Preoperative mechanical bowel preparation combined with oral antibacterials in the prevention of complications of surgery for rectal and rectosigmoid junction cancer

Aim: To evaluate the efficacy of mechanical bowel preparation (MBP) combined with oral antibacterials for the prevention of postoperative complications when preparing a patient for anterior rectal resection.Materials and methods: We analyzed shortterm results in 77 patients who had undergone anterior rectal resection for rectal and rectosigmoid junction cancer. Forty five (45) patients were prepared for surgery only with MBP. In 32 patients, in addition to MBP, oral antibacterial agents ciprofloxacin and metronidazole were used preoperatively.Results: The overall rate of postoperative complications was 6.25% (2/32 patients) in the group of combined preparation for surgery and 15.5% (7/45) in the group using only MBP. Surgical wound infection occurred in 1 patient in the combined preparation group and in 4 patients in the MBP only group. There was no anastomotic leak in the combined preparation group, whereas in the MBP only group, anastomotic leak occurred in 2 patients.Conclusion: Combined use of oral antibacterials and MBP before anterior rectal resection makes it possible to achieve an extremely low rate of the colorectal anastomosis leak. Further studies into the efficacy of this preparation regimen are needed, along with their discussion in the professional communities.

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection

Background: Anastomotic leakage (AL) after colorectal surgery is associated with insufficient vascular perfusion of the anastomotic ends. This study aimed to evaluate the effect of high vs. low ligation of the ileocolic artery and inferior mesenteric artery, respectively, on the vascular perfusion of the bowel stumps during ileocecal resection (ICR) and anterior rectal resection (AR).Methods: We retrospectively evaluated patients who underwent ICR or AR between 2016 and 2020. Real-time indocyanine green fluorescence angiography was performed to measure the fluorescence time (FT) as a marker of the blood flow in the proximal and distal stumps before anastomosis.Results: Thirty-four patients with lower right-sided colon cancer underwent laparoscopic ICR. Forty-one patients with rectosigmoid colon or rectal cancer underwent robotic high AR (HAR) (n = 8), robotic low AR (LAR) (n = 6), laparoscopic HAR (n = 8), or laparoscopic LAR (n = 19). The FT was similar in the ileal and ascending colon stumps (p = 1.000) and did not differ significantly between high vs. low ligation of the ileocolic artery (p = 0.934). The FT was similar in the sigmoid colon and rectal stumps (p = 0.642), but high inferior mesenteric artery ligation significantly prolonged FT in the sigmoid colon during AR compared with low ligation (p = 0.004), indicating that the high ligation approach caused significant hypoperfusion compared with low ligation. The AL rate was similar after low vs. high ligation.Conclusions: Low vascular perfusion of the bowel stumps may not be an absolute risk factor for AL. High inferior mesenteric artery ligation could induce sigmoid colon stump hypoperfusion during anterior rectal resection.

Bacteriological concentration of peritoneal drainage fluid could make an early diagnosis of anastomotic leakage following rectal resection

To investigate that the bacteriological concentration and pH value in peritoneal drainage fluid might serve as indicators of early diagnosis of anastomotic leakage following rectal resection. We prospectively analyzed consecutive patients who were treated for rectal diseases with anastomosis at the department of general surgery, the affiliated hospital of Nanjing University Medical School between August 2018 and December 2020. The bacteriological concentration and the pH value in peritoneal drainage fluid were tested on the first, fourth, seventh days postoperatively. A total of 300 consecutive patients underwent rectal resection were tested. 21 patients present with AL and the overall AL rate was 7%. The bacteriological concentration in peritoneal drainage fluid of AL group was significantly higher than that in non-AL group. The AUC value was 0.98 (95% confidence intervals 0.969–1.000) according to the ROC curve. The best cut-off value was 1143/uL. The sensitivity and specificity were 100% and 93.19% respectively. There was no difference of pH value between the AL and non-AL groups. According the results of present study, a high bacteriological concentration in peritoneal drainage fluid is a good marker for predicting and diagnosing AL following rectal resection. However, owing to the limitation of the sample, there was no validation attempt in the study. A large sample study is needed to validate the conclusion.

Ureteral injury during laparoscopic rectal resection and concurrent laparoscopic repair by uretero-ureterostomy

Iatrogenic ureteral injury is an uncommon but severe complication of laparoscopic colorectal surgery. If it is detected intraoperatively, conversion to open surgery is usually inevitable. Here, we described a complete ureteral transection during laparoscopic low anterior resection, which was simultaneously repaired by laparoscopic uretero-ureterostomy. The most important points during the anastomosis of two tiny tubular tissues are dissecting the tubular organs without trauma, obtaining meticulous hemostasis without causing any necrosis, and achieving accurate approximation of tissues with the sutures. To the best of our knowledge, this is the first report that focused on laparoscopic repair of ureteral injury during laparoscopic colorectal surgery. As there are still few data on laparoscopic repair of ureteral lesions, no firm conclusions can be drawn. But, in appropriate cases, if intracorporeal suture expertise is available, laparoscopic repair can be done during colorectal surgery.

Quality of Life in a Randomized Trial Comparing Two Neoadjuvant Regimens for Locally Advanced Rectal Cancer – INCAGI004.

