nach oben

Erschienen in:

18.07.2022 | Original Paper

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study

verfasst von: Peter Tschann, Markus P. Weigl, Philipp Szeverinski, Daniel Lechner, Thomas Brock, Stephanie Rauch, Jana Rossner, Helmut Eiter, Paolo N. C. Girotti, Tarkan Jäger, Jaroslav Presl, Klaus Emmanuel, Alexander De Vries, Ingmar Königsrainer, Patrick Clemens

Erschienen in: Langenbeck's Archives of Surgery | Ausgabe 7/2022

Einloggen, um Zugang zu erhalten

Abstract

Purpose

Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy.

Methods

A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage −).

Results

A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172–309] vs. 93 days [50–182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08–7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01–4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors.

Conclusion

We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.

Nur mit Berechtigung zugänglich

Artus A, Tabchouri N, Iskander O et al (2020) Long term outcome of anastomotic leakage in patients undergoing low anterior resection for rectal cancer. BMC Cancer 20:780. https://doi.org/10.1186/s12885-020-07109-4CrossRefPubMedPubMedCentral

Glynne-Jones R, Wyrwicz L, Tiret E et al (2017) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 28:iv22–iv40. https://doi.org/10.1093/annonc/mdx224CrossRefPubMed

Bosset J-F, Collette L, Calais G et al (2006) Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 355:1114–1123. https://doi.org/10.1056/NEJMoa060829CrossRefPubMed

Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616. https://doi.org/10.1002/bjs.1800691019CrossRefPubMed

Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646. https://doi.org/10.1056/NEJMoa010580CrossRefPubMed

Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740. https://doi.org/10.1056/NEJMoa040694CrossRefPubMed

Rullier E, Laurent C, Bretagnol F et al (2005) Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 241:465–469. https://doi.org/10.1097/01.sla.0000154551.06768.e1CrossRefPubMedPubMedCentral

Kanso F, Maggiori L, Debove C et al (2015) Perineal or abdominal approach first during intersphincteric resection for low rectal cancer: which is the best strategy? Dis Colon Rectum 58:637–644. https://doi.org/10.1097/DCR.0000000000000396CrossRefPubMed

Bonjer HJ, Deijen CL, Abis GA et al (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332. https://doi.org/10.1056/NEJMoa1414882CrossRefPubMed

10.

Hol JC, van Oostendorp SE, Tuynman JB et al (2019) Long-term oncological results after transanal total mesorectal excision for rectal carcinoma. Tech Coloproctol 23:903–911. https://doi.org/10.1007/s10151-019-02094-8CrossRefPubMedPubMedCentral

11.

Jayne D, Pigazzi A, Marshall H et al (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318:1569–1580. https://doi.org/10.1001/jama.2017.7219CrossRefPubMedPubMedCentral

12.

Tschann P, Seitinger G, Lechner D et al. (2021) Reduced port versus open right hemicolectomy for colorectal cancer: a retrospective comparison study of two centers. Int J Colorectal Dis. https://doi.org/10.1007/s00384-021-03923-9

13.

Tschann P, Lechner D, Girotti PNC et al. (2022) Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem? Langenbecks Arch Surg. https://doi.org/10.1007/s00423-021-02416-1

14.

Cedermark B, Dahlberg M, Glimelius B et al (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 336:980–987. https://doi.org/10.1056/NEJM199704033361402CrossRefPubMed

15.

Feeney G, Sehgal R, Sheehan M et al (2019) Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol 25:4850–4869. https://doi.org/10.3748/wjg.v25.i33.4850CrossRefPubMedPubMedCentral

16.

Diaz-Canton E, Pazdur R (1997) Preoperative combined oral UFT plus leucovorin and radiation therapy for rectal cancer. Oncology (Williston Park) 11:58–60PubMed

17.

Bauer TW, Spitz FR (1998) Adjuvant and neoadjuvant chemoradiation therapy for primary colorectal cancer. Surg Oncol 7:175–181. https://doi.org/10.1016/s0960-7404(99)00027-4CrossRefPubMed

18.

