Keywords
rectal cancer - anastomosis leak - proctectomy
Palavras-chave
câncer retal - vazamento de anastomose - protectomia
Introduction
Colorectal cancer is the second most common type of cancer and the third leading cause
of death from cancers in the world. In 2012, 1,360,602 new cases of colorectal cancers
have been identified. Its mortality rate in 2008 was estimated as 48 in 100,000. Colorectal
cancer is associated with advanced age, so that at least 50% of the individuals in
western societies up to the age of 70 have a variety of colorectal problems, including
a range of benign polyps and malignant adenocarcinomas.[1]
[2]
[3]
Proctectomy via laparoscopy or open approach is widely performed in many medical centers.
However, it is associated with some complications intra or postoperatively.
Anastomosis leak can be clinically diagnosed between 5 and 8 days after the operation.[4] Anastomosis leak presents differently. It can manifest as a generalized peritonitis
requiring re-operation, or localized accumulation of fluid that can be drained by
radiology. Anastomosis leak requires numerous radiological evaluations, long-term
admission into hospital, and increased morbidity and mortality.[5]
The incidence of colorectal anastomosis stenosis leak varies from 3 to 30%. Most of
these stenoses are simple narrowing of the lumen that can be treated with dilation;
however, up to 28% of patients need resurgical repairs. The presence of ileostomy
cannot affect the rate of anastomosis leakage but reduces the complications to some
extent.[6]
[7]
[8]
[9] Another complication of rectal anastomosis is fecal incontinence,[10] which is associated with disability, reduced quality of life, and high cost of treatment.
In many of these patients, diverting ostomy is needed until the end of life. Many
surgeons also recommend abdominoperineal resection and end colostomy for such patients.
A systematic review of the World Journal of Gastrointestinal Surgery in 2015 examined
the risk factors and treatment of colorectal anastomosis. A Hartmann procedure was
performed in case of wide detachment and necrosis of the anastomosis site. On the
other hand, in patients with better general condition, some endoscopic methods such
as sponge, stent, and clips have been studied.[11] Hartmann's technique has been approved widely in patients with a major anastomosis
detachment and pelvic necrosis.
In another study, conducted in 2007, 1,421 patients with pelvic floor anastomosis
were studied, 41 of whom, including 25 men and 16 women, presented with symptoms of
anastomosis leak. They were treated with 3 methods of surgical procedures, antibiotic
therapy, and radiological drainage.[12] The median time for diagnosis of anastomosis leak was ∼ 7 days. Twenty-one patients
underwent resurgical operation, and a permanent ostomy was considered. Despite this,
colon resection and pull-through in anastomosis leak after proctectomy is a choice
that is superior to other approaches in some respects. In patients who undergo abdominoperineal
resection (APR) for rectal cancer, recurrence of a pelvic mass could be a disaster.
However, if the GI continuity is preserved, recurrence might be diagnosed faster by
rectorrhagia or obstruction in earlier stages.
Therefore, the aim of the present study was to assess the results of colon resection
and pull-through in anastomosis leak after proctectomy and compare the results with
those of other approaches in the literature.
Methods and Materials
Patients and Method
This was a cross-sectional study of 12 patients with postoperative anastomosis leak
after rectal cancer surgery referred to the Firoozgar Hospital of Teheran between
2015 and 2018. All patients underwent resection of the residue of rectum and pull-through
of rectum. All patients with rectal cancer who underwent either open or laparoscopic
proctectomy due to rectal cancer and were admitted due to anastomosis leak were included
in the study. The exclusion criteria included those patients with obstructive rectal
cancer in whom curative treatment could not be performed; patients with other non-rectal
cancers; those with solitary rectal ulcer, familial adenomatous polyposis (FAP), or
other entities which were treated by performing a proctectomy; and patients with anastomosis
leak presenting with a generalized peritonitis with the need of urgent laparotomy
or those with unstable hemodynamic status who could not tolerate conservative treatment
of anastomosis leak. An informed consent was obtained from each patient before recruitment
in the study, and they were ensured of the confidentiality of their information. The
protocol of the study was approved by the Research Ethics Committee of the Iran university
of medical science. All steps of the study were in accordance with the guidelines
of the Helsinki Declaration. The patients were free to drop out of the study at any
stage without affecting their standard process of treatment.
