Is a Diverting Stoma Always Necessary for a Low Anterior Resection in Rectal Cancer?
Anterior resection with total mesorectal excision is the standard operation for rectal cancer. The coloanal or colorectal anastomosis represents the critical step of this surgical procedure, with a risk of leakage between 3% and 27%. The occurrence of ana
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Claudio Coco and Gianluca Rizzo
54.1 Introduction 54.1.1 Anastomotic Leak: The Achilles’ Heel of an Anterior Resection Surgery with total mesorectal excision (TME) is considered a milestone in the treatment of rectal cancer. In recent years, the introduction of rectal stapling devices, new reconstruction techniques, and the accepted concept of a safe distal resection margin no longer than 1–2 cm in clinical practice have significantly improved the proportion of patients who can undergo a sphincter-saving procedure. The colorectal or coloanal anastomosis represents a critical step during anterior resection due to the potential postoperative development of anastomotic leakage. In 2010, the International Study Group of Rectal Cancer established the definition of anastomotic leakage after anterior resection as a communication between the intraand extraluminal compartments due to a defect in the integrity of the intestinal wall at the anasto-
C. Coco (*) • G. Rizzo Department of General Surgery, Catholic University of Sacred Heart, Rome, Italy Fondazione Policlinico Gemelli - Presidio Columbus, U.O.C. Chirurgia Generale, Via Moscati 31, 33 – 00168, Rome, Italy e-mail: [email protected]; [email protected]
mosis between the colon and rectum or the colon and anus [20]. Both a leakage originating from the suture or staple line of the neorectal reservoir (e.g., colon J-pouch) and a pelvic abscess in the proximity of the anastomosis are considered anastomotic leakage. This study also proposed a severity grading classification system for anastomotic leakage: grade A if the anastomotic leakage requires no active therapeutic intervention (also called “radiologic leakage”), grade B if the anastomotic leakage requires active therapeutic intervention but is manageable without re- laparotomy, and grade C if the anastomotic leakage requires a re-laparotomy [20]. The incidence of anastomotic leakage varies from 3% to 27% in the literature; this wide range is due to differences in the definition of anastomotic leakage. However, a recent systematic review analyzed the rate of anastomotic leakage according to the grading system proposed by the International Study Group of Rectal Cancer. Seventy studies (2000–2012) were analyzed for a total population of 24,288 patients operated on with an anterior resection for rectal cancer [4]. The pooled overall median rate of anastomotic leakage was 8.58% (range: 1.22–20.50%). The pooled rate (range) of anastomotic leakage according to grade was 2.57% (0–7.37%) for grade A, 2.37% (0–8.99%) for grade B, and 5.40% for grade C (0–11.97%) [4]. Anastomotic leakage significantly increases postoperative morbidity and early mortality. A retrospective analysis on 72,055 anterior
© Springer-Verlag Berlin Heidelberg 2018 V. Valentini et al. (eds.), Multidisciplinary Management of Rectal Cancer, https://doi.org/10.1007/978-3-319-43217-5_54
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r esections for rectal cancer (Nationwide Inpatient Sample 2006–2009) [10] showed that if anastomotic leakage occurred (13.68%), patients
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