Minsky BD, Cohen AM, Enker WE et al (1997) Preoperative 5-FU, low-dose leucovorin, and radiation therapy for locally advanced and unresectable rectal cancer. Int J Radiat Oncol Biol Phys 37:289–295. https://doi.org/10.1016/s0360-3016(96)00487-7CrossRefPubMed

19.

Harris LJ, Phillips BR, Maxwell PJ et al (2010) Outcomes of low anterior resection anastomotic leak after preoperative chemoradiation therapy for rectal cancer. Am Surg 76:747–751CrossRefPubMed

20.

Hasegawa H, Matsuda T, Arimoto A et al (2020) Does anastomotic leakage after rectal cancer resection worsen long-term oncologic outcome? Int J Colorectal Dis 35:1243–1253. https://doi.org/10.1007/s00384-020-03577-zCrossRefPubMed

21.

Wang F-G, Yan W-M, Yan M et al (2019) Comparison of anastomotic leakage rate and reoperation rate between transanal tube placement and defunctioning stoma after anterior resection: A network meta-analysis of clinical data. Eur J Surg Oncol 45:1301–1309. https://doi.org/10.1016/j.ejso.2019.01.182CrossRefPubMed

22.

Lee BC, Lim S-B, Lee JL et al. (2020) Defunctioning protective stoma can reduce the rate of anastomotic leakage after low anterior resection in rectal cancer patients. Annals coloproctol. https://doi.org/10.3393/ac.2019.11.19.1

23.

Zhao S, Zhang L, Gao F et al (2021) Transanal drainage tube use for preventing anastomotic leakage after laparoscopic low anterior resection in patients with rectal cancer: a randomized clinical trial. JAMA Surg 156:1151–1158. https://doi.org/10.1001/jamasurg.2021.4568CrossRefPubMedPubMedCentral

24.

Du P, Burke JP, Khoury W et al (2016) Factors associated with the location of local rectal cancer recurrence and predictors of survival. Int J Colorectal Dis 31:825–832. https://doi.org/10.1007/s00384-016-2526-5CrossRefPubMed

25.

Jäger T, Nawara C, Neureiter D et al (2015) Einfluss der Anastomoseninsuffizienz auf das Langzeitüberleben beim tiefen Rektumkarzinom (Impact of anastomotic leakage on long-term survival in mid-to-low rectal cancer). Chirurg 86:1072–1082. https://doi.org/10.1007/s00104-015-0090-0CrossRefPubMed

26.

Iancu C, Mocan LC, Todea-Iancu D et al (2008) Host-related predictive factors for anastomotic leakage following large bowel resections for colorectal cancer. J Gastrointestin Liver Dis 17:299–303PubMed

27.

Jestin P, Påhlman L, Gunnarsson U (2008) Risk factors for anastomotic leakage after rectal cancer surgery: a case-control study. Colorectal Dis 10:715–721. https://doi.org/10.1111/j.1463-1318.2007.01466.xCrossRefPubMed

28.

Nishigori H, Ito M, Nishizawa Y et al (2014) Effectiveness of a transanal tube for the prevention of anastomotic leakage after rectal cancer surgery. World J Surg 38:1843–1851. https://doi.org/10.1007/s00268-013-2428-4CrossRefPubMed

29.

Little JP (1995) Consistency of ASA grading. Anaesthesia 50:658–659PubMed

30.

Doyle DJ, Goyal A, Garmon EH. American Society of Anesthesiologists Classification. [Updated 2022 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441940/

31.

Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196. https://doi.org/10.1097/SLA.0b013e3181b13ca2CrossRefPubMed

32.

Brierley J, Gospodarowicz MK, Wittekind C (eds) (2017) TNM classification of malignant tumours, 8th edn. John Wiley & Sons Inc, Chichester, West Sussex, UK, Hoboken, NJ

33.

Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Kolorektales Karzinom, Langversion 2.1,2019, AWMF Registrierungsnummer: 021/007OL, http://www.leitlinienprogramm-onkologie.de/leitlinien/kolorektales-karzinom/ Deutsche S3 Leitline

34.

