Top

International Journal of Colorectal Disease

Published in:

01-06-2018 | Original Article

Standardization of surgical procedures to reduce risk of anastomotic leakage, reoperation, and surgical site infection in colorectal cancer surgery: a retrospective cohort study of 1189 patients

Authors: Ken Eto, Mitsuyoshi Urashima, Makoto Kosuge, Masahisa Ohkuma, Rota Noaki, Kai Neki, Daisuke Ito, Yasuhiro Takeda, Hiroshi Sugano, Katsuhiko Yanaga

Published in: International Journal of Colorectal Disease | Issue 6/2018

Abstract

Purpose

Anastomotic leakage (AL) and surgical site infection (SSI) are prevalent complications of colorectal surgery. To lower this risk, we standardized our surgical procedures in 2012, with a preferential use of laparoscopic approach (LS) for both colon and rectal surgery, combined with triangulating anastomosis (TA) for colon surgery and defunctioning ileostomy (DI) for low anterior resection. Our aim was to evaluate the outcomes of our standardized procedures.

Methods

The incidence rate of AL (primary outcome) and of reoperation and SSI (secondary outcome) was compared before (early period, n = 648) and after (late period, n = 541) standardization, through a retrospective analysis.

Results

The incidence rate of AL (6.6 versus 1.8%; P = 0.001), reoperation (3.5 versus 0.7%; P = 0.0012), and SSI (7.7 versus 4.6%; P = 0.029) was lower in late than in the early period. For colon cancer, TA and LS reduced the risk of AL (2.1 versus 0.3%, P = 0.020, for TA, and 3.2 versus 0.4%, P = 0.0027, for LS) and reoperation (2.9 versus 0.3%, P = 0.003, for TA, and 2.5 versus 0.2%, P = 0.0040, for LS). For rectal cancer, the incidence of all adverse outcomes (AL, reoperation, and SSI) was lower in cases treated by LS. However, the incidence of AL was lower in the late than in early period (P = 0.002) and with LS (P = 0.002). On multivariate analysis, late period and LS were independent factors of a lower risk of adverse outcomes.

Conclusions

Our surgical standardization seems to be effective in lowering the risks of AL, reoperation, and SSI after colorectal cancer surgery.

Alves A, Panis Y, Trancart D, Regimbeau JM, Pocard M, Valleur P (2002) Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients. World J Surg 26:499–502. https://doi.org/10.1007/s00268-001-0256-4 CrossRefPubMed

Frasson M, Flor-Lorente B, Rodriguez JL, Granero-Castro P, Hervas D, Alvarez Rico MA, Brao MJ, Sanchez Gonzalez JM, Garcia-Granero E (2015) Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg 262:321–330. https://doi.org/10.1097/sla.0000000000000973 CrossRefPubMed

Leichtle SW, Mouawad NJ, Welch KB, Lampman RM, Cleary RK (2012) Risk factors for anastomotic leakage after colectomy. Dis Colon Rectum 55:569–575. https://doi.org/10.1097/DCR.0b013e3182423c0d CrossRefPubMed

Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, Friel CM, LaPar DJ, Stukenborg GJ, Jones RS (2015) Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 220:195–206. https://doi.org/10.1016/j.jamcollsurg.2014.11.002 CrossRefPubMed

Nachiappan S, Askari A, Malietzis G, Giacometti M, White I, Jenkins JT, Kennedy RH, Faiz O (2015) The impact of anastomotic leak and its treatment on cancer recurrence and survival following elective colorectal cancer resection. World J Surg 39:1052–1058. https://doi.org/10.1007/s00268-014-2887-2 CrossRefPubMed

Hawn MT, Vick CC, Richman J, Holman W, Deierhoi RJ, Graham LA, Henderson WG, Itani KM (2011) Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg 254:494–499. https://doi.org/10.1097/SLA.0b013e31822c6929 CrossRefPubMed

Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C (2015) Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery 158:66–77. https://doi.org/10.1016/j.surg.2015.03.009 CrossRefPubMed

Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, Dineen S, Huerta S, Asolati M, Varela E, Anthony T (2007) Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered? Surgery 142:704–711. https://doi.org/10.1016/j.surg.2007.05.012 CrossRefPubMed

Serra-Aracil X, Garcia-Domingo MI, Pares D, Espin-Basany E, Biondo S, Guirao X, Orrego C, Sitges-Serra A (2011) Surgical site infection in elective operations for colorectal cancer after the application of preventive measures. Arch Surg 146:606–612. https://doi.org/10.1001/archsurg.2011.90 CrossRefPubMed

10.

Kurmann A, Vorburger SA, Candinas D, Beldi G (2011) Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study. Surg Endosc 25:3531–3534. https://doi.org/10.1007/s00464-011-1753-7 CrossRefPubMed

11.

Mahmoud NN, Turpin RS, Yang G, Saunders WB (2009) Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect 10:539–544. https://doi.org/10.1089/sur.2009.006 CrossRef

12.

Amri R, Bordeianou LG, Sylla P, Berger DL (2015) Renewed assessment of the stapled anastomosis with the increasing role of laparoscopic colectomy for colon cancer. Surg Endosc 29:2675–2682. https://doi.org/10.1007/s00464-014-3989-5 CrossRefPubMed

13.

Gustafsson P, Jestin P, Gunnarsson U, Lindforss U (2015) Higher frequency of anastomotic leakage with stapled compared to hand-sewn ileocolic anastomosis in a large population-based study. World J Surg 39:1834–1839. https://doi.org/10.1007/s00268-015-2996-6 CrossRefPubMed

14.

