SP1.2.12A meta-analysis of the impact of rectal washout on local recurrence following anterior resection for rectal cancers

Background Standardisation of surgical technique in form of total mesorectal excision (TME) and the use of preoperative radiotherapy have led to improved oncological outcomes in rectal cancer. However, the effectiveness of rectal washout in reducing local recurrence (LR) following anterior resection remains debatable. The aim of this meta-analysis was to evaluate the effectiveness of rectal washout in reducing incidence of LR after anterior resection for rectal cancer. Methods A literature search of electronic databases including PubMed, Embase, Scopus and Cochrane was performed for studies that compared rectal washout to no washout after anterior resection using TME for rectal cancers. The review included all articles reporting oncological outcome of local recurrence. Meta-analysis was carried out using random effect model. Results A total of 5 studies involving 5315 patients were included in meta-analysis. Median follow-up was 60 (range 33–60) months. Overall local recurrence rate was 6.6 % with no significant difference in LR rate between the rectal washout and no washout groups (5.23% vs. 9 %)(P = 0.93; RR 0.97; 95% CI 0.52- 1.83).Similarly in subgroup analysis including prospective studies only no significant difference in LR was seen after washout (P = 0.06) or in group of patients treated with a curative intent(P = 0.50). LR was significantly lower in patients who had a rectal washout with normal saline (P < 0.00001; RR 0.59; 95% CI 0.47-0.74). Conclusion This meta-analysis shows that there is no benefit of rectal washout in reducing incidence of local recurrence after anterior resection for rectal cancers.

780 Effectiveness of Colonic/Rectal Washout in Reducing Risk of Local Recurrence in Rectal and Distal Left Sided Colonic Cancer Resection. A Meta-Analysis

Background Lab and clinical studies have shown evidence that local recurrence (LR) occurs due to free cancer cells at resection sites. Evidence for the effectiveness of rectal washout (RW) in washing out these cells and reducing the incidence of local recurrence in the literature is equivocal. Aims To determine whether intraoperative RW can effectively reduce the incidence of LR in rectal and distal colonic tumour resection. Method A literature search was conducted according to PRISMA guidelines. The primary endpoint was incidence of local recurrence of cancer after rectal cancer surgery. Results The meta-analysis revealed that at 5 year follow up, local recurrence in the washout group (WO) was 6.08% compared to 9.48% in the no-washout group (NWO) group (OR 0.63, 95% CI = 0.51 –0.73, Chi2 = 6.76, df = 7, p = 0.45). Based on this study we found the number needed to treat would be 29.3 (95%CI 20.9 –56.6) in order to prevent one local recurrence at 5 years. Conclusions RW reduces the risk of LR in patients with distal colorectal cancer resection in the long term follow up. A small number of patients needed to be treated to avoid one local recurrence in the five year follow up.

Rectal washout does not increase the complication risk after anterior resection for rectal cancer

Background To reduce local recurrence risk, rectal washout (RW) is integrated in the total mesorectal excision (TME) technique when performing anterior resection (AR) for rectal cancer. Although RW is considered a safe practice, data on the complication risk are scarce. Our aim was to examine the association between RW and 30-day postoperative complications after AR for rectal cancer. Methods Patients from the Swedish Colorectal Cancer Registry who underwent AR between 2007 and 2013 were analysed using multivariable methods. Results A total of 4821 patients were included (4317 RW, 504 no RW). The RW group had lower rates of overall complications (1578/4317 (37%) vs. 208/504 (41%), p = 0.039), surgical complications (879/4317 (20%) vs. 140/504 (28%), p < 0.001) and 30-day mortality (50/4317 (1.2%) vs. 12/504 (2.4%), p = 0.020). In multivariable analysis, RW was a risk factor neither for overall complications (OR 0.73, 95% CI 0.60–0.90, p = 0.002) nor for surgical complications (OR 0.62, 95% CI 0.50–0.78, p < 0.001). Conclusions RW is a safe technique that does not increase the 30-day postoperative complication risk after AR with TME technique for rectal cancer.

Randomized clinical trial on the use of a colon-occlusion device to assist rectal washout

Background Transrectal Natural Orifice Transluminal Endoscopic Surgery is currently limited by the inherent risk of surgical site infection due to peritoneal contamination after rectotomy. Coloshield has been developed as a temporary colon occlusion device to facilitate rectal washout. However, effectiveness and safety has not been evaluated in humans. Methods Twenty-two patients have been randomly assigned to undergo proctological intervention with a rectal washout with and without the use of Coloshield. Patients and assessors were blinded. Boston Bowel Preparation Scale (BBPS) has been determined 30 min as well as immediately after rectal washout. Feasibility, pain, intra- and postoperative morbidity as well as bowel function and continence 6 weeks after surgery were assessed. Results BBPS 30 min after rectal washout with and without Coloshield was in mean 2.42 ± 1.02 and 2.12 ± 0.89 (p = 0.042). Mean BBPS immediately after rectal washout was 2.39 ± 1.02 and 2.24 ± 0.66 (p = 0.269). Mean BBPS immediately after rectal washout and 30 min thereafter did not differ (p = 0.711). Coloshield application was feasible without any complications. The median (interquartile range) numeric rating scale for pain 4 h after surgery was 1 (0–1) and 3 (0–4) (p = 0.212). Six weeks after surgery 0/11 and 1/11 patients suffered from evacuation difficulties (p = 1.0) and the median Vaizey–Wexner score was 1 (0–3) and 1 (0–2) (p = 0.360). Conclusions Coloshield application in humans is feasible and safe. Slight benefits in rectal preparation by washout are found when Coloshield is used. Colon occlusion by Coloshield for transrectal NOTES should be evaluated within clinical studies. Trial registration Clinicaltrials.gov NCT02579330

Quantitative Assessment of Rectal Washout With Irrigation and Aspiration

Local recurrence of rectal cancer is defined as any evidence of relapse within the small pelvis after surgical resection of the primary tumor. After removal of a rectal tumor, necrotic cellular debris and viable exfoliated cancer cells are present in the rectal lumen; using saline or povidone-iodine solution, many surgeons perform rectal washout beyond an occlusive clamp to remove these exfoliated malignant cells, which may lead to local recurrence. A meta-analysis showed that intraoperative rectal washout at the surgical anastomosis site can reduce the risk of local recurrence after rectal cancer resection. Therefore, intraluminal lavage is useful to prevent local recurrence. Although intraoperative rectal washing is considered to be important, there is probably room for improvement on this method. We described the idea of a new transanal irrigation and aspiration system for small rectal contents. The aim of this research was to investigate the effect of a new rectal washout system using a chemiluminescent imaging system. We attempted to evaluate and compare the washout efficiency between this new system and the conventional irrigation system using a cylindrical rectum model. Our results implied that, at the same volume of solution, the irrigation–aspiration rectal washout system was more effective than the irrigation washout system. This new rectal washout system was easy to use and allowed a good washout. To the best of our knowledge, this was the first report that evaluated the efficacy of a rectal washout system using quantitative data.

Phosphate Enema Causing Life-Threatening Rectal Perforation

We report a near fatal rectal perforation due to a phosphate enema in an elderly male. The presentation in septic shock within 4 hours of the enema is quite rare. Early recognition and prompt management are essential for a good outcome. A defunctioning colostomy is standard for these cases but we recommend a distal rectal washout since intraluminal faeces in a loaded rectum could be a cause of ongoing sepsis. Although enemas are commonly used for constipation in the elderly, suppositories and oral preparations should be used preferentially where appropriate.