Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer.

INTRODUCTION: The need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer. MATERIALS AND METHODS: Patients having TME with primary anastomosis and HSD for low or mid rectal cancer between December 2014 and March 2017 were compared with a historical control group with RD in the preceding period since January 2011. HSD was introduced in conjunction with uptake of transanal TME. RESULTS: In the RD group, 45/50 patients (90%) had a primary diverting stoma, and 3/40 patients (8%) in the HSD group. Anastomotic leakage occurred in 10 (20%) and three (8%) cases after a median follow-up of 36 and 19 months after RD and HSD, respectively. There was no postoperative mortality. An unintentional stoma beyond 1 year postoperative was present in six and two patients, respectively. One-year stoma-related readmission and reoperation rate (including reversal) after RD were 84% and 86%, respectively. Corresponding percentages were significantly lower after HSD (17% and 17%; P < 0.001). Total hospital stay within one year was median 11 days (IQR 8-19) versus 5 days (IQR 4-11), respectively (P < 0.001). CONCLUSION: This single institutional comparative cohort study shows that highly selective defunctioning of a low anastomosis in rectal cancer patients did not adversely affect incidence or consequences of anastomotic leakage with a substantial decrease in 1-year readmission and reintervention rate, leading to an overall significantly reduced hospital stay.

What to do with the rectal stump during sphincter preserving rectal cancer resection with end colostomy: a collaborative snapshot study.

AIM: Low Hartmann's resection (LHR) and intersphincteric abdominoperineal excision (iAPR) are both feasible options in the treatment of rectal cancer when restoration of bowel continuity is not desired. The aim of this study was to compare the incidence of pelvic abscess and associated need for re-intervention and readmission after LHR and iAPR. METHOD: From a snapshot research project in which all rectal cancer resections from 71 Dutch hospitals in 2011 were evaluated, patients who underwent LHR or iAPR were selected. RESULTS: A total of 185 patients were included: 139 LHR and 46 iAPR. No differences in baseline characteristics were found except for more multivisceral resections in the iAPR group (22% vs 10%; P = 0.041). Pelvic abscesses were diagnosed in 17% of the LHR group after a median of 21 days (interquartile range 10-151 days), compared to 11% in the iAPR group (P = 0.352) after a median of 90 days (interquartile range 44-269 days; P = 0.102). All 28 patients with a pelvic abscess underwent at least one re-intervention. Four patients (9%) in the iAPR group and nine (7%) after LHR were readmitted because of a pelvic abscess over a median 39 months of follow-up. CONCLUSION: This cross-sectional multicentre study suggests that cross-stapling and intersphincteric resection of the rectal stump, during non-restorative rectal cancer resection, are associated with an equal risk of pelvic abscess formation and have a similar need for re-intervention and readmission.

Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases.

AIM: The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA. METHOD: This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up. RESULTS: A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8-27]. The median duration of follow-up was 27 months (IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004-0.122). CONCLUSION: Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.

Surgical wound complications after groin dissection in melanoma patients - a historical cohort study and risk factor analysis.

BACKGROUND AND OBJECTIVES: Wound complications occur frequently after inguinal lymph node dissection (ILND) in melanoma patients. Evidence on risk factors for complications is scarce and inconsistent. This study assessed wound complication rates after ILND and investigated associated risk factors, in the melanoma unit of a specialised cancer hospital. METHODS: A chart review was conducted of all patients on whom inguinal lymph node dissection had been performed between 2003 and 2013. Wound infections, seroma formation and skin flap problems were assessed according to explicit definitions and graded through the modified Clavien system. Univariable and multivariable penalized logistic regression was used to identify risk factors. The primary factors of interest were body mass index, age, smoking, diabetes, cardiovascular and/or pulmonal comorbidity, palpable disease and postoperative bedrest. Additionally, the influence of incision-type, sartorius transposition, saphenous vein sparing and skin removal was examined. RESULTS: A total of 145 procedures was examined. One or more complications occurred in 104 (72%) of the procedures; wound infection in 45%, seroma formation in 37% and skin flap problems in 26%. The only statistically significant risk factor was age (odds ratio for one standard deviation increase: 1.46, 95%CI 1.01-2.14, p = 0.05). CONCLUSIONS: Wound complication rates after ILND in melanoma patients are high. Age was the only predictor of complications in this cohort, other previously identified risk factors could not be confirmed.