695DiVA: diva2:22692
Public defence
2006-04-20, Wilandersalen, Universitetssjukhuset i Örebro, Örebro, 09:15 (English)
Opponent
Supervisors
Available from: 2006-11-06 Created: 2006-11-06 Last updated: 2009-12-03Bibliographically approved
List of papers
1. Intraoperative adverse events and outcome after anterior resection of the rectum
Open this publication in new window or tab >>Intraoperative adverse events and outcome after anterior resection of the rectum
2004 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 91, no 12, 1608-1612 p.Article in journal (Refereed) Published
Abstract [en]

Background: The aim of this population-based study was to analyse the relationship between intraoperative adverse events and outcome after anterior resection.

Methods: All 140 patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days, were compared with a group of 423 randomly selected patients who underwent the same procedure during the same interval but survived the operation. Intraoperative adverse events and intraoperative measures taken were analysed in relation to outcome of surgery.

Results: Of those who died, 45.7 per cent had intraoperative adverse events compared with 30.3 per cent in the cohort group. Major bleeding, gross spillage of faeces, and two or more intraoperative adverse events were more common among those who died. When the anastomosis was considered unsatisfactory, it was more frequently reconstructed (restapled or completely resutured), with or without a temporary stoma, in those who survived. The use of a temporary stoma was comparable in the two groups when adverse events were present.

Conclusion: Intraoperative adverse events were important contributors to morbidity and mortality. Complete reconstruction of an unsatisfactory anastomosis, with or without addition of a temporary stoma, was more frequently performed in the survivors, and may have diminished the risk of postoperative death.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-28272 (URN)10.1002/bjs.4530 (DOI)13379 (Local ID)13379 (Archive number)13379 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
2. Risk factors for anastomotic leakage after anterior resection of the rectum
Open this publication in new window or tab >>Risk factors for anastomotic leakage after anterior resection of the rectum
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2004 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 6, no 6, 462-469 p.Article in journal (Refereed) Published
Abstract [en]

Objective. Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage.

Patients and methods. In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient-and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients.

Results. The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (≤ 6 cm), pre-operative radiation, presence of intra-opcrative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients Arithout leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days).

Conclusion. In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-28273 (URN)10.1111/j.1463-1318.2004.00657.x (DOI)13380 (Local ID)13380 (Archive number)13380 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
3. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial
Open this publication in new window or tab >>Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: A randomized multicenter trial
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2007 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 246, no 2, 207-214 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The aim of this randomized multicenter trial was to assess the rate of symptomatic anastomotic leakage in patients operated on with low anterior resection for rectal cancer and who were intraoperatively randomized to a defunctioning stoma or not.

SUMMARY BACKGROUND DATA: The introduction of total mesorectal excision surgery as the surgical technique of choice for carcinoma in the lower and mid rectum has led to decreased local recurrence and improved oncological results. Despite these advances, perioperative morbidity remains a major issue, and the most feared complication is symptomatic anastomotic leakage. The role of the defunctioning stoma in regard to anastomotic leakage is controversial and has not been assessed in any randomized trial of sufficient size.

METHODS: From December 1999 to June 2005, a total of 234 patients were randomized to a defunctioning loop stoma or no loop stoma. Loop ileostomy or loop transverse colostomy was at the choice of the surgeon. Inclusion criteria for randomization were expected survival >6 months, informed consent, anastomosis ≤7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events.

RESULTS: The overall rate of symptomatic leakage was 19.2% (45 of 234). Patients randomized to a defunctioning stoma (n = 116) had leakage in 10.3% (12 of 116) and those without stoma (n = 118) in 28.0% (33 of 118) (odds ratio = 3.4, 95% confidence interval, 1.6-6.9, P < 0.001). The need for urgent abdominal reoperation was 8.6% (10 of 116) in those randomized to stoma and 25.4% (30 of 118) in those without (P < 0.001). After a follow-up of median 42 months (range, 6-72 months), 13.8% (16 of 116) of the initially defunctioned patients still had a stoma of any kind, compared with 16.9% (20 of 118) those not defunctioned (not significant). The 30-day mortality after anterior resection was 0.4% (1 of 234) and after elective reversal a defunctioning stoma 0.9% (1 of 111). Median age was 68 years (range, 32-86 years), 45.3% (106 of 234) were females, 79.1% (185 of 234) had preoperative radiotherapy, the level of anastomosis was median 5 cm, and intraoperative blood loss 550 mL, without differences between the groups.

