ABSTRACT
Objective:To investigate the incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer.Methods:The retrospective case-control study was conducted. The clinicopathological data of 804 patients with rectal cancer who were admitted to Peking Union Medical College Hospital of Chinese Academy of Medical Sciences from January 2017 to December 2019 were collected. There were 521 male and 283 female, aged 63(range, 27-94)years. All 804 patients underwent laparoscopic anterior resection for rectal cancer. Observation indicators: (1) surgical situations; (2) incidence of postoperative anastomotic leakage; (3) follow-up; (4) influencing factors of postoperative anastomotic leakage; (5) subgroup analysis. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribu-tion were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Univariate analysis was conducted using the chi-square test or independent sample t test. Factors with P≤0.2 in univariate analysis were included in multivariate Logistic regression analysis. Results:(1) Surgical situations. All 804 patients underwent laparoscopic radical resection of upper and middle rectal cancer successfully, with the operation time and volume of intraoperative blood loss as 135(range, 118-256)minutes and 30(range, 5-350)mL. All 804 patients completed end-to-end colon rectal anastomosis, including 287 patients with reinforced sutures at the anastomotic site, and 517 patients with routine anastomosis. (2) Incidence of postoperative anastomotic leakage. Of the 804 patients, 40 patients had postoperative anastomotic leakage, with the incidence rate as 4.98%(40/804). (3) Follow-up. All 804 patients were followed up for 32(range, 6-49)months. None of patient died during the perioperative period. (4) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that unreinforced suture at the anastomotic site was an independent risk factor for postoperative anastomotic leakage ( odds ratio=2.78, 95% confidence interval as 1.21-6.37, P<0.05). (5) Subgroup analysis. Of the 804 patients, 202 patients received neoadjuvant therapy and 602 patients did not receive neoadjuvant therapy. Of the 602 patients who did not receive neo-adjuvant therapy, cases with postoperative anastomotic leakage was 6 in the 253 patients with reinforced sutures, versus 21 in the 349 patients with routine sutures, showing a significant difference between them ( χ2=4.56, P<0.05). Conclusion:Unreinforced anastomosis at the anasto-motic site is an independent risk factor for anastomotic leakage after laparoscopic anterior rectal resection, especially for rectal cancer patients without neoadjuvant radiochemotherapy.
ABSTRACT
Objective@#To investigate the effect of anastomotic reinforcing sutures on the incidence of anastomotic leakage after laparoscopic radical resection of rectal cancer.@*Methods@#In this study, 300 patients diagnosed with rectal cancer, scheduled to undergo laparoscopic anterior resection at the Department of Gastrointestinal Surgery of Anhui Provincial Hospital, between September 2014 and December 2016, were prospectively enrolled. Patients were randomly assigned to undergo laparoscopic rectal resection with (reinforcing group, n = 150) or without (control group, n = 150) anastomotic reinforcing sutures. The laparoscopic total mesorectal excision was followed for all patients. In the reinforcing group, 4-0 absorbable sutures were used to reinforce the 2-4 needles used for the 2 cross-cutting lines that formed the stapler. Concurrent obstructions; the need for hemorrhagic emergency surgery, preventive ileostomy, Hartmann operation, abdominoperineal resection, or open surgery; and the presence of unresectable cancer were all reasons for excluding patients from the study. Univariate and multivariate analyses were performed on the clinical data collected for the two groups. According to the multivariate analysis results, patients were further divided into high-risk (≥ 2 high risk factors) and low-risk (≤1 high risk factor) groups, and were stratified to analyze the relationship between reinforcing suture use and the incidence of anastomotic leakage. This trial, approved by the Ethics Committee of Anhui Provincial Hospital, was registered as NCT02830633.@*Results@#A total of 291 patients were included in the study, namely 145 in the reinforcing group and 146 in the control group. There were no significant differences between the two groups with respect to their general data or intra-operative conditions (all P > 0.05) . The overall incidence of anastomotic leakage was 7.6% (22/291) ; 3.4% (5/145) in the reinforcing group and 11.6% (17/146) in the control group (χ2 = 6.992, P = 0.008) . Multivariate analyses showed that the lack of reinforcing sutures was an independent risk factor for anastomotic leakage (OR = 2.75; 95%CI, 1.72-5.48; P = 0.014) . Other independent risk factors included NRS2002 score ≥ 3 points, tumor diameter ≥ 4 cm, and tumor to anal margin distance < 5 cm. There were 80 patients in the high-risk group and 211 in the low-risk group, based on the aforementioned 3 risk factors. The incidence of anastomotic leakage was 27.1% (13/48) among the control patients in the high-risk group, but only 6.2% (2/32) among high-risk patients receiving reinforcing anastomotic sutures (χ2 = 5.470, P = 0.019) . In the low-risk group, the incidence of anastomotic leakage was 2.7% (3/113) among patients receiving reinforcing anastomotic sutures, and 4.1% (4/98) among those not receiving reinforcing sutures. No significant difference was observed (χ2 = 0.333, P = 0.564) .@*Conclusion@#Anastomotic reinforcing sutures for the prevention of anastomotic leakage after laparoscopic radical resection of rectal cancer is convenient and effective, particularly for patients with multiple risk factors.