Background: Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC), but the emergence of different drug regimens may result in different response rates. Good clinical response translates into greater sphincter preservation, but quality of life (QOL) may be impaired after treatment due to chemoradiotherapy and surgical side effects. Objective: To prospectively evaluate the QOL in a randomized trial comparing two neoadjuvant regimens for locally advanced rectal cancer.Methods: Stage II and III rectal cancer patients were randomized to receive neoCRT with either capecitabine (Group 1) or 5-Fu and leucovorin (Group 2) concomitant to long course radiotherapy. Clinical downstaging was accessed using MRI 6-8 weeks after treatment. EORTCs QLQ C30 and CR38 were applied before treatment (T0), after neoCRT (T1), after rectal resection (T2), early after adjuvant chemotherapy (T3), and one year after end of treatment or stoma closure (T4). Wexner scale was used for continence evaluation at T4. A C30SummaryScore (Geisinger et cols) was calculated to compare QOL results. Results: 32 patients were assigned to Group 1 and 31 to Group 2. Clinical downstaging occurred in 70.0% of Group 1 and 53.3% of Group 2 (p=0.288). pCR was 23.3% in group 1 and 10.0% in Group 2(p=0.165). Sphincter preservation was 83.3% in Group 1 and 80.0% in Group 2(p=0.111). No difference in QOL was detected comparing the two treatment groups before and after neoCRT. C30SummaryScore detected improvement comparing T0 to T1 and deterioration comparing T1 to T2 (p=0.025), and global health status improved at T1 and T4 compared to T0(p=0.004). Mean Wexner scale score was 9.2, and a high score correlated with symptoms of diarrhea and defecation problems at T4.Conclusions: Clinical and pathological response rates were equivalent in both treatment groups. QOL was improved after neoCRT corresponding to clinical response but decreased following rectal resection. Wexner score was high after sphincter preservation. C30SummaryScore was a useful tool to detect differences in overall QOL in EORTCs multiple item questionnaire.Trial registration: NCT03428529. Registered 02/09/2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03428529.

RISK FACTOR ANALYSIS OF TYPE COLORECTAL OPERATION AND INTRAABDOMEN CONTAMINATION ON EVENT POST OPERATIVE ADHESION: SYSTEMATIC REVIEW AND METAANALYSIS

BACKGROUND: Colorectal surgery is the highest incidence of adhesion-related problems. The type of surgery might be total coletomy, right hemicolectomy, left hemicolectomy, segmental colectomy, Hartmann procedure, and colostomy. Surgical procedures performed on the colon could be contaminated. The most common contamination is faecal contamination. Various causes of peritoneal irritation result in localized brin production, which results in adhesion to the surfaces in contact. PURPOSE: This study focused on the type of colorectal surgery and intra-abdominal contamination on the incidence of postoperative adhesions. METHOD: Systematic review and meta-analysis. We searched for published journal on types of colorectal surgery and contamination with adhesion events published from 2010-2020 using electronic database : Pubmed, Science Direct and Cochrane. RESULT: Ten journals (8 cohort and 2 case control) were included in the meta-analysis. In the risk factors for colorectal surgery: APR surgery, total colectomy and rectal resection had a signicant risk of postoperative adhesions with a pooled odds ratio of 1.74 (95% CI 1 respectively). ,10-2,78); 2.89 (95% CI 2.44-3.41) and 9.91 (95% CI 8.66-11.35). Intra-abdominal contamination also had a risk of adhesions with a pooled odds ratio of 863.47 (95% CI 177.73-4194.13). CONCLUSION: Types of colorectal surgery : APR, total colectomy, and rectal resection and intra-abdominal contamination had a risk of postoperative adhesions.

The results of anterior rectal resection with the formation of a hardware anastomosis in cancer patients

Purpose of the study. A retrospective analysis of the immediate results of performing anterior rectal resections in cancer. Materials and methods. In the Department of Abdominal Oncology No. 1 with a group of X-ray vascular methods of diagnosis and treatment of the clinic of the National Medical Research Centre for Oncology of the Ministry of Health of Russia treatment for rectal cancer operations of anterior rectal resection were performed in 334 patients, while in 143 (42.8 %) cases they were low. As a standard, total mesenteric excision and lymphoid dissection in volume D2 were performed. Combined surgical interventions were performed in 68 (20.4 %) patients for locally spread tumors. As a rule, they were resection in nature and were performed with tumor infiltration of adjacent organs (bladder with ureters, ovaries, uterus, vagina, small intestine, abdominal wall). Colorectal anastomosis using crosslinking devices was formed in all cases, in 316 (94.6 %) cases it was a "side – to-end" junction, in 18 patients – "end-to-end". A preventive proximal intestinal stoma was formed in 73 (21.9 %) cases, where 67 cases it was an ileostomy, and 6 – a transversostomy. The preventive proximal intestinal stoma was not formed among 261 patients. Results. After performing anterior resections for rectal cancer operations, the complications developed in 75 (22.5 %) patients. The most threatening and dangerous complication was the failure of the colorectal anastomosis, which was noted in 12 (3.5 %) cases.This complication occurred in 8.2 % (6 patients out of 73) of preventatively stoma-treated patients, in 2.3 % of patients without a stoma (6 patients out of 261).Conclusion. The use of a preventive proximal intestinal stoma allows you to form a colorectal anastomosis even in the presence of complicated forms of rectal cancer. The number of complications directly referred to the formation of a preventive proximal intestinal stoma is relatively small, but when planning surgery for uncomplicated rectal cancer, the probability of their possible occurrence should be taken into account.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.