Prognosis after anastomotic leakage in colorectal surgery.

INTRODUCTION: Anastomotic leakage is a major complication of colorectal surgery causing a significant increase in 30-day mortality. The long-term prognosis of anastomotic leakage is poorly documented. This study was designed to assess whether anastomotic leakage affects five-year survival and local recurrence. METHODS: A total of 5,173 patients were recruited to the Wessex Colorectal Cancer Audit during the period September 1991 to August 1995 (prospective data, 5-year follow-up). The effect of anastomotic leakage on five-year survival and local recurrence was analyzed using Kaplan-Meier curves and the log-rank test. RESULTS: A total of 1,834 patients underwent a curative resection with an anastomosis (anastomotic leak = 71; 3.9 percent): 30-day mortality: 18.3 percent in the leak group, and 3.5 percent in the nonleak group (P < 0.001); local recurrence: 19 percent in the leak group, and 9.8 percent in the nonleak group (P = 0.018). A total of 1,201 patients underwent colonic anastomosis (anastomotic leak = 31; 2.6 percent). There was no significant difference in local recurrence or five-year survival between the leak and nonleak groups. A total of 633 patients underwent rectal anastomosis (anastomotic leakage = 40; 6.3 percent): 30-day mortality: 10 percent in the leak group, and 2 percent in the nonleak group (P = 0.014); cumulative five-year estimate of local recurrence: 25.1 (95 percent confidence interval, 9.6-40.5) percent in the leak group, and 10.4 (95 percent confidence interval, 7.7-13) percent in the nonleak group (P = 0.007). Cumulative five-year estimate of overall survival: 52.8 (95 percent confidence interval, 36.1-69.4) percent in the leak group, and 63.9 (95 percent confidence interval, 59.9-67.9) percent in the nonleak group (P = 0.19). CONCLUSIONS: After rectal anastomosis, an anastomotic leak is associated with a significant increase in local recurrence.

Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer?

INTRODUCTION: This study was designed to assess whether preoperative magnetic resonance imaging scans were able to predict 1) pathologic tumor and node stage, and 2) those patients with a pathologically clear circumferential resection margin. METHODS: Patients with histologically proven carcinoma of the rectum were staged preoperatively using magnetic resonance imaging. Histologic specimens from patients undergoing mesorectal excision were reported according to the Royal College of Pathologists minimum dataset. Agreement between radiologic staging of tumor, local lymph nodes and circumferential resection margin involvement, and pathologic reporting was assessed by means of the Kappa statistic. RESULTS: After exclusions (10 radiotherapy, 3 failed scans, 10 no surgery, 9 local surgery), 40 patients remained. Magnetic resonance imaging correctly staged the tumor in 20 patients, understaged in 12, and overstaged in 8. Statistically, there was poor correlation between pathologic and radiologic tumor staging (Kappa, 0.18; 95 percent confidence interval, -0.13 to 0.42). Magnetic resonance imaging correctly staged node status in 27 patients, overstaged in 9, and understaged in 4. Statistically, there was poor correlation between pathologic and radiologic node staging (Kappa, 0.38; 95 percent confidence interval, 0.08-0.64). Magnetic resonance imaging correctly reported the status of the circumferential resection margin in 39 patients and understaged 1. Statistically, there was good correlation between pathologic and radiologic reporting of circumferential resection margin involvement (Kappa, 0.66; 95 percent confidence interval, 0.03-1). CONCLUSIONS: Preoperative magnetic resonance imaging scans provide poor predictive data as to subsequent pathologic tumor and node stage. Preoperative magnetic resonance imaging does produce reliable prediction of clear circumferential resection margins and provides valuable information in assessing whether patients can proceed to surgery without the need for preoperative radiotherapy.