Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery.

PURPOSE: This study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR). METHODS: Between January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine. RESULTS: Of the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis. CONCLUSION: WCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.

Comparison of recurrence patterns between ≤5 years and >5 years after curative operations in colorectal cancer patients.

BACKGROUND AND OBJECTIVES: To identify characteristics of recurrent colorectal cancer in terms of follow-up periods, that is, ≤5 years and >5 years after curative operations METHODS: This study enrolled 4,023 patients. Of them, 835 patients showed recurrence after primary curative resection for colorectal cancer. Recurrence occurred ≤5 years (n = 799) or >5 years (n = 36) after curative surgery. Variables and recurrence patterns were compared between the groups. RESULTS: Among the 835 patients who experienced recurrence, only 4.3% recurred >5 years after surgery. This group showed lower preoperative serum carcinoembryonic antigen levels, more tumors with expanding growth, well-differentiated histology, and no lymph node metastasis (all P < 0.05). In terms of haematogenous metastasis, lung or liver was the most prevalent site in patients who recurred after >5 years or ≤5 years, respectively (P = 0.005). In rectal cancer patients, recurrence patterns revealed the same results. In colon cancer patients, the liver was the most prevalent site in both groups. CONCLUSIONS: After 5 years of follow-up, routine surveillance for detecting other malignancies seems to be sufficient. However, the possibility of late (particularly late pulmonary) recurrence should be considered. Radiologic examination to detect pulmonary metastasis should be considered in the follow-up program.

Characteristics and risk factors associated with permanent stomas after sphincter-saving resection for rectal cancer.

BACKGROUND: The aim of the present study was to identify the risk factors and patient characteristics associated with permanent stomas after sphincter-saving resection for rectal cancer. METHOD: Between 2000 and 2007, 2,362 patients underwent sphincter-saving surgery [low anterior resection or ultra-low anterior resection (uLAR)] for rectal cancer. These patients were divided into two groups: 71 patients with permanent stomas and 2,291 patients without permanent stomas after rectal cancer surgery. RESULTS: Of the 71 permanent stomas (3 % of the patients), 34 (48 %) were ileostomies, 11 (15 %) were loop colostomies, 10 (14 %) were treated by Hartmann's operation, and 16 (23 %) were treated by abdominoperineal resection. Diverting stomas were created in 364 patients; 3 % (n = 11) of them could not be reversed due to anastomosis-related complications. Permanent stomas were constructed at a median of 20 months after sphincter-saving surgery for rectal cancer. The main causes of permanent stomas were local recurrence (n = 27), anastomotic leakage (n = 12), fistula (n = 9), and anastomosis site stricture (n = 7). The main causes of early permanent stomas (<1 year) were anastomosis-related complications, whereas for late permanent stomas (≥1 year), the main cause was local cancer recurrence. The independent risk factors for permanent stomas were local recurrence, postoperative pelvic sepsis, male gender of the patient, the uLAR operation type, and perioperative radiation therapy. CONCLUSIONS: In a high-volume surgical center, sphincter-saving surgery for rectal cancer is associated with a low incidence of permanent stoma.

The Role of Diverting Stoma After an Ultra-low Anterior Resection for Rectal Cancer.

PURPOSE: A diverting stoma is known to reduce the consequences of distal anastomotic failure following colorectal surgery. The aim of this study was to evaluate the efficacy of a diverting stoma after an ultra-low anterior resection (uLAR) for rectal cancer. METHODS: Between 2000 and 2007, 836 patients who underwent an uLAR were divided into two groups, depending on the fecal diversion: 246 received fecal diversion, and 590 had no diversion. Patient- and disease-related variables were compared between the two groups. RESULTS: Thirty-two of the 836 patients (3.8%) had immediate anastomosis-related complications and required reoperation. Anastomosis leakage comprised 72% of the complications (23/32). The overall immediate complication rate was significantly lower in patients with a diverting stoma (0.8%, 2/246) compared to those without a diverting stoma (5.1%, 30/590; P = 0.005). The fecal diversion group had lower tumor location, lower anastomosis level, and more preoperative chemo-radiation therapy (P < 0.001). In total, 12% of patients in the diverting stoma group had complications either in making or reversing the stoma (30/246). CONCLUSION: The diverting stoma decreased the rate of immediate anastomosis-related complications. However, the rate of complications associated with the diverting stoma was non-negligible, so strict criteria should be applied when deciding whether to use a diverting stoma.

Feasibility of transanal minimally invasive surgery for mid-rectal lesions.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery. We assessed the feasibility of TAMIS for lesions located in the mid rectum. METHODS: From July 2010 to October 2011, 16 consecutive patients with rectal pathology underwent TAMIS. After a single-incision laparoscopic surgery port was introduced into the anal canal, pneumorectum was established with a laparoscopic device, followed by transanal excision with conventional laparoscopic instruments, including graspers, monopolar electrocautery, and needle drivers. Clinicopathological findings, surgical procedure results, and perioperative outcomes were determined prospectively. RESULTS: Of the 16 patients, 11 had rectal cancers (3 T1 lesions and 8 after preoperative chemoradiotherapy), 4 had neuroendocrine tumors, and 1 had a mucocele. The median length of the lesions from anal verge was 7.5 cm (range 4-10 cm). All procedures were completed laparoscopically without conversion to conventional transanal approach. The median operating time was 86 min (range 33-160 min), and the median estimated blood loss was 15 ml (range 0-150 ml) with no patient requiring intraoperative transfusions. There was no surgical morbidity or mortality, but one patient died during follow-up due to synchronous advanced gastric cancer. The median postoperative hospital stay was 3 days (range 2-6 days). CONCLUSIONS: TAMIS seems to be a feasible and safe treatment option for lesions located in the mid rectum.