ORIGINAL ARTICLE
Endoscopic Management for the Assessment and Treatment of Anastomotic Bleeding in Laparoscopic Anterior Resection for Rectal Cancer Jun-Jun Ma, MD, PhD, Tian-Long Ling, MD, Ai-Guo Lu, MD, PhD, Ya-Ping Zong, MD, Bo Feng, MD, PhD, Xiao-Ye Liu, MD, Ming-Liang Wang, MD, Jian-Wen Li, MD, Feng Dong, MD, Lu Zang, MD, and Min-Hua Zheng, MD
Objective: To evaluate the impact of routine intraoperative endoscopy (IOE) on postoperative anastomotic bleeding of laparoscopic anterior resection (LAR) for rectal cancer, and to investigate the value of the IOE in terms of prevention and treatment of postoperative anastomotic bleeding. Methods: Medical records of the 279 cases of LAR from January 2006 to December 2011 were retrospectively analyzed, of which postoperative anastomotic bleeding occurred in 18. Univariate analysis was taken to determine the possible influencing factors of the bleeding. Then related influencing factors were put into the multivariate logistic regression analysis to ultimately determine the independent influencing factors of anastomotic bleeding. The efficacy of treatments to the anastomotic bleeding was also evaluated. Results: The incidence of anastomotic bleeding after LAR is 6.5% (18/279).The rates of anastomotic bleeding in lower tumor location group and upper tumor location group were 9.2% (16/173) and 1.9% (2/106), respectively, as in intraoperative colonoscopy and nonintraoperative colonoscopy group were 3.3% (5/151), and 10.2% (13/128), respectively. Comparing the location of the tumor, the coefficient of regression and relative risk value for lower tumor were 1.564 and 4.776. Comparing the intraoperative colonoscopy and nonintraoperative colonoscopy group, the value for intraoperative colonoscopy group were 1.085 and 0.338. Sex, age, tumor stage, pathologic type, and preventive ileostomy had no relevance with the anastomotic bleeding. In 18 cases of the anastomotic bleeding, 7 received conservative treatments, 9 underwent endoscopic treatment, and 2 underwent reoperation. All the 18 cases had reached hemostasis. Conclusion: IOE is an independent protective factor of anastomotic bleeding after LAR. Endoscopic hemostasis is recommended for an anastomotic bleeding after LAR for rectal cancer with a stapling technique. Key Words: rectal cancer, laparoscopic surgery, anastomotic bleeding, risk factors, intraoperative endoscopy
(Surg Laparosc Endosc Percutan Tech 2014;24:465–469)
Received for publication January 3, 2013; accepted February 27, 2013. From the Department of General Surgery, Shanghai Minimal Invasive Surgery Center, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China. The authors declare no conflicts of interest. Jun-Jun Ma and Tian-Long Ling contributed equally to this work. Reprints: Min-Hua Zheng, MD, Department of General Surgery, Ruijin Hospital, Shanghai Minimally Invasive Surgery Center, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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A
nastomotic bleeding is one of the severe complications at early stage of postcolorectal cancer surgery. The incidence rate is approximately 0.5% to 9.6%. It is even higher in the postrectal cancer surgery.1–4 With the feasibility and curability of laparoscopic surgery in colorectal cancer demonstrated by a series of randomized controlled trials,5–11 laparoscopic low anterior resection for low rectal tumors has also been greatly developed worldwide these years. It was reported that the anastomotic bleeding after laparoscopic low anterior resection was higher than that after open surgery.12 However, there are only limited clinical researches emphasizing on the prophylaxis and treatments of anastomotic bleeding in the laparoscopic mid or low rectal cancer surgery. As the application of intraoperative endoscopy (IOE) has gained wider acceptances,13–16 this modality is playing more important roles in the anastomotic bleeding management? This study focuses on the possible factors leading to the anastomotic bleeding after laparoscopic mid or low rectal cancer surgery. This also aims on the feasibilities of IOE or postoperative endoscopic management to prevent and to cure the bleeding.