CONCLUSION: Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-39703 (URN)10.1097/SLA.0b013e3180603024 (DOI)50858 (Local ID)50858 (Archive number)50858 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2017-12-13Bibliographically approved
4. Increase of serum C-reactive protein is an early indicator of subsequent symptomatic anastomotic leakage after anterior resection
Open this publication in new window or tab >>Increase of serum C-reactive protein is an early indicator of subsequent symptomatic anastomotic leakage after anterior resection
Show others...
2008 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 10, no 1, 75-80 p.Article in journal (Refereed) Published
Abstract [en]

Objective: This prospective study investigated the factors which might indicate anastomotic leakage after low anterior resection.

Method: Thirty-three patients who underwent anterior resection for rectal carcinoma (n = 32) and severe dysplasia (n = 1), were monitored daily by serum C-reactive protein (CRP) and white blood cell count (WBC) estimations until discharge from hospital. Computed tomography (CT) scans were performed on postoperative days 2 and 7 and the amount of presacral fluid collection was assessed. All patients had a pelvic drain and the volume of drainage was measured daily.

Results: The level of the anastomosis was at a median 5 cm (3-12 cm) above the anal verge. There was no 30-day mortality. Nine (27.2%) of the 33 patients developed a symptomatic anastomotic leakage which was diagnosed at a median of 8 days (range 4-14) postoperatively. The serum CRP was increased in patients who leaked from postoperative day 2 onwards (P = 0.004 on day 2, P < 0.001 on day 3-8). The WBC was decreased in preoperatively irradiated patients on days 1-5 (P = 0.021), with no difference seen between patients with or without leakage. Patients with leakage had a larger presacral fluid collection on CT on day 7 (median 76 ml vs 52 ml, P = 0.016) and a larger increase in the fluid collection between the first and the second CT examinations (28 ml vs 3 ml, P = 0.046).

Conclusion: An early rise in serum CRP was a strong indicator of leakage. Monitoring of CRP for possible early detection of symptomatic anastomotic leakage is recommended.

Keyword
Anastomotic leakage, C-reactive protein, CT-scan, Pelvic fluid collection, Rectal cancer, White blood cell count
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-47310 (URN)10.1111/j.1463-1318.2007.01300.x (DOI)
Note
On the day of the defence day the title of this article was: "Assessment of pelvic fluid collection and C-reactive protein after anterior resection of the rectum for cancer".Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved
5. Is early detection of anastomotic leakage possible by intraperitoneal microdialysis and intraperitoneal cytokines after anterior resection of the rectum for cancer?
Open this publication in new window or tab >>Is early detection of anastomotic leakage possible by intraperitoneal microdialysis and intraperitoneal cytokines after anterior resection of the rectum for cancer?
Show others...
2007 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 50, no 11, 1918-27 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: This prospective study assessed methods of detecting intraperitoneal ischemia and inflammatory response in patients with and without postoperative complications after anterior resection of the rectum.

METHODS: In 23 patients operated on with anterior resection of the rectum for rectal carcinoma, intraperitoneal lactate, pyruvate, and glucose levels were monitored postoperatively for six days by using microdialysis with catheters applied in two locations: intraperitoneally near the anastomosis, and in the central abdominal cavity. A reference catheter was placed subcutaneously in the pectoral region. Cytokines, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-alpha, were measured in intraperitoneal fluid by means of a pelvic drain for two postoperative days.

RESULTS: The intraperitoneal lactate/pyruvate ratio near the anastomosis was higher on postoperative Day 5 (P = 0.029) and Day 6 (P = 0.009) in patients with clinical anastomotic leakage (n = 7) compared with patients without leakage (n = 16). The intraperitoneal levels of IL-6 (P = 0.002; P = 0.012, respectively) and IL-10 (P = 0.002; P = 0.041, respectively) were higher on postoperative Days 1 and 2 in the leakage group, and TNF-alpha was higher in the leakage group on Day 1 (P = 0.011). In-hospital clinical anastomotic leakage was diagnosed on median Day 6, and leakage after hospital discharge on median Day 20.

CONCLUSIONS: The intraperitoneal lactate/pyruvate ratio and cytokines, IL-6, IL-10, and TNF-alpha, were increased in patients who developed symptomatic anastomotic leakage before clinical symptoms were evident.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-52066 (URN)10.1007/s10350-007-9023-4 (DOI)17763907 (PubMedID)
Note
On the day of the defence data the status of this article was: Submitted.Available from: 2009-12-02 Created: 2009-12-02 Last updated: 2017-12-12Bibliographically approved

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