Surgical Technique
After placing the patient in a semi-lithotomy position, the residue of rectum was
resected and pull-through was performed. Subsequently, using a Lone Star retractor
in full lithotomy, the colon was withdrawn from the anus and coloanal anastomosis
was performed. The amount of bleeding during the operation, the need for intraoperative
blood transfusion, and the duration of the operation were recorded by the surgeon
in the checklist.
The patients were discharged from the hospital after recovery. Their ileostomy was
re-closed after examination with contrast agent after 2 to 3 months. Then, the complete
results of the patients' surgery and the number of hospital days and possible postoperative
complications and fecal incontinence score using the Jorge-Wexner questionnaire were
collected and evaluated. The patients' quality of life was also evaluated using the
36-Item Short Form Health Survey (SF-36) questionnaire. Finally, the information obtained
from the checklists, intraoperative findings, and the final result, including existence
or absence of anastomosis, were analyzed by the SPSS software version 16 (SPSS Inc.,
Chicago, Il, USA).
Results
In the present study, of the 110 cases who underwent proctectomy, 13 cases of postoperative
anastomosis leak were reported (11.81%). Of these 13 patients, one refused to participate
in the study. Therefore, 12 patients were enrolled in the study. Of these 12 patients,
7 came from our center and 5 were referred from other surgeons. Five (41.7%) were
male and 7 (58.3%) were female. The mean age of the patients was 41.5 years (33–51).
All patients had undergone chemo-radiotherapy prior to their first operation (proctectomy),
and the most recent operation was postponed after completion of their chemotherapy
course to exclude the probability of metastasis to other organs by imaging. During
this period, the ileostomy was not closed. Three patients (25%) were smokers and none
of the patients used steroids or alcohol.
All of these 12 patients were operated using the laparoscopic approach. Red blood
cell transfusion was not required for any patient during the operation. The mean albumin
level of the patients before the operation was 3.9 g/dl (3.7–4.375). The mean amount
of bleeding during the operation was 30 ml. The median time of rectum resection and
pull-through operation was 155 (120–180) minutes. The mean days of hospitalization
in our study was 27 (14–40) days, which consisted of 3 courses—the first one when
the patient underwent primary proctectomy, the second one was when the patient admitted
to our center with the diagnosis of anastomosis leak and medical therapy was performed,
and the third one was when the patient underwent the operation as resection of the
new rectum and pull through. A summary of the demographic and intraoperative characteristics
of the participants is presented in [Table 1].
Table 1
A Summary of demographic and intraoperative characteristics of the participants
|
Variable
|
Value
|
|
Gender
|
|
|
Male
|
5 (41.7%)
|
|
Female
|
7 (58.3%)
|
|
Age (years) (mean ± SD)
|
41.5 ± 4.3
|
|
Preoperative albumin level (g/dl)
|
3.9 ± 0.8
|
|
Intra-operative bleeding (mL) (mean ± SD)
|
30 ± 4.6
|
|
Operation time (minutes) (median; range)
|
155 (120–180) minutes
|
|
Hospitalization (days) (median; range)[*]
|
27 (14–40)
|
|
Jorge-Wexner score after the operation
[**]
|
12.8 ± 7.25
|
Abbreviation: SD, standard deviation.
* including primary proctectomy, admitting due to anastomosis leak and medical therapy,
and the course of resection of the new rectum and pull-through.
** Wexner score after 2 months of resection of the new rectum and pull-through.
The mean score of fecal incontinence after resection of rectum and pull-through was
12.8 ± 7.25. None of the patients had any postoperative complications such as stenosis
or detachment of the new colon-anal anastomosis. The mean score in each of the 8 subcategories
of the SF-36 questionnaire is shown in [Table 2].
Table 2
Scores of quality of life for participants
|
Variable
|
Value
|
|
Vitality (mean ± SD)
|
60.0 ± 33.22
|
|
Physical functioning (mean ± SD)
|
56.0 ± 45.01
|
|
Body pain (mean ± SD)
|
40.0 ± 41.16
|
|
Health perception (mean ± SD)
|
46.66 ± 42.16
|
|
Physical role function (mean ± SD)
|
42.49 ± 34.34
|
|
Emotional role function (mean ± SD)
|
43.55 ± 10.22
|
|
Social role function (mean ± SD)
|
60.0 ± 37.63
|
|
Mental health (mean ± SD)
|
39.10 ± 19.79
|
Abbreviation: SD, standard deviation.