METHODS Patients A total of 279 consecutive patients received laparoscopic anterior resection (LAR) in our department from January 2006 to December 2011 were retrospectively reviewed and analyzed in a collected database at Shanghai Minimally Invasive Surgery Center, Shanghai Ruijin Hospital affiliated Shanghai Jiaotong University, School of Medicine. All the patients had undergone series of examinations leading to preoperative diagnosis of rectal cancer. These examinations complied with the standard diagnosis criteria, including colonoscopy, digital examination, and histopathologic confirmations. In addition, blood routine test; routine urianalysis; and stool routine tests, abdominal ultrasound, computed tomography, and chest x-ray were applied to eliminate patients with possible hematologic, hepatic, and renal diseases that could lead to coagulation defects. The study considered one of the following scenarios to be postoperative anastomotic bleeding: patients who suffered from (a) postoperative blood stool; (b) haemostatic instability; or (c) hypovolumic shock that required either blood transfusions or other emergency interventions.
Variables The demographic data, intraoperative variables, histopathologic characteristics of the tumor; tumor TNM
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stage [American Joint Committee on Cancer (AJCC) stage], location of the tumor (distance to the anal verge), presence of the temporary ileum stoma; and whether IOE was applied were recorded and analyzed.
Surgical Procedures The surgical resections strictly complied with the principles of tumor isolation and total mesorectal excision. Colon-rectal or colon-anal anastomosis was established by the double stapling device following the proper tumor resection. The decision to construct a temporary ileum stoma mainly depends on the position of the anastomosis or the surgeon’s satisfaction toward it. In the IOE group, IOE was applied to confirm the absence of the anastomotic bleeding (Fig. 1). The electronic colonoscopy was inserted to the anastomosis through the anus to gain proper visual field. Once the active bleeding (Fig. 2) or bright red clot was observed, irrigation was applied to wash away the blood staining. After the clear view was obtained, one or more of the following interventions was taken to manage the bleeding: (a) irrigation of coagulant; (b) electrocautery (Fig. 3); and (c) titanium clipping (Fig. 4).
Postoperative Hemorrhage Management (1) Conservative management: (a) intravenous administration of coagulant medicine; (b) blood transfusion; (c) irrigation of cold epinephrine solution on the anastomosis or rectoclysis thru transanal intubation. (2) Endoscopic management: the patients did not require bowel preparations before the endoscopic management. During the procedure, the endoscopy was inserted 5 to 10 cm above the anal verge through the anus to observe the integrity of the anastomosis. If there were anastomotic bleeding, including active bleeding or presence of the clot, same IOE managements described previously would be applied. (3) Surgical management: surgical management would be indicated if there were difficulties in insertion of the
FIGURE 1. Normal anastomosis. Normal anastomosis without active bleeding under colonoscopic view.
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FIGURE 2. Anastomotic bleeding. Anasotomosis with active bleeding.
endoscopy or the failure of the managements. Depending on the position and amount of the anastomotic bleeding, either surgical exploration or transanal sutures under direct vision was chosen.
Statistical Analysis The software of Statistical Product and Service Solutions, S.P.S.S 13.0 (Chicago, IL), was utilized for all the statistical calculations. All the parameters were assured of normal distribution by normality tests. The numerical values were all expressed in ± s after the parameter was confirmed to obey normal distribution. Also, Student t test and w2 test were applied to quantitative and qualitative parameters, respectively. Each influencing parameters first underwent univariate statistical analysis. The parameters
FIGURE 3. Electrocautery. Electrocautery is an effective alternative for small amount of bleeding. r
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treatment. Nine of them underwent electronic colonoscopic management and the other 2 received surgical intervention. All the 18 anastomotic bleeding cases fully recovered. No death occurred. Within the 279 cases, 151 of them received the IOE after construction of the anastomosis. Among the IOE cases, active bleeding was observed in 12 (7.9%) of them. The IOE intervention was instantly administered, including titanium clipping (10 cases) and/or electrocautery (3 cases). Postoperative anastomotic bleeding occurred in 5 (3.3%) of the IOE cases, 3 of which already had received IOE due to the intraoperative bleeding. The anastomotic bleeding was not observed under IOE in the other 2 cases which recovered after the postoperative colonoscopic management. As of the 128 non-IOE cases, 13 (10.2%) of them had postoperative anastomotic bleeding. Four, 7, and 2 of them received conservative, endoscopic management, and surgical intervention, respectively.
FIGURE 4. Titanium clipping. Titanium clipping was used for pulse bleeding or arteriole bleeding.
with P < 0.10 in univariate statistical analysis further received multivariate logistic regression analysis. P < 0.05 was considered statistically significant.
