Postoperative radiotherapy-induced morbidity in rectal cancer Morbilidad de la radioterapia postoperatoria en el cáncer de recto

Objectives: we analyzed long-term morbidity and bowel function alteration after postoperative radiotherapy for rectal cancer following resection with anastomosis. Patients and methods: thirty-seven patients who underwent surgery with intention to cure and a minimal follow-up period of 3 years were included. These patients were divided into two groups: in the first group, 14 patients received postoperative chemo-radiotherapy, 5-fluorouracil plus folinic acid, and 45 Gy plus 5 Gy boost. In the second group, there were 23 patients regarded as controls. We designed a questionnaire about their bowel function and analyzed the morbidity detected in their follow-up. Results: the group that was treated with postoperative chemo-radiotherapy had more daily bowel movements (p = 0.03) and night-time movements (p = 0.04); incontinence (69.2 versus 17.4% in the control group; p = 0.002), and perianal skin irritation (p = 0.04) versus the control group. Although without meaningful differences, the group under treatment wore a pad more often, had more defecatory urgency, could distinguish worse gas from stool, and needed more frequently antidiarrheal measures. Major complications were present in 28.6% of the under-treatment group: three intestinal resections were performed due to actinic stenosis; one patient had a residual stercoral fistula; another had several occlusive crises solved with medical treatment. Conclusions: postoperative chemo-radiotherapy had a high morbidity rate, which determined a significant alteration in quality of life. Accuracy in indication is therefore necessary, as well as a consideration of other alternatives for treatment, such as preoperative chemo-radiotherapy and total mesorectal excision.<br>Objetivos: analizar la morbilidad y alteración del funcionalismo rectal a largo plazo de la radioterapia postoperatoria tras resección con anastomosis en el cáncer de recto. Material y métodos: se incluyen 37 pacientes intervenidos con intención curativa y con una evolución mínima de 3 años. Se dividen en dos grupos: 14 tratados con quimio-radioterapia postoperatoria, 5-fluoracilo más ác. folínico y 45 Gy más "boost" de 5 Gy y 23 no tratados utilizados como grupo control. Se realizó una encuesta sobre su funcionalismo rectal y se analizó la morbilidad detectada en el seguimiento. Resultados: el grupo tratado con quimio-radioterapia postoperatoria presentaba mayor frecuencia defecatoria diaria (p=0,03) y nocturna (p=0,04); incontinencia en el 69,2% frente al 17,4% del grupo control (p=0,002) y mayor irritación perianal (p=0,04). Aunque sin diferencias significativas, el grupo tratado precisó usar más frecuentemente compresas, tenía más urgencia defecatoria, diferenciaba peor gases y heces y precisó más medidas antidiarreicas. El 28,6% del grupo tratado presentaron complicaciones mayores: 3 resecciones intestinales por estenosis actínicas quedando uno con una fístula estercorácea residual; otro tuvo varias crisis suboclusivas resueltas con tratamiento conservador. Conclusiones: la quimio-radioterapia postoperatoria tiene una alta tasa de morbilidad, que condiciona una alteración importante de la calidad de vida por lo que es necesario sopesar bien la indicación y tener presente las posibilidades que se abren con la quimio-radioterapia preoperatoria y la excisión mesorrectal total

Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate

BACKGROUNDRight hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn's disease (CD) and malignant ones like colon cancer (CC).AIMTo investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODSThis is a sub-group analysis of the European Society of Coloproctology's prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.RESULTSThree hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P &lt; 0.01), had lower American Society of Anesthesiology score (ASA) grade (P &lt; 0.01) and less comorbidity (P &lt; 0.01), but were more likely to be current smokers (P &lt; 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P &lt; 0.01) and frequently underwent ileocecal resection (P &lt; 0.01) with higher rate of de-functioning/primary stoma construction (P &lt; 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P &lt; 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSIONPatients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complication's rate was not different between the two groups

The impact of stapling technique and surgeon specialism on anastomotic failure after right?sided colorectal resection: an international multicentre, prospective audit

Aim There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Method Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side?to?side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. Results One thousand three hundred and forty?seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54–1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52–1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46–4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04–2.64, P = 0.04). Conclusion This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high?risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim: The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30\ua0days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results: This study included 3208 patients, of whom 78.4% (n\ua0=\ua02515) underwent surgery for malignancy and 11.7% (n\ua0=\ua0375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% (n\ua0=\ua03041) of patients, which was handsewn in 38.9% (n\ua0=\ua01183) and stapled in 61.1% (n\ua0=\ua01858). Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (P\ua0=\ua00.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR\ua0=\ua01.43; 95% CI: 1.04\u20131.95; P\ua0=\ua00.03). Conclusion: Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe

The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit.

