Risk factors for prolonged postoperative ileus after laparoscopic sphincter-saving total mesorectal excision for rectal cancer: an analysis of 428 consecutive patients.

BACKGROUND: Prolonged postoperative ileus (PPOI) is a common complication after colorectal resection but data regarding PPOI risk factors after laparoscopic rectal cancer surgery is lacking. This study aimed to identify risk factors for PPOI after laparoscopic sphincter-saving total mesorectal excision (TME) for cancer. METHODS: All patients who underwent a laparoscopic sphincter-saving TME for cancer from 2005 to 2014 were identified from our prospective database. PPOI was defined as abdominal distension, nausea, and/or vomiting, requiring a nasogastric tube insertion, during the postoperative period. RESULTS: Among 428 consecutive patients, 65 patients (15%) presented with POI. In multivariate analysis, male gender (Odds Ratio (OR) 2.3 [1.1-4.5]; p = 0.026, age >70 years (OR: 2.0 [1.1-4.0]; p = 0.037)], conversion to open approach (OR 4.9 [1.5-15.4]; p = 0.007), and intra-abdominal surgical site infection (OR 3.8 [1.9-7.5]; p < 0.001) were identified as independent risk factor for PPOI. PPOI risk was 5% in patients without any risk factor but raised to 11, 28, and 54% in patients with 1, 2, or ≥3 risk factors, respectively (p < 0.001). CONCLUSION: PPOI is observed in 15% of the patients after laparoscopic sphincter-saving surgery for rectal cancer. We identified four independent factors for PPOI in multivariate analysis: male, gender, age >70, conversion to open approach, and intra-abdominal surgical site infection, leading to the construction of a simple and pragmatic predictive score. This score might help the surgeon to assess patient at risk of PPOI.

Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients.

BACKGROUND: Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. METHODS: From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n = 44), 45-54 (n = 80), 55-64 (n = 166), 65-74 (n = 95) and ≥75 years (n = 61). RESULTS: Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson comorbidity index (p < 0.0001) and more frequent cardiovascular, pulmonary (p < 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43 %, p = 0.70). Medical morbidity slightly increased with age (14-9-14-19-26 %, p = 0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034) and operative time ≥240 min (p = 0.013). CONCLUSIONS: This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.

Bowel dysfunction after anastomotic leakage in laparoscopic sphincter-saving operative intervention for rectal cancer: A case-matched study in 46 patients using the Low Anterior Resection Score.

BACKGROUND: After sphincter-saving operation for rectal cancer, the impact of anastomotic leakage on function has been well studied. The purpose of the present work was to assess the influence of symptomatic and asymptomatic anastomotic leakage on bowel function and health-related quality of life using the Low Anterior Resection Syndrome score and the disease-specific questionnaire European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer. METHODS: The study was a case-matched study with multiple controls per case in a variable ratio from a prospectively maintained database conducted at a tertiary, colorectal operation referral center. A total of 46 patients with postoperative anastomotic leakage (symptomatic, n = 23, asymptomatic, n = 23) after laparoscopic, sphincter-saving operative intervention for rectal cancer were matched with all available patients without anastomotic leakage (control group, n = 89) using the following criteria: age, sex, type of neoadjuvant treatment, and type of anastomosis. The Low Anterior Resection Syndrome score and European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer were submitted to all included patients. The Low Anterior Resection Syndrome scores were categorized into 3 categories (no Low Anterior Resection Syndrome, minor Low Anterior Resection Syndrome, and major Low Anterior Resection Syndrome). RESULTS: Mean follow-up after stoma closure was 46 ± 26 months. Median (interquartile range) Low Anterior Resection Syndrome score for all included patients was 27 (16-36). Patients with symptomatic anastomotic leakage had impaired Low Anterior Resection Syndrome score: median 30 (23-39) vs 27 (15-34) in the control group (P = .02), with no Low Anterior Resection Syndrome in 4% (vs 31%), minor Low Anterior Resection Syndrome in 52% (vs 52%), and major Low Anterior Resection Syndrome in 44% (vs 17%) (P = .004). No difference was noted between the asymptomatic anastomotic leakage group and control group for median Low Anterior Resection Syndrome score (P = .70) and Low Anterior Resection Syndrome categories (no Low Anterior Resection Syndrome, minor LARS, and major Low Anterior Resection Syndrome; P = .58). Patients with symptomatic anastomotic leakage had significantly more anorectal and urinary symptoms compared with patients with no or asymptomatic anastomotic leakage. CONCLUSION: Symptomatic anastomotic leakage impairs function and quality of life after laparoscopic, sphincter-saving operative intervention for rectal cancer.