RESULTS General Information There was no conversion case in all the qualified 279 rectal cancer patients who underwent LAR. The pathologic results were classified into the following according to the AJCC classification: 67, 97, 107, and 8 cases with stage I, II, III, and IV, respectively. Table 1 demonstrates the general information of the 279 patients. Eighteen of them manifested anastomotic bleeding with the incidence rate of 6.5% (18/279). Among them, 13 were men and 5 were women. All the bleeding occurred within 1 to 24 hours after the surgery. Seven of the bleeding cases received conservative treatment including either coagulant or blood transfusion. The other 11 cases received nonconservative TABLE 1. General Information of the Patients
Laparoscopic Anterior Resection (n = 279) Age (y) Sex (M/F) Tumor size (cm) Distance to anal verge (cm) Histologic differentiation I II III IV AJCC stage I II III IV
r
59.7 ± 15.2 (23-92) 160/119 3.59 ± 1.3 (1.0-8) 6.47 ± 2.1 (2.5-10)
2014 Lippincott Williams & Wilkins
12 248 17 2 67 97 107 8
Univariate Statistical Analysis and Multivariate Logistic Regression Analysis on Postoperative Anastomotic Bleeding Univariate statistical analysis was manipulated between the clinical parameters and the post-LAR anastomotic bleeding (Table 2). The variables with P < 0.10 after subjecting to the univariate statistical analysis included tumor location, tumor classification, and IOE. A logistic regression model was established to determine the relationships between anastomotic bleeding and these 3 contributing factors (Table 3). As a result, the anastomosis for low anterior resection is the independent risk factor to postoperative anastomotic bleeding. On the contrary, the IOE is the “protective” factor.
DISCUSSION Prophylaxis of Post-LAR Anastomotic Bleeding by IOE As demonstrated by the retrospective study of 253 colorectal cancer surgeries by Shamiyeh et al,14 IOE owns clinical significance on the evaluations of the status of the stabled anastomosis. It is not only capable of detecting the anastomotic bleeding at relatively early stage but also providing respective treatments. According to the current study, within the IOE group, 14 (9.3%) bleeding cases, including 12 cases managed intraoperatively by IOE and 2 cases postoperatively which showed no signs of the bleeding under IOE, demonstrates minimal differences to the nonIOE group of 13 cases (10.2%). However, the postoperative bleeding only occurred in 5 (3.3%) of the IOE cases which was significantly lower than the non-IOE group (P = 0.02). The multivariate logistic regression analysis in the current research also discovered that the IOE was the “protective” factor to postoperative anastomotic bleeding after LAR (0.047). In our experience, when the IOE was applied after a stapling technique, the vicinity of the anastomosis should be examined carefully. Once bleeding was observed, interventions should be taken instantly to avoid severe postoperative bleeding which might cause hemostatic instability again. Besides, the multivariate logistic regression analysis in the current research discovered that the location was also an independent risk factor to the postoperative anastomotic www.surgical-laparoscopy.com |
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TABLE 2. Univariate Statistical Analysis on Parameters of Postlaparoscopic Anterior Resection Anastomotic Bleeding
Parameters
Subcategories
Total (n) No Anastomotic Bleeding (n) Anastomotic Bleeding [n (%)]
Sex
Male Female Age Z55 y < 55 y Tumor size Diameter Z3 cm Diameter 7 cm AJCC stage Stage I Stage II Stage III Stage IV Temporary ilostomy Present Absent Intraoperative endoscopy Performed Nonperformed
160 119 185 94 204 75 12 248 17 2 173 106 67 97 107 8 36 243 128 151
147 114 173 88 189 72 11 234 14 2 157 104 64 92 98 7 33 228 115 146
13 5 12 6 15 3 1 14 3 0 16 2 3 5 9 1 3 15 13 5
(8.1) (4.2) (6.5) (6.4) (7.4) (4.0) (8.3) (5.6) (17.6) (0) (9.2) (1.9) (4.5) (5.2) (8.4) (12.5) (8.3) (6.2) (10.2) (3.3)
v2
P
1.740 0.187 0.001 0.973 1.021 0.312 4.006 0.261
5.902 0.015* 1.869 0.600
0.242 0.622 5.378 0.020*
*P < 0.05.
bleeding with P = 0.041. In the cases with the tumor locating r7 cm from the anal verge, the rate of postoperative anastomotic bleeding was 9.2% (16/173), which was significantly higher than the location > 7 cm, 1.9% (2/106) (P = 0.015). Similar to Lipska et al,17 tumor size, types, and classification of the histopathologic findings are irrelevant to the bleeding. This could be accounted for the fact that lower tumor leads to lower anastomosis which is closer to the anus sphincter whose vicinity contains rich blood supply. Furthermore, an efficient dissection to the low rectum is relatively difficult to achieve. Finally, according to the study,12 the abundance of blood vessels rooted from hemorrhoid vessels at the low anastomosis area also adds up the bleeding rate.