BACKGROUND: Anastomosis technique following right sided colonic resection is widely variable and may affect patient outcomes. This study aimed to assess the association between leak and anastomosis technique (stapled versus handsewn) METHODS: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a two-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, using a pre-specified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random effect variable. RESULTS: This study included 3208 patients, of whom 78.4% (n=2515) underwent surgery for malignancy and 11.7% (n=375) for Crohn's disease. An anastomosis was performed in 94.8% (n=3041) of patients, which was handsewn in 38.9% (n=1183) and stapled in 61.1% (n=1858) cases. Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn versus 12.9% stapled) and to undergo open surgery (54.7% versus 36.6%). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (p=0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted odds ratio 1.43, 95% confidence interval 1.04-1.95, p=0.03). DISCUSSION: Despite being used in lower risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. This article is protected by copyright. All rights reserve

Predictors for anastomotic leak, postoperative complications, and mortality after right colectomy for cancer: Results from an international snapshot audit

Background: A right hemicolectomy is among the most commonly performed operations for colon cancer, but modern high-quality, multination data addressing the morbidity and mortality rates are lacking. Objective: This study reports the morbidity and mortality rates for right-sided colon cancer and identifies predictors for unfavorable short-term outcome after right hemicolectomy. Design: This was a snapshot observational prospective study. Setting: The study was conducted as a multicenter international study. Patients: The 2015 European Society of Coloproctology snapshot study was a prospective multicenter international series that included all patients undergoing elective or emergency right hemicolectomy or ileocecal resection over a 2-month period in early 2015. This is a subanalysis of the colon cancer cohort of patients. Main Outcome Measures: Predictors for anastomotic leak and 30-day postoperative morbidity and mortality were assessed using multivariable mixed-effect logistic regression models after variables selection with the Lasso method. Results: Of the 2515 included patients, an anastomosis was performed in 97.2% (n = 2444), handsewn in 38.5% (n = 940) and stapled in 61.5% (n = 1504) cases. The overall anastomotic leak rate was 7.4% (180/2444), 30-day morbidity was 38.0% (n = 956), and mortality was 2.6% (n = 66). Patients with anastomotic leak had a significantly increased mortality rate (10.6% vs 1.6% no-leak patients; p 65 0.001). At multivariable analysis the following variables were associated with anastomotic leak: longer duration of surgery (OR = 1.007 per min; p = 0.0037), open approach (OR = 1.9; p = 0.0037), and stapled anastomosis (OR = 1.5; p = 0.041). Limitations: This is an observational study, and therefore selection bias could be present. For this reason, a multivariable logistic regression model was performed, trying to correct possible confounding factors. Conclusions: Anastomotic leak after oncologic right hemicolectomy is a frequent complication, and it is associated with increased mortality. The key contributing surgical factors for anastomotic leak were anastomotic technique, surgical approach, and duration of surgery

Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S-ECCO

Aim: Patient- and disease-related factors, as well as operation technique, all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. The aim was to investigate the effect of preoperative and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease. Method: This was an international prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. The study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien\u2013Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, reoperation, surgical site infection and length of stay in hospital. Multivariable binary logistic regression analyses were used to produce odds ratios and 95% confidence intervals. Results: In all, 375 resections in 375 patients were included. The median age was 37 and 57.1% were women. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36, 95% CI 1.10\u20134.97), urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13\u20133.55) and unplanned intra-operative adverse events (OR 2.30, 95% CI 1.20\u20134.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, 95% CI 1.08\u20131.61) and those who had urgent/expedited operations (OR 1.21, 95% CI 1.07\u20131.37). Conclusion: Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intra-operative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results This study included 3208 patients, of whom 78.4\% (n = 2515) underwent surgery for malignancy and 11.7\% (n = 375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8\% (n = 3041) of patients, which was handsewn in 38.9\% (n = 1183) and stapled in 61.1\% (n = 1858). Patients undergoing hand-sewn anastomosis were more likely to be emergency admissions (20.5\% handsewn vs 12.9\% stapled) and to undergo open surgery (54.7\% handsewn vs 36.6\% stapled). The overall anastomotic leak rate was 8.1\% (245/3041), which was similar following handsewn (7.4\%) and stapled (8.5\%) techniques (P = 0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR = 1.43; 95\% CI: 1.04-1.95; P = 0.03). Conclusion Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe