Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler.

BACKGROUND: Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJETIVE: The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications. DESIGN: This was a prospective randomized clinical study. SETTINGS: This study was conducted at a university hospital within a specialized colorectal unit. PATIENTS: Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement. INTERVENTION: Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement. MAIN OUTCOME MEASURES: The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay. RESULTS: Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died. LIMITATIONS: Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study. CONCLUSIONS: The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis >5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).

Abordaje quirúrgico de la recidiva locorregional del cáncer de recto / Surgical approach to the locoregional recurrence of cancer of the rectum

Se ha realizado una revisión literaria relativa a la cirugía de la recurrencia pélvica del cáncer de recto utilizando las bases de datos MedLine, Ovid, EMBASE, Cochrane y Cinahl. La evaluación por pruebas de imagen de la recidiva locorregional debe realizarse tanto para descartar la presencia de metástasis como con el objetivo de localizar el sitio preciso (subsitio) de la misma dentro de la pelvis. Como el único tratamiento curativo será la resección completa de la recidiva con márgenes negativos, se deben realizar preoperatoriamente TC, RMN, ecografía endorrectal y PET-TC para determinar la resecabilidad. Para una potencial curación, se deben realizar resecciones radicales, variando la técnica según la localización de la recurrencia sea central (axial), posterior (presacra) o lateral, así como el tratamiento efectuado del tumor primario. Los tratamientos neoadyuvantes, la braquiterapia y la RTIO mejoran los resultados de control local y la supervivencia en estos pacientes (AU)

A literature review has been made on the pelvic recurrence of rectal cancer using the MedLine, Ovid, EMBASE, Cochrane and Cinahl data bases. Assessment of the locoregional recurrence must be made using imaging tests in order to rule out the presence of metastasis, as well as for locating its exact location within the pelvis. As the only curative treatment should be complete resection of the recurrence with negative margins, a pre-operative CT,NMR, endorectal ultrasound and PET-CT must be performed to determine its resectability. For a potential cure, radical resections must be made, with the technique varying according to whether the location is central (axial), posterior (presacral) or lateral, as well as treatment directed at the primary tumour. Neoadjuvant treatments, brachiterapy and intra-operative radiotherapy improve the local control results and survival in these patients (AU)

Patterns of local recurrence in rectal cancer after a multidisciplinary approach.

Improvements in surgery and the application of combined approaches to fight rectal cancer have succeeded in reducing the local recurrence (LR) rate and when there is LR it tends to appear later and less often in isolation. Moreover, a subtle change in the distribution of LRs with respect to the pelvis has been observed. In general terms, prior to total mesorectal excision the most common LRs were central types (perianastomotic and anterior) while lateral and posterior forms (presacral) have become more common since the growth in the use of combined treatments. No differences have been reported in the current pattern of LRs as a function of the type of approach used, that is, neo-adjuvant therapies (short-term or long-course radiotherapy, or chemoradiotherapy versus extended lymphadenectomy, though there is a trend towards posterior or presacral LR in patients in the Western world and lateral LR in Asia. Nevertheless, both may arise from the same mechanism. Moreover, as well as the mode of treatment, the type of LR is related to the height of the initial tumor. Nowadays most LRs are related to the advanced nature of the disease. Involvement of the circumferential radial margin and spillage of residual tumor cells from lymphatic leakage in the pelvic side wall are two plausible mechanisms for the genesis of LR. The patterns of pelvic recurrence itself (pelvic subsites) also have important implications for prognosis and are related to the potential success of salvage curative approach. The re-operability for cure and prognosis are generally better for anastomotic and anterior types than for presacral and lateral recurrences. Overall survival after LR diagnosis is lower with radio or chemoradiotherapy plus optimal surgery approaches, compared to optimal surgery alone.

[Surgical approach to the locoregional recurrence of cancer of the rectum]. / Abordaje quirúrgico de la recidiva locorregional del cáncer de recto.

A literature review has been made on the pelvic recurrence of rectal cancer using the MedLine, Ovid, EMBASE, Cochrane and Cinahl data bases. Assessment of the locoregional recurrence must be made using imaging tests in order to rule out the presence of metastasis, as well as for locating its exact location within the pelvis. As the only curative treatment should be complete resection of the recurrence with negative margins, a pre-operative CT, NMR, endorectal ultrasound and PET-CT must be performed to determine its resectability. For a potential cure, radical resections must be made, with the technique varying according to whether the location is central (axial), posterior (presacral) or lateral, as well as treatment directed at the primary tumour. Neoadjuvant treatments, brachiterapy and intra-operative radiotherapy improve the local control results and survival in these patients.