Managements of Post-LAR Anastomotic Bleeding Conservative managements should be considered the first choice for the postoperative anastomotic bleeding. Nonconservative treatments should be taken after conservative treatments show no effects or when hemostatic instability occurs. Within the current study, 7 of the 18 bleeding cases successfully recovered with conservative treatments. There were 2 cases that underwent nonconservative managements. The first one received transanal suture under direct vision and general anesthesia. Surgical exploration was applied to the other case.
Because of haemostatic instability, the other 9 bleeding cases received endoscopic managements including irrigation of cold epinephrine solution; electrocautery or ultrasonic energy, or titanium clipping. Endoscopic management owns several advantages. The modality not only is capable of performing diagnosis and treatment simultaneously but also of identifying the location and amount of the bleeding under direct vision. It minimizes extra injuries and complications to the bleeding managements. Finally, it avoids lengthy hospitalization and extra expenses due to surgical interventions.18 Furthermore, it is safe and effective to utilize endoscopic management to treat anastomotic bleeding after anterior resection. This procedure should be considered before surgical intervention as the treatment to the bleeding cases under regular bases. On the basis of the experiences obtained from the current study, several suggestions are drawn regarding the endoscopic management. The management is the choice right after the failure of the nonconservative treatments for the postoperative anastomotic bleeding. During the management, patient’s general conditions are the first concern. The endoscopic doctor should only swiftly proceed the management under the circumstances that the patient owns volumic stability and the establishment of intraveneous administration. Complete suction of the blood or clotting in the lumen to gain a vivid field is the key to an effective identification of the bleeding site. Once the site is found, respective treatments could be applied accordingly. For
TABLE 3. Analysis of Multivariate Logistic Regression on Postlaparoscopic Anterior Resection Anastomotic Bleeding
Parameters Intraoperative endoscopy Distance to anal verge Constant
Regression Coefficient 1.085 1.564 3.903
SD
Wald v2
Degree of Freedom
P
Exp (B)
0.546 0.764 1.652
3.952 4.184 5.583
1 1 1
0.047* 0.041* 0.018
0.338 4.776 0.020
*P < 0.05.
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small amount of bleeding, transendoscopic irrigation of epinephrine solution is suitable. Electrocautery is also an effective alternative. This causes tissue edema through heat conduction to establish necessary vessel pressing. For larger amount of bleeding, especially pulse bleeding or arteriole bleeding, titanium clipping should be utilized after the irrigation of the epinephrine solution. However, during the surgery, IOE is the “protective” factor to the postoperative anastomotic bleeding after LAR. IOE can effectively prevent postoperative anastomotic bleeding. Besides, the location of the tumor is the independent “risk” factor for the bleeding. Postoperative endoscopic hemostasis is an effective treatment for an anastomotic bleeding after LAR for rectal cancer using a stapling technique.
REFERENCES 1. Ishihara S, Watanabe T, Nagawa H. Intraoperative colonoscopy for stapled anastomosis in colorectal surgery. Surg Today. 2008;38:1063–1065. 2. Li VK, Wexner SD, Pulido N, et al. Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc. 2009;23:2459–2465. 3. Martinez-Serrano MA, Pares D, Pera M, et al. Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis. Tech Coloproctol. 2009;13:49–53. 4. Zhu QL, Feng B, Lu AG, et al. Laparoscopic low anterior resection for rectal carcinoma: complications and management in 132 consecutive patients. World J Gastroenterol. 2010;16:4605–4610. 5. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomized controlled trial. [J] Lancet. 2005;365:1718–1726. 6. Veldkamp R, Kuhry E, Hop WC, et al. Colon cancer Laparoscopic or Open Resection Study Group (COLOR). Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomized trial. [J] Lancet Oncol. 2005;6:477–484.