Katsuno H, Shiomi A, Ito M, Koide Y, Maeda K, Yatsuoka T, Hase K, Komori K, Minami K, Sakamoto K, Saida Y, Saito N (2016) Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients. Surg Endosc 30:2848–2856. https://doi.org/10.1007/s00464-015-4566-2 CrossRefPubMed

15.

van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, Bonjer HJ (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)70016-0 CrossRefPubMed

16.

Kawada K, Hasegawa S, Hida K, Hirai K, Okoshi K, Nomura A, Kawamura J, Nagayama S, Sakai Y (2014) Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc 28:2988–2995. https://doi.org/10.1007/s00464-014-3564-0 CrossRefPubMedPubMedCentral

17.

Park JS, Choi GS, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee SI, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257:665–671. https://doi.org/10.1097/SLA.0b013e31827b8ed9 CrossRefPubMed

18.

Midura EF, Hanseman D, Davis BR, Atkinson SJ, Abbott DE, Shah SA, Paquette IM (2015) Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum 58:333–338. https://doi.org/10.1097/dcr.0000000000000249 CrossRefPubMed

19.

Frasson M, Granero-Castro P, Ramos Rodriguez JL, Flor-Lorente B, Braithwaite M, Marti Martinez E, Alvarez Perez JA, Codina Cazador A, Espi A, Garcia-Granero E (2016) Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients. Int J Color Dis 31:105–114. https://doi.org/10.1007/s00384-015-2376-6 CrossRef

20.

Kosuge M, Eto K, Hashizume R, Takeda M, Tomori K, Neki K, Mitsumori N, Yanaga K (2017) Which is the safer anastomotic method for colon surgery?—ten-year results. In Vivo 31:683–687CrossRefPubMedPubMedCentral

21.

Mrak K, Uranitsch S, Pedross F, Heuberger A, Klingler A, Jagoditsch M, Weihs D, Eberl T, Tschmelitsch J (2016) Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: a prospective, randomized, multicenter trial. Surgery 159:1129–1139. https://doi.org/10.1016/j.surg.2015.11.006 CrossRefPubMed

22.

Kiran RP, El-Gazzaz GH, Vogel JD, Remzi FH (2010) Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg 211:232–238. https://doi.org/10.1016/j.jamcollsurg.2010.03.028 CrossRefPubMed

23.

Gervaz P, Bandiera-Clerc C, Buchs NC, Eisenring MC, Troillet N, Perneger T, Harbarth S (2012) Scoring system to predict the risk of surgical-site infection after colorectal resection. Br J Surg 99:589–595. https://doi.org/10.1002/bjs.8656 CrossRefPubMed

24.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20:250–278. https://doi.org/10.1086/501620 CrossRefPubMed

25.

Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, Shiozawa M, Horie H, Kuriu Y, Saito N (2015) Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1,014 consecutive patients. J Am Coll Surg 220:186–194. https://doi.org/10.1016/j.jamcollsurg.2014.10.017 CrossRefPubMed

26.

Messaris E, Connelly TM, Kulaylat AN, Miller J, Gusani NJ, Ortenzi G, Wong J, Bhayani N (2015) Is a diverting ostomy needed in mid-high rectal cancer patients undergoing a low anterior resection after neoadjuvant chemoradiation? An NSQIP analysis. Surgery 158:686–691. https://doi.org/10.1016/j.surg.2015.02.026 CrossRefPubMed

27.

Wong NY, Eu KW (2005) A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 48:2076–2079. https://doi.org/10.1007/s10350-005-0146-1 CrossRefPubMed

28.

Fukunaga Y, Higashino M, Tanimura S, Osugi H (2007) Triangulating stapling technique for reconstruction after colectomy. Hepato-Gastroenterology 54:414–417PubMed

29.

Yoshimatsu K, Ishibashi K, Yokomizo H, Umehara A, Yoshida K, Fujimoto T, Watanabe K, Ogawa K (2007) Triangulating anastomosis using a linear cutter in a colectomy. Hepato-Gastroenterology 54:1988–1990PubMed

Title: Standardization of surgical procedures to reduce risk of anastomotic leakage, reoperation, and surgical site infection in colorectal cancer surgery: a retrospective cohort study of 1189 patients
Authors: Ken Eto
Mitsuyoshi Urashima
Makoto Kosuge
Masahisa Ohkuma
Rota Noaki
Kai Neki
Daisuke Ito
Yasuhiro Takeda
Hiroshi Sugano
Katsuhiko Yanaga
Publication date: 01-06-2018
Publisher: Springer Berlin Heidelberg
Published in: International Journal of Colorectal Disease / Issue 6/2018
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI: https://doi.org/10.1007/s00384-018-3037-3

At a glance: The STEP trials

Springer Medicine

Standardization of surgical procedures to reduce risk of anastomotic leakage, reoperation, and surgical site infection in colorectal cancer surgery: a retrospective cohort study of 1189 patients

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 6/2018

Hemorrhoidal disease: is it time for a new classification?

Safety of mFOLFOX6/XELOX as adjuvant chemotherapy after curative resection of stage III colon cancer: phase II clinical study (The FACOS study)

Long-term outcomes after stenting as a bridge to surgery in patients with obstructing left-sided colorectal cancer

Perianal minimally invasive surgery (PAMIS) for rectal stump resection after previous colectomy

The prognostic implications of primary tumor location on recurrence in early-stage colorectal cancer with no associated risk factors

Chronic diarrhoea following surgery for colon cancer—frequency, causes and treatment options