Optimal strategies of rectovaginal fistula after rectal cancer surgery

PURPOSE: Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is a type of anastomotic leakage. The aim of this study was to find out the difference of leakage, according to RVF presence or absence and to identify the optimal strategy for RVF. METHODS: All female patients who underwent low anterior resection with colorectal anastomosis or coloanal anastomosis (n = 950) were retrospectively analyzed. Patients' demographics and perioperative outcomes were analyzed between the RVF group and leakage without the RVF (nRVF) group. We performed 4 types of procedures—primary repair, diverting stoma, redo coloanal anastomosis (RCA), and conservative procedure—to treat RVF, and calculated the success rates of each type of procedure. RESULTS: The leakage occurred in 47 patients (4.9%). Among them, 18 patients (1.9%) underwent an RVF and 29 (3.0%) underwent nRVF. The RVF group received more perioperative radiotherapy (27.8% vs. 3.4%, P < 0.015) and occurred late onset after surgery (181.3 ± 176.4 days vs. 23.2 ± 53.6 days, P < 0.001) more than did the nRVF group. In multivariate analysis for the risk factor of the RVF group, the RVF group was statistically associated with less than 5 cm of anastomosis more than was the no-leakage group. A total of 35 procedures were performed in 18 patients with RVF for treatment. RCA showed satisfactory success rates (85.7%, n = 6) and, primary repair (transanal or transvaginal) showed acceptable success rate (33.3%, n = 8). CONCLUSION: After low anterior resection for rectal cancer, RVF was strongly correlated with a lower level of primary tumor location. Among the patients who underwent leakages, receipt of perioperative radiotherapy was significantly high in the RVF group than that of the nRVF group. Additionally, this study suggests that RCA might be considered another successful treatment strategy for RVF.

A novel robotic right colectomy for colon cancer via the suprapubic approach using the da Vinci Xi system: initial clinical experience

PURPOSE: We developed a technique of totally-robotic right colectomy with D3 lymphadenectomy and intracorporeal anastomosis via a suprapubic transverse linear port. This article aimed to introduce our novel robotic surgical technique and assess the short-term outcomes in a series of five patients. METHODS: All colectomies were performed using the da Vinci Xi system. Four robot trocars were placed transversely in the supra pubic area. Totally-robotic right colectomy was performed, including colonic mobilization, D3 lymphadenectomy, and intra corporeal stapled functional anastomosis. The 2 middle suprapubic trocar incisions were then extended to retrieve the specimen. RESULTS: Five robotic right colectomies via the suprapubic approach were performed between August 2015 and February 2016. The mean operation time was 183 ± 29.37 minutes, and the mean estimated blood loss was 27 ± 9.75 mL. The time to clear liquid intake was 3 days in all patients, and the mean length of stay after surgery was 6.2 ± 0.55 days. No patient required conversion to conventional laparoscopic surgery. There were no perioperative complications. According to the pathology report, the mean number of harvested lymph nodes was 36.6 ± 4.45. Four patients were stage III, and 1 patient was stage II according to the 7th edition of the American Joint Committee on Cancer system. CONCLUSION: Totally-robotic right colectomy via the suprapubic approach can be performed successfully in selected patients. Further comparative studies are required to verify the clinical advantages of our technique over conventional robotic surgery.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis

PURPOSE: Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. METHODS: Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. RESULTS: A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). CONCLUSION: In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

Change of Common Iliac Artery after Abdominal Aortic Aneurysm Repair Using a Tube Graft / 대한혈관외과학회지

PURPOSE: It remains controversial whether to use a tube graft or a bifurcated graft during open abdominal aortic aneurysm (AAA) repair, due to the potential for progression or development of a common iliac artery (CIA) aneurysm. This study evaluated the fate of CIA after tubular AAA repair. METHODS: On a retrospective basis, we reviewed 61 patients who underwent open AAA repair with a tube graft, between March 2000 and December 2009. Fifty-seven patients were included in this study; we excluded 4 cases in which the patients died in-hospital. Of those enrolled, 24 patients underwent follow-up computed tomography at least 1-year after surgery. CIAs were categorized into 3 groups: normal (< or =12 mm), ectasia (range, 13 to 18 mm), and aneurysm (range, 19 to 25 mm). The incidence of CIA aneurysm rupture was investigated, and the expansion rate of CIA was calculated. RESULTS: Mean patient age was 64 years and 73% of patients were male. Preoperatively, 8 patients had 2 normal CIAs, 14 patients had one CIA aneurysm at least, 27 patients had one CIA ectasia, and 8 patients were unknown. There was a mean follow-up of 51 months; no deaths were caused by rupture of CIA aneurysm, and no patient underwent invasive treatment for a CIA aneurysm. The mean follow-up for 24 patients with 48 CIAs was 45 months. The mean expansion rate of CIA was 0.5 mm/y. CONCLUSION: AAA repair using a tube graft was a safe and durable procedure. However, a bifurcated graft should be considered when patients are young and there is the expectation of a long life expectancy is anticipated allowing for a CIA expansion rate of 0.5 mm/y.