Endoscopy for Rectal Anastomotic Bleeding
7. Leung KL, Kwok SP, Lam SC, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. [J] Lancet. 2004;363:1187–1192. 8. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. [J] N Engl J Med. 2004;350:2050–2059. 9. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25:3061–3068. 10. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection in rectal cancer patients: outcome and cost-benefit analysis. Dis Colon Rectum. 2007;50:464–471. 11. Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol. 2009;10:44–52. 12. Yan SL, Xu ZB, Chi P, et al. Comparing the influencing factors of anastomotic bleeding in rectal carcinoma resection between laparoscopic and open radical approaches. Zhonghua Wei Chang Wai Ke Za Zhi. 2007;10:157–159. 13. Milsom JW, Pavoor RS, Shukla PJ. Evaluating the vascularity of intestinal anastomoses—can narrow band imaging play a role? Med Hypotheses. 2011;77:290–293. 14. Shamiyeh A, Szabo K, Ulf Wayand W, et al. Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech. 2012;22:65–67. 15. Wilhelm D, von Delius S, Weber L, et al. Combined laparoscopic-endoscopic resections of colorectal polyps: 10year experience and follow-up. Surg Endosc. 2009;23:688–693. 16. Yan J, Trencheva K, Lee SW, et al. Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach. Dis Colon Rectum. 2011; 54:753–758. 17. Lipska MA, Bissett IP, Parry BR, et al. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J. Surg. 2006;76:579–585. 18. Martı´ nez-Serrano MA, Pare´s D, Pera M, et al. Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis. Tech Coloproctol. 2009;13:49–53.
Erratum Bilateral Axillo-breast Approach (BABA) Endoscopic Sistrunk Operation in Patients With Thyroglossal Duct Cyst: Technical Report of the Novel Endoscopic Sistrunk Operation: Erratum In the article that appeared on pages e95–e98 in the June issue of SLEPT, several author affiliations appeared incorrectly. The correct author affiliations are below. Se Hyun Paek, MD is affiliated with the Department of Surgery, Chung-Ang University Hospital, Seoul, Korea. June Young Choi, MD is affiliated with the Department of Surgery, Seoul National University College of Medicine, Seoul, Korea and the Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea. Kyu-Eun Lee, MD and Yeo-Kyu Youn are affiliated with the Department of Surgery, Seoul National University College of Medicine, Seoul, Korea and the Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea. The Publisher apologizes for these errors. REFERENCE Paek SH, Choi JY, Lee KE, et al. Bilateral axillo-breast approach (BABA) endoscopic Sistrunk operation in patients with thyroglossal duct cyst: technical report of the novel endoscopic Sistrunk operation. Surg Laparosc Endosc Percutan Tech. 2014;24:e95–e98.
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Endoscopic Management for the Assessment and Treatment of Anastomotic Bleeding in Laparoscopic Anterior Resection for Rectal Cancer Jun-Jun Ma, MD, PhD, Tian-Long Ling, MD, Ai-Guo Lu, MD, PhD, Ya-Ping Zong, MD, Bo Feng, MD, PhD, Xiao-Ye Liu, MD, Ming-Liang Wang, MD, Jian-Wen Li, MD, Feng Dong, MD, Lu Zang, MD, and Min-Hua Zheng, MD
Objective: To evaluate the impact of routine intraoperative endoscopy (IOE) on postoperative anastomotic bleeding of laparoscopic anterior resection (LAR) for rectal cancer, and to investigate the value of the IOE in terms of prevention and treatment of postoperative anastomotic bleeding. Methods: Medical records of the 279 cases of LAR from January 2006 to December 2011 were retrospectively analyzed, of which postoperative anastomotic bleeding occurred in 18. Univariate analysis was taken to determine the possible influencing factors of the bleeding. Then related influencing factors were put into the multivariate logistic regression analysis to ultimately determine the independent influencing factors of anastomotic bleeding. The efficacy of treatments to the anastomotic bleeding was also evaluated. Results: The incidence of anastomotic bleeding after LAR is 6.5% (18/279).The rates of anastomotic bleeding in lower tumor location group and upper tumor location group were 9.2% (16/173) and 1.9% (2/106), respectively, as in intraoperative colonoscopy and nonintraoperative colonoscopy group were 3.3% (5/151), and 10.2% (13/128), respectively. Comparing the location of the tumor, the coefficient of regression and relative risk value for lower tumor were 1.564 and 4.776. Comparing the intraoperative colonoscopy and nonintraoperative colonoscopy group, the value for intraoperative colonoscopy group were 1.085 and 0.338. Sex, age, tumor stage, pathologic type, and preventive ileostomy had no relevance with the anastomotic bleeding. In 18 cases of the anastomotic bleeding, 7 received conservative treatments, 9 underwent endoscopic treatment, and 2 underwent reoperation. All the 18 cases had reached hemostasis. Conclusion: IOE is an independent protective factor of anastomotic bleeding after LAR. Endoscopic hemostasis is recommended for an anastomotic bleeding after LAR for rectal cancer with a stapling technique. Key Words: rectal cancer, laparoscopic surgery, anastomotic bleeding, risk factors, intraoperative endoscopy