Hofheinz R-D, Wenz F, Post S et al (2012) Chemoradiotherapy with capecitabine versus fluorouracil for locally advanced rectal cancer: a randomised, multicentre, non-inferiority, phase 3 trial. Lancet Oncol 13:579–588. https://doi.org/10.1016/S1470-2045(12)70116-XCrossRefPubMed

35.

Rahbari NN, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351. https://doi.org/10.1016/j.surg.2009.10.012CrossRefPubMed

36.

Jang JH, Kim HC, Huh JW et al (2019) Anastomotic leak does not impact oncologic outcomes after preoperative chemoradiotherapy and resection for rectal cancer. Ann Surg 269:678–685. https://doi.org/10.1097/SLA.0000000000002582CrossRefPubMed

37.

Rödel C, Martus P, Papadoupolos T et al (2005) Prognostic significance of tumor regression after preoperative chemoradiotherapy for rectal cancer. J Clin Oncol 23:8688–8696. https://doi.org/10.1200/JCO.2005.02.1329CrossRefPubMed

38.

Shapiro SS, Wilk MB (1965) An analysis of variance test for normality (complete samples). Biometrika 52:591. https://doi.org/10.2307/2333709CrossRef

39.

Altman DG (1990) Practical statistics for medical research. Chapman and Hall/CRC Texts in Statistical Science. CRC Press LLC, Boca Raton

40.

Salvans S, Mayol X, Alonso S et al. (2014) Postoperative peritoneal infection enhances migration and invasion capacities of tumor cells in vitro: an insight into the association between anastomotic leak and recurrence after surgery for colorectal cancer. Ann Surg 260:939–43; discussion 943–4. https://doi.org/10.1097/SLA.0000000000000958

41.

Matsubara N, Miyata H, Gotoh M et al (2014) Mortality after common rectal surgery in Japan: a study on low anterior resection from a newly established nationwide large-scale clinical database. Dis Colon Rectum 57:1075–1081. https://doi.org/10.1097/DCR.0000000000000176CrossRefPubMed

42.

Hu M-H, Huang R-K, Zhao R-S et al (2017) Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis. Colorectal Dis 19:16–26. https://doi.org/10.1111/codi.13424CrossRefPubMed

43.

Penna M, Hompes R, Arnold S et al (2019) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry. Ann Surg 269:700–711. https://doi.org/10.1097/SLA.0000000000002653CrossRefPubMed

44.

Wang L, Gu J (2010) Risk factors for symptomatic anastomotic leakage after low anterior resection for rectal cancer with 30 Gy/10 f/2 w preoperative radiotherapy. World J Surg 34:1080–1085. https://doi.org/10.1007/s00268-010-0449-9CrossRefPubMed

45.

McDermott FD, Heeney A, Kelly ME et al (2015) Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 102:462–479. https://doi.org/10.1002/bjs.9697CrossRefPubMed

46.

Sparreboom CL, Wu Z, Lingsma HF et al (2018) Anastomotic leakage and interval between preoperative short-course radiotherapy and operation for rectal cancer. J Am Coll Surg 227:223–231. https://doi.org/10.1016/j.jamcollsurg.2018.03.034CrossRefPubMed

47.

Graffner H, Fredlund P, Olsson SA et al (1983) Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument. A randomized study. Dis Colon Rectum 26:87–90. https://doi.org/10.1007/BF02562579CrossRefPubMed

48.

Pakkastie TE, Ovaska JT, Pekkala ES et al (1997) A randomised study of colostomies in low colorectal anastomoses. Eur J Surg 163:929–933PubMed

49.

Phan K, Oh L, Ctercteko G et al (2019) Does a stoma reduce the risk of anastomotic leak and need for re-operation following low anterior resection for rectal cancer systematic review and meta-analysis of randomized controlled trials. J Gastrointest Oncol 10:179–187. https://doi.org/10.21037/jgo.2018.11.07CrossRefPubMedPubMedCentral

50.

Jin D, Chen L (2021) Early prediction of anastomotic leakage after laparoscopic rectal surgery using creactive protein. Medicine (Baltimore) 100:e26196. https://doi.org/10.1097/MD.0000000000026196CrossRefPubMed

51.

van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218. https://doi.org/10.1016/S1470-2045(13)70016-0CrossRefPubMed

52.

