Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis.

OBJECTIVE: To examine the long-term oncological impact of anastomotic leakage (AL) after restorative surgery for colorectal cancer using meta-analytical methods. Outcomes evaluated were local recurrence, distant recurrence, and survival. BACKGROUND: Recurrence after potentially curative surgery for colorectal cancer remains a significant clinical problem and has a poor prognosis. AL may be a risk factor for disease recurrence, however available studies have been conflicting. A meta-analysis was conducted to investigate the impact of AL on disease recurrence and long-term survival. METHODS: Studies published between 1965 and 2009 evaluating the long-term oncological impact of AL were identified by an electronic literature search. Outcomes evaluated included local recurrence, distant recurrence, and cancer specific survival. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute odds ratio and 95% confidence intervals. Study heterogeneity was evaluated using Q statistics and I and publication bias assessed with funnel plots and Egger's test. RESULTS: Twenty-one studies comprising 13 prospective nonrandomized studies, 1 prospective randomized, and 7 retrospective studies met the inclusion criteria, yielding a total of 21,902 patients. For rectal anastomoses, the odd ratios (OR) of developing a local recurrence when there was AL was 2.05 (95% CI = 1.51-2.8; P = 0.0001). For studies describing both colon and rectal anastomoses, the OR of local recurrence when there was an AL was 2.9 (95% CI = 1.78-4.71; P < 0.001). The OR of developing a distant recurrence after AL was 1.38 (95% CI = 0.96-1.99; P = 0.083). Long term cancer specific mortality was significantly higher after AL with an OR of 1.75 (95% CI = 1.47-2.1; P = 0.0001). CONCLUSIONS: AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted. No association between AL and distant recurrence was found.

Male faecal incontinence presents as two separate entities with implications for management.

AIM: In contrast to females, male faecal incontinence has received little attention. We investigate its pattern and management at a large UK teaching hospital. METHODS: Men presenting with faecal incontinence between January 2006 and December 2008 were identified from a gastrointestinal physiology database and classified into faecal leakage or faecal incontinence on the basis of symptomatology. Demographics, Cleveland Clinic incontinence score (CCIS), aetiological factors, investigations and treatments were collected by case note review and compared to clinical outcomes. RESULTS: Forty-three symptomatic patients were identified with faecal incontinence, in which 33 were classified as having faecal leakage (FL) and ten as faecal incontinence (FI). The mean CCIS was 10.7 (range, 4-14) and 14.2 (8-20) for FL and FI, respectively. The FL group had normal anal sphincter pressures, whilst the FI group had significantly lower mean resting pressure, 45 mmHg (8-90 mmHg), and mean squeeze pressure, 62.1 mmHg (18-110 mmHg). Thirteen out of 33 patients in the FL group and seven out of ten in the FI group had undergone previous anorectal surgery and had demonstrable sphincter defects whilst in the remainder, no definite aetiological factor could be identified. All patients in the FL group improved with lifestyle changes (28/33) or biofeedback (5/33). Six patients in the FI group required surgical intervention (3/6, collagen injection; 1/6, graciloplasty; 1/6, sacral nerve stimulation; 1/6, rectopexy). CONCLUSIONS: Patients presenting with FL characteristically have normal anorectal physiology and respond to non-operative measures, as compared to patients with FI who tend to have weakened anal sphincters, previous history of anorectal surgery, and more often require surgical intervention.

Atypical abdominal pain: post-traumatic transverse colon stricture.

A driver presented to the emergency department 1 day after an accident driving his excavator with abdominal pain and vomiting. He was admitted to the surgical ward 2 days later, after reattending. A CT scan revealed wall thickening and oedema in the transverse colon. This was supported by a subsequent CT virtual colonoscopy which raised the suspicion of neoplasia. A follow-up colonoscopy was not carried further than the transverse colon due to an indurated, tight stricture. Biopsies from that area showed ulceration and inflammatory changes non-specific for ischaemia, drug-induced changes or inflammatory bowel disease. As a consequence of the subocclusive symptoms and the possibility of a neoplastic diagnosis, a laparoscopic-assisted transverse colectomy was performed. The histology of the resected segment revealed post-traumatic inflammation and fibrosis with no evidence of neoplasia.