(Surg Laparosc Endosc Percutan Tech 2014;24:465–469)
Received for publication January 3, 2013; accepted February 27, 2013. From the Department of General Surgery, Shanghai Minimal Invasive Surgery Center, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China. The authors declare no conflicts of interest. Jun-Jun Ma and Tian-Long Ling contributed equally to this work. Reprints: Min-Hua Zheng, MD, Department of General Surgery, Ruijin Hospital, Shanghai Minimally Invasive Surgery Center, Shanghai Jiaotong University School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
A
nastomotic bleeding is one of the severe complications at early stage of postcolorectal cancer surgery. The incidence rate is approximately 0.5% to 9.6%. It is even higher in the postrectal cancer surgery.1–4 With the feasibility and curability of laparoscopic surgery in colorectal cancer demonstrated by a series of randomized controlled trials,5–11 laparoscopic low anterior resection for low rectal tumors has also been greatly developed worldwide these years. It was reported that the anastomotic bleeding after laparoscopic low anterior resection was higher than that after open surgery.12 However, there are only limited clinical researches emphasizing on the prophylaxis and treatments of anastomotic bleeding in the laparoscopic mid or low rectal cancer surgery. As the application of intraoperative endoscopy (IOE) has gained wider acceptances,13–16 this modality is playing more important roles in the anastomotic bleeding management? This study focuses on the possible factors leading to the anastomotic bleeding after laparoscopic mid or low rectal cancer surgery. This also aims on the feasibilities of IOE or postoperative endoscopic management to prevent and to cure the bleeding.
METHODS Patients A total of 279 consecutive patients received laparoscopic anterior resection (LAR) in our department from January 2006 to December 2011 were retrospectively reviewed and analyzed in a collected database at Shanghai Minimally Invasive Surgery Center, Shanghai Ruijin Hospital affiliated Shanghai Jiaotong University, School of Medicine. All the patients had undergone series of examinations leading to preoperative diagnosis of rectal cancer. These examinations complied with the standard diagnosis criteria, including colonoscopy, digital examination, and histopathologic confirmations. In addition, blood routine test; routine urianalysis; and stool routine tests, abdominal ultrasound, computed tomography, and chest x-ray were applied to eliminate patients with possible hematologic, hepatic, and renal diseases that could lead to coagulation defects. The study considered one of the following scenarios to be postoperative anastomotic bleeding: patients who suffered from (a) postoperative blood stool; (b) haemostatic instability; or (c) hypovolumic shock that required either blood transfusions or other emergency interventions.
Variables The demographic data, intraoperative variables, histopathologic characteristics of the tumor; tumor TNM
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Ma et al
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stage [American Joint Committee on Cancer (AJCC) stage], location of the tumor (distance to the anal verge), presence of the temporary ileum stoma; and whether IOE was applied were recorded and analyzed.
Surgical Procedures The surgical resections strictly complied with the principles of tumor isolation and total mesorectal excision. Colon-rectal or colon-anal anastomosis was established by the double stapling device following the proper tumor resection. The decision to construct a temporary ileum stoma mainly depends on the position of the anastomosis or the surgeon’s satisfaction toward it. In the IOE group, IOE was applied to confirm the absence of the anastomotic bleeding (Fig. 1). The electronic colonoscopy was inserted to the anastomosis through the anus to gain proper visual field. Once the active bleeding (Fig. 2) or bright red clot was observed, irrigation was applied to wash away the blood staining. After the clear view was obtained, one or more of the following interventions was taken to manage the bleeding: (a) irrigation of coagulant; (b) electrocautery (Fig. 3); and (c) titanium clipping (Fig. 4).