Matsumoto Y, Tsujimoto H, Ono S et al (2016) Abdominal infection suppresses the number and activity of intrahepatic natural killer cells and promotes tumor growth in a murine liver metastasis model. Ann Surg Oncol 23(Suppl 2):S257–S265. https://doi.org/10.1245/s10434-015-4466-7CrossRefPubMed

53.

Fang C, Nie P, Jing P et al (2021) Effects of adjuvant therapy compliance and anastomotic leakage on the oncologic outcomes of patients with rectal cancer after curative resection. Dis Colon Rectum 64:689–696. https://doi.org/10.1097/DCR.0000000000001824CrossRefPubMed

54.

Koedam TWA, Bootsma BT, Deijen CL et al (2022) Oncological outcomes after anastomotic leakage after surgery for colon or rectal cancer: increased risk of local recurrence. Ann Surg 275:e420–e427. https://doi.org/10.1097/SLA.0000000000003889CrossRefPubMed

55.

Yang J, Chen Q, Jindou L et al (2020) The influence of anastomotic leakage for rectal cancer oncologic outcome: a systematic review and meta-analysis. J Surg Oncol 121:1283–1297. https://doi.org/10.1002/jso.25921CrossRefPubMed

56.

Wang S, Liu J, Wang S et al (2017) Adverse effects of anastomotic leakage on local recurrence and survival after curative anterior resection for rectal cancer: a systematic review and meta-analysis. World J Surg 41:277–284. https://doi.org/10.1007/s00268-016-3761-1CrossRefPubMed

57.

Warschkow R, Steffen T, Thierbach J et al (2011) Risk factors for anastomotic leakage after rectal cancer resection and reconstruction with colorectostomy. A retrospective study with bootstrap analysis. Ann Surg Oncol 18:2772–2782. https://doi.org/10.1245/s10434-011-1696-1CrossRefPubMed

58.

Bhangu A, Rasheed S, Brown G et al (2014) Does rectal cancer height influence the oncological outcome? Colorectal Dis 16:801–808. https://doi.org/10.1111/codi.12703(30thApril2021)CrossRefPubMed

Titel: Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study
verfasst von: Peter Tschann
Markus P. Weigl
Philipp Szeverinski
Daniel Lechner
Thomas Brock
Stephanie Rauch
Jana Rossner
Helmut Eiter
Paolo N. C. Girotti
Tarkan Jäger
Jaroslav Presl
Klaus Emmanuel
Alexander De Vries
Ingmar Königsrainer
Patrick Clemens
Publikationsdatum: 18.07.2022
Verlag: Springer Berlin Heidelberg
Erschienen in: Langenbeck's Archives of Surgery / Ausgabe 7/2022
Print ISSN: 1435-2443
Elektronische ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-022-02609-2

Neu im Fachgebiet Chirurgie

Häusliche Gewalt in der orthopädischen Notaufnahme oft nicht erkannt

28.05.2024 Häusliche Gewalt Nachrichten

In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.

Fehlerkultur in der Medizin – Offenheit zählt!

28.05.2024 Fehlerkultur Podcast

Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.

Mehr Frauen im OP – weniger postoperative Komplikationen

21.05.2024 Allgemeine Chirurgie Nachrichten

Ein Frauenanteil von mindestens einem Drittel im ärztlichen Op.-Team war in einer großen retrospektiven Studie aus Kanada mit einer signifikanten Reduktion der postoperativen Morbidität assoziiert.

TAVI versus Klappenchirurgie: Neue Vergleichsstudie sorgt für Erstaunen

21.05.2024 TAVI Nachrichten

Bei schwerer Aortenstenose und obstruktiver KHK empfehlen die Leitlinien derzeit eine chirurgische Kombi-Behandlung aus Klappenersatz plus Bypass-OP. Diese Empfehlung wird allerdings jetzt durch eine aktuelle Studie infrage gestellt – mit überraschender Deutlichkeit.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Aktuelle BDC Leitlinien-Webinare

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare

CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare

CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske

Dr. med. Benjamin Meyknecht

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare

CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric

Live-Webinar "Urologie und Sexualmedizin in der Praxis"

Springer Medizin

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study