Metastatic Gas gangrene and Colonic Perforation: a case report.

Clostridium septicum myonecrosis is associated with diabetes, colorectal and haematological malignancies. We present a case of metastatic myonecrosis in a diabetic patient with a perforated caecal tumour. The literature since 1989 is reviewed and 28 cases of Clostridium septicum myonecrosis are discussed.

Clinical and subclinical leaks after low colorectal anastomosis: a clinical and radiologic study.

PURPOSE: This study was designed to examine the natural history of subclinical leaks and their effect on bowel function and quality of life and to evaluate water-soluble contrast enema features that predict anastomotic healing after leaks. METHODS: Consecutive patients who underwent low rectal anastomosis were followed up postoperatively for leaks. All leaks were confirmed radiologically with CT scanning and water-soluble contrast enema imaging. Water-soluble contrast enemas were serially repeated to identify healing. Characteristics on initial water-soluble contrast enema were correlated with observed healing. Postoperatively, patients were required to fill in a quality of life and a bowel function questionnaire. RESULTS: A total of 138 patients underwent low rectal anastomosis procedures with a median follow-up period of 26 (interquartile range, 19-37) months. There were 23 documented leaks of which 13 (9 percent) presented clinically and 10 (8 percent) presented subclinically. Ileostomy closure was possible in 4 of 13 (30 percent) patients with a clinical leak and all 10 (100 percent) patients with a subclinical leak. Median quality of life scores were lower for patients with clinical leaks and no ileostomy closure (P = 0.03). Bowel function for subclinical leak patients and clinical leak patients with ileostomy closure were similarly impaired. The presence of a cavity (P = 0.01) and a stricture (P = 0.01) at the anastomotic site were unfavorable radiologic features associated with nonhealing. CONCLUSIONS: Subclinical leaks are more benign in their natural history compared with clinical leaks. Quality of life and bowel function is no better in patients with a subclinical leak compared with patients with a clinical leak who have ileostomy closure. Anastomotic leaks may resolve if favorable radiologic features are present.

Evaluation of a protocol-based management of rectal cancer.

INTRODUCTION: The management of rectal cancer is multidisciplinary. We have devised and implemented a standardized protocol. This study was designed to evaluate the protocol and identify areas for improvement. METHODS: All patients with a diagnosis of rectal cancer were staged preoperatively. Magnetic resonance imaging and computed tomography were used to predict whether surgical resection would be complete (RO) or involved (R1/2). Data were collected on preoperative adjuvant therapy, surgical procedure, and subsequent pathologic stage, including circumferential resection margin status. RESULTS: Between January 2000 and October 2002, 163 patients were studied (107 male; median age, 70 (range, 60-77) years). One hundred and fifty seven patients underwent surgical excision for rectal cancer of whom 155 were discussed in the multidisciplinary meeting. One hundred seventeen patients (75 percent) had pelvic magnetic resonance scan and staging computed tomography of chest and abdomen, whereas 38 had computed tomography only. Seventy-seven tumors were predicted as R0 and 78 as likely R1/2. In the predicted RO group, 50 had surgery alone, 25 had short-course radiotherapy, and 2 had chemoradiotherapy. Twelve patients (15.5 percent) had involved circumferential resection margin on the histologic specimen. In the predicted R1/2 group (n = 78), 40 patients received chemoradiotherapy, 11 had short-course radiotherapy, and 27 had surgery alone. Thirty patients (38.4 percent) had involved circumferential resection margin. Circumferential margin involvement was seen in 11 of 40 patients (27.5 percent) who received chemoradiotherapy, 6 of 11 patients (54.5 percent) who received short-course preoperative radiotherapy, and 13 of 27 patients (48.1 percent) who had surgery alone. CONCLUSIONS: Protocol-driven management of rectal cancer within the context of a multidisciplinary team has been demonstrated to work. Regular audit allows for modification and improvement of the protocol as newer management strategies evolve.