Postoperative Hemorrhage Management (1) Conservative management: (a) intravenous administration of coagulant medicine; (b) blood transfusion; (c) irrigation of cold epinephrine solution on the anastomosis or rectoclysis thru transanal intubation. (2) Endoscopic management: the patients did not require bowel preparations before the endoscopic management. During the procedure, the endoscopy was inserted 5 to 10 cm above the anal verge through the anus to observe the integrity of the anastomosis. If there were anastomotic bleeding, including active bleeding or presence of the clot, same IOE managements described previously would be applied. (3) Surgical management: surgical management would be indicated if there were difficulties in insertion of the
FIGURE 1. Normal anastomosis. Normal anastomosis without active bleeding under colonoscopic view.
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FIGURE 2. Anastomotic bleeding. Anasotomosis with active bleeding.
endoscopy or the failure of the managements. Depending on the position and amount of the anastomotic bleeding, either surgical exploration or transanal sutures under direct vision was chosen.
Statistical Analysis The software of Statistical Product and Service Solutions, S.P.S.S 13.0 (Chicago, IL), was utilized for all the statistical calculations. All the parameters were assured of normal distribution by normality tests. The numerical values were all expressed in ± s after the parameter was confirmed to obey normal distribution. Also, Student t test and w2 test were applied to quantitative and qualitative parameters, respectively. Each influencing parameters first underwent univariate statistical analysis. The parameters
FIGURE 3. Electrocautery. Electrocautery is an effective alternative for small amount of bleeding. r
2014 Lippincott Williams & Wilkins
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Volume 24, Number 5, October 2014
Endoscopy for Rectal Anastomotic Bleeding
treatment. Nine of them underwent electronic colonoscopic management and the other 2 received surgical intervention. All the 18 anastomotic bleeding cases fully recovered. No death occurred. Within the 279 cases, 151 of them received the IOE after construction of the anastomosis. Among the IOE cases, active bleeding was observed in 12 (7.9%) of them. The IOE intervention was instantly administered, including titanium clipping (10 cases) and/or electrocautery (3 cases). Postoperative anastomotic bleeding occurred in 5 (3.3%) of the IOE cases, 3 of which already had received IOE due to the intraoperative bleeding. The anastomotic bleeding was not observed under IOE in the other 2 cases which recovered after the postoperative colonoscopic management. As of the 128 non-IOE cases, 13 (10.2%) of them had postoperative anastomotic bleeding. Four, 7, and 2 of them received conservative, endoscopic management, and surgical intervention, respectively.
FIGURE 4. Titanium clipping. Titanium clipping was used for pulse bleeding or arteriole bleeding.
with P < 0.10 in univariate statistical analysis further received multivariate logistic regression analysis. P < 0.05 was considered statistically significant.
RESULTS General Information There was no conversion case in all the qualified 279 rectal cancer patients who underwent LAR. The pathologic results were classified into the following according to the AJCC classification: 67, 97, 107, and 8 cases with stage I, II, III, and IV, respectively. Table 1 demonstrates the general information of the 279 patients. Eighteen of them manifested anastomotic bleeding with the incidence rate of 6.5% (18/279). Among them, 13 were men and 5 were women. All the bleeding occurred within 1 to 24 hours after the surgery. Seven of the bleeding cases received conservative treatment including either coagulant or blood transfusion. The other 11 cases received nonconservative TABLE 1. General Information of the Patients
Laparoscopic Anterior Resection (n = 279) Age (y) Sex (M/F) Tumor size (cm) Distance to anal verge (cm) Histologic differentiation I II III IV AJCC stage I II III IV
r
59.7 ± 15.2 (23-92) 160/119 3.59 ± 1.3 (1.0-8) 6.47 ± 2.1 (2.5-10)
2014 Lippincott Williams & Wilkins
12 248 17 2 67 97 107 8
Univariate Statistical Analysis and Multivariate Logistic Regression Analysis on Postoperative Anastomotic Bleeding Univariate statistical analysis was manipulated between the clinical parameters and the post-LAR anastomotic bleeding (Table 2). The variables with P < 0.10 after subjecting to the univariate statistical analysis included tumor location, tumor classification, and IOE. A logistic regression model was established to determine the relationships between anastomotic bleeding and these 3 contributing factors (Table 3). As a result, the anastomosis for low anterior resection is the independent risk factor to postoperative anastomotic bleeding. On the contrary, the IOE is the “protective” factor.