Bioprosthetic mesh reinforcement during temporary stoma closure decreases the rate of incisional hernia: A blinded, case-matched study in 94 patients with rectal cancer.

BACKGROUND: This case-matched study aimed to assess the feasibility and the potential benefits of placement of a prophylactic bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after total mesorectal excision (TME) for rectal cancer. METHODS: From September 2012 to March 2013, 30 consecutive patients underwent placement of a retromuscular bioprosthetic mesh in the abdominal wall during closure of a diverting ileostomy after sphincter-saving laparoscopic TME for rectal cancer (mesh group). These 30 patients were matched individually to all identical patients who underwent a closure of the ileostomy without mesh after laparoscopic TME extracted from our prospective database (control group). The matching process was performed according to sex, age, body mass index, medically treated diabetes mellitus, neoadjuvant radiotherapy, and the delay between TME and closure of the ileostomy. The primary endpoint was stoma site incisional hernia, assessed in a blinded fashion by CT 1 year later. RESULTS: Mesh placement was feasible in all mesh group patients. There was no postoperative mortality. Overall postoperative morbidity rates were similar between mesh and control groups (n = 5 [17%] vs n = 7 [11%], respectively; P = .512). On the 1-year CT, incisional hernia at the site of stomal closure was less in the mesh group (n = 1) compared with the control group (n = 12; P = .043). Reoperation for incisional hernia at the site of stomal closure was performed in 8 patients (13%) in the control group, whereas no patient from the mesh group required repair of the hernia (P = .052). CONCLUSION: Placement of a bioprosthetic collagen porcine mesh during closure of the temporary ileostomy after laparoscopic TME for rectal cancer seems to decrease the chance of hernia formation at the stoma site, at least at the 1-year follow-up.

Does anastomotic leakage impair functional results and quality of life after laparoscopic sphincter-saving total mesorectal excision for rectal cancer? A case-matched study.

PURPOSE: Anastomotic leakage (AL) after total mesorectal excision (TME) for rectal cancer is suspected to alter function. However, very few reports have been devoted to this problem. The aim of this study was to assess the influence of AL on function and quality of life (QoL) after laparoscopic TME for cancer. METHODS: A total of 170 patients who underwent laparoscopic TME and sphincter-saving surgery for mid and low rectal cancer were included (67 % after neoadjuvant chemoradiotherapy). Twenty-one patients with AL were assessed for function and QoL (Short Form 36 (SF-36), Fecal Incontinence Quality of Life (FIQL), CR-29, and Wexner's score) at the most recent follow-up. These patients were matched to 42 patients without AL according to sex, body mass index, ypTNM, radiotherapy, and type of anastomosis. RESULTS: After a median follow-up of 30 months, AL significantly impaired physical activity (SF-36) (p = 0.004), self-respect (FIQL) (p = 0.029), wear pad's score (Wexner's score) (p = 0.043), and blood and mucus in stool score (CR-29) (p = 0.001). Overall Wexner's score did not show any significant difference in the two groups, 8.9 in AL patients vs. 11.6 in patients without AL (p = 0.1). CONCLUSION: AL significantly impairs both functional results and quality of life after laparoscopic sphincter-saving TME for rectal cancer. However, the observed difference was only limited, leading to similar outcomes on most of the tested scores. Patients with AL should be warned that if they initially experience severely impaired results, outcomes tend with time to become similar to those observed in noncomplicated patients.