Discussion
Regarding the high prevalence of colorectal cancer, the follow-up and treatment of
these patients are important. Intersphincteric resection (ISR) is one of the accepted
methods for distal rectal cancer, and it is performed by laparoscopic approach.[13]
[14] Possible complications include leakage of anastomosis and stenosis, which will increase
the mortality rate and hospitalization stay. Different treatments have been proposed
from drainage to resurgical procedures.[15]
[16]
In the study by Braun et al., in 1992, the results of the APR and ISR surgery were
compared (63 ISR patients and 77 APR patients). Among patients undergoing ISR curative
surgery, 11% had pelvic recurrence and 33% had distant metastasis, and among patients
with APR, 17% had pelvic recurrence and 35% had distant metastases. The 5-year survival
rate in patients with ISR and APR were 62% and 53%, respectively. Overall, 85% of
patients had a good function. The study found that ISR is a valuable method for middle
and high-grade neoplasms, which allows a minimum of 3 cm distal margin.[17]
In another study by Nachiappan et al. in 2014, 1,048 patients who underwent different
kinds of colectomy were examined. Generally, 99 patients developed anastomosis leak
(9.4%), which is quite similar to the rate reported in our study. Of 99 patients,
56 underwent reoperation and 43 managed with antibiotics or radiological drainage.
They finally concluded that patients with anastomotic leaks who require reoperations
have shorter overall survival than those without leak, but disease-free survival was
not significantly different between the two groups.[18]
Another large study assessed 72,055 patients with rectal cancer who underwent elective
anterior resection. They tried to build a predictive model for anastomosis leak using
demographic characteristics and preadmission comorbidities. was According to their
study, the probability of anastomosis leak was 13.68%, which is higher than the rate
found in our patients. Mortality rate, hospital stay, and expenses were significantly
higher in patients in whom anastomosis leak occurred. They found that weight loss
and malnutrition, electrolyte imbalance, male gender, and stoma placement were risk
factors for anastomosis leak. They also found that laparoscopy approach for proctectomy
decreased the risk of anastomosis leak.[19]
In the present study, resection of rectum residue and pull-through were assessed.
Also, the literature was searched regarding detachment of the anastomosis and a permanent
end colostomy. In the current study, all patients with anastomosis leak after rectal
cancer surgery entered the study. Twelve patients were eventually examined (mean age
of 41.5 years). In general, 25% of our patients were smokers; however, there was no
statistically significant effect for smoking on hospitalization stay, incontinency
score, or SF-36 score.
In this study, we assessed incontinency using the Jorge-Wexner questionnaire. The
mean incontinency score in our study was 12.8, which is superior to end-colostomy
naturally.
However, the quality of life of these patients was assessed using the SF-36 questionnaire.
Scores related to each of the areas of physical and mental health were calculated.
In spite of the higher score of each of the two domains in our study, this difference
was not statistically significant, which could be due to the small sample size in
our study.
In general, anastomosis leak after proctectomy can be easily managed by resection
of rectum and pull-through and a protective loop ileostomy. It is a safe method, which
is superior to APR in some aspects. For instance, the new rectum is accessible to
evaluate possible recurrence via rectal examination or endosonography, but it cannot
be done in APR. However, The GI continuity is preserved, and, if the new anastomosis
functions well, loop ileostomy can be further closed, and a relative fecal continence
is attained.
It should be noted that only stable patients with anastomosis leak entered our study.
Those patients who needed laparotomy due to peritonitis and those with unstable hemodynamic
status who transferred to the operation room after the first admission were excluded.
Despite this, the rate of anastomosis leak in our study included those patients who
were referred to our center from other surgeons, as our hospital is a center for colorectal
diseases. Therefore, our actual rate of anastomosis leak could be very lower if only
our patients were considered. Further studies with larger sample sizes and longer
follow-ups are recommended to compare the outcome of resection and pull-through with
APR.