Recto (colpo, perineo) sacropexia ventral en el tratamiento del prolapso rectal y rectogenital / Ventral rectal sacropexy (colpo-perineal) in the treatment of rectal and rectogenital prolapse

Introducción La sacrorrectopexia ventral con malla permite la corrección del prolapso rectal minimizando la disección del recto. La colpopexia posterior corrige los prolapsos apicales y posteriores de la vagina. La combinación de ambos procedimientos permite la corrección simultánea de los prolapsos de los órganos pelvianos (POP).Objetivo Presentar los resultados de una serie de pacientes con distintos tipos de POP tratados mediante la misma técnica quirúrgica. Material y método Entre enero de 2005 y agosto de 2008 intervinimos mediante una recto(colpo)sacropexia ventral a 57 pacientes diagnosticados de alguna forma de POP, que dividimos en tres grupos: grupo A, prolapso rectal total aislado o combinado con histerocele o colpocele (11 pacientes); grupo B, rectoenterocele con invaginación rectal interna y/o periné descendente (4 pacientes), y grupo C, prolapso genital del compartimento medio-posterior (42 pacientes). Se intervino por vía laparoscópica a los 15 pacientes de los grupos A y B y a 11 del grupo C. En 41 casos se empleó una malla biológica, y en los demás, una sintética macroporosa. Resultados La media de edad de la serie era 66 (19–81) años; 55 eran mujeres y 2, varones; la mediana de seguimiento fue 25 (4–48) meses). No hubo complicaciones postoperatorias mayores. En el grupo A registramos una recurrencia del prolapso (1/11); los 7 pacientes que presentaban incontinencia mejoraron tras la intervención; no se registró ningún caso de estreñimiento de novo y 8 de los 9 pacientes de los grupos A y B, con defecación obstructiva, mejoraron. En el grupo C se detectaron 9 (21%) recurrencias de alguno de los compartimentos vaginales, pero sólo 4 (9%) requirieron reintervención. En todas las recurrencias se había utilizado una malla biológica (..) (AU)

Introduction Ventral sacral-rectopexy with mesh corrects rectal prolapse and minimises rectal dissection. Subsequent colpopexy corrects apical and posterior prolapses of the vagina. The combination of both procedures can lead to the simultaneous correction of pelvic organ prolapses (POP). Objective To present the results of a patient series with several types of POP treated using the same approach and operation. Material and method A total of 57 patients diagnosed with any type of POP were operated on between January 2005 and August 2008 using ventral rectal-colpo-sacropexy, who were grouped into three types: A, total rectal prolapse isolated or combined with a hysterocele or colpocele (11 patients); B, rectoenterocele with internal rectal invagination and/or descending perineum (4 patients); and C, middle and posterior genital compartment prolapse (42 patients). The laparoscopic approach was used in the 15 patients of groups A and B and 11 from group C. A b iological mesh was used in 41 patients and a macroporous synthetic one in the rest. Results The mean age of the patients in the series was 66 (19–81) years, with 55 females and 2 males. The median follow up was 25 (4–48) months. There were no major post-surgical complications. A recurrence of prolapse was recorded in one patient in group A (1/11); the 7 patients who suffered from incontinence improved after the surgery, no case of de novo constipation being recorded and an improvement in 8 of the 9 patients from groups A and B with obstructive defaecation. There were 9 (21%) recurrences detected in group C, but only 4 (9%) required reintervention. In all the recurrences a biological mesh had been used. Conclusions Laparoscopic ventral rectal-colpo-pexy is an effective technique to correct POP. Although safe and innocuous, the results with biological meshes did not last as long (AU)

[Ventral rectal sacropexy (colpo-perineal) in the treatment of rectal and rectogenital prolapse]. / Recto (colpo, perineo) sacropexia ventral en el tratamiento del prolapso rectal y rectogenital.

INTRODUCTION: Ventral sacral-rectopexy with mesh corrects rectal prolapse and minimises rectal dissection. Subsequent colpopexy corrects apical and posterior prolapses of the vagina. The combination of both procedures can lead to the simultaneous correction of pelvic organ prolapses (POP). OBJECTIVE: To present the results of a patient series with several types of POP treated using the same approach and operation. MATERIAL AND METHOD: A total of 57 patients diagnosed with any type of POP were operated on between January 2005 and August 2008 using ventral rectal-colpo-sacropexy, who were grouped into three types: A, total rectal prolapse isolated or combined with a hysterocele or colpocele (11 patients); B, rectoenterocele with internal rectal invagination and/or descending perineum (4 patients); and C, middle and posterior genital compartment prolapse (42 patients). The laparoscopic approach was used in the 15 patients of groups A and B and 11 from group C. A biological mesh was used in 41 patients and a macroporous synthetic one in the rest. RESULTS: The mean age of the patients in the series was 66 (19-81) years, with 55 females and 2 males. The median follow up was 25 (4-48) months. There were no major post-surgical complications. A recurrence of prolapse was recorded in one patient in group A (1/11); the 7 patients who suffered from incontinence improved after the surgery, no case of de novo constipation being recorded and an improvement in 8 of the 9 patients from groups A and B with obstructive defaecation. There were 9 (21%) recurrences detected in group C, but only 4 (9%) required reintervention. In all the recurrences a biological mesh had been used. CONCLUSIONS: Laparoscopic ventral rectal-colpo-pexy is an effective technique to correct POP. Although safe and innocuous, the results with biological meshes did not last as long.