DISCUSSION Prophylaxis of Post-LAR Anastomotic Bleeding by IOE As demonstrated by the retrospective study of 253 colorectal cancer surgeries by Shamiyeh et al,14 IOE owns clinical significance on the evaluations of the status of the stabled anastomosis. It is not only capable of detecting the anastomotic bleeding at relatively early stage but also providing respective treatments. According to the current study, within the IOE group, 14 (9.3%) bleeding cases, including 12 cases managed intraoperatively by IOE and 2 cases postoperatively which showed no signs of the bleeding under IOE, demonstrates minimal differences to the nonIOE group of 13 cases (10.2%). However, the postoperative bleeding only occurred in 5 (3.3%) of the IOE cases which was significantly lower than the non-IOE group (P = 0.02). The multivariate logistic regression analysis in the current research also discovered that the IOE was the “protective” factor to postoperative anastomotic bleeding after LAR (0.047). In our experience, when the IOE was applied after a stapling technique, the vicinity of the anastomosis should be examined carefully. Once bleeding was observed, interventions should be taken instantly to avoid severe postoperative bleeding which might cause hemostatic instability again. Besides, the multivariate logistic regression analysis in the current research discovered that the location was also an independent risk factor to the postoperative anastomotic www.surgical-laparoscopy.com |
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TABLE 2. Univariate Statistical Analysis on Parameters of Postlaparoscopic Anterior Resection Anastomotic Bleeding
Parameters
Subcategories
Total (n) No Anastomotic Bleeding (n) Anastomotic Bleeding [n (%)]
Sex
Male Female Age Z55 y < 55 y Tumor size Diameter Z3 cm Diameter 7 cm AJCC stage Stage I Stage II Stage III Stage IV Temporary ilostomy Present Absent Intraoperative endoscopy Performed Nonperformed
160 119 185 94 204 75 12 248 17 2 173 106 67 97 107 8 36 243 128 151
147 114 173 88 189 72 11 234 14 2 157 104 64 92 98 7 33 228 115 146
13 5 12 6 15 3 1 14 3 0 16 2 3 5 9 1 3 15 13 5
(8.1) (4.2) (6.5) (6.4) (7.4) (4.0) (8.3) (5.6) (17.6) (0) (9.2) (1.9) (4.5) (5.2) (8.4) (12.5) (8.3) (6.2) (10.2) (3.3)
v2
P
1.740 0.187 0.001 0.973 1.021 0.312 4.006 0.261
5.902 0.015* 1.869 0.600
0.242 0.622 5.378 0.020*
*P < 0.05.
bleeding with P = 0.041. In the cases with the tumor locating r7 cm from the anal verge, the rate of postoperative anastomotic bleeding was 9.2% (16/173), which was significantly higher than the location > 7 cm, 1.9% (2/106) (P = 0.015). Similar to Lipska et al,17 tumor size, types, and classification of the histopathologic findings are irrelevant to the bleeding. This could be accounted for the fact that lower tumor leads to lower anastomosis which is closer to the anus sphincter whose vicinity contains rich blood supply. Furthermore, an efficient dissection to the low rectum is relatively difficult to achieve. Finally, according to the study,12 the abundance of blood vessels rooted from hemorrhoid vessels at the low anastomosis area also adds up the bleeding rate.
Managements of Post-LAR Anastomotic Bleeding Conservative managements should be considered the first choice for the postoperative anastomotic bleeding. Nonconservative treatments should be taken after conservative treatments show no effects or when hemostatic instability occurs. Within the current study, 7 of the 18 bleeding cases successfully recovered with conservative treatments. There were 2 cases that underwent nonconservative managements. The first one received transanal suture under direct vision and general anesthesia. Surgical exploration was applied to the other case.
Because of haemostatic instability, the other 9 bleeding cases received endoscopic managements including irrigation of cold epinephrine solution; electrocautery or ultrasonic energy, or titanium clipping. Endoscopic management owns several advantages. The modality not only is capable of performing diagnosis and treatment simultaneously but also of identifying the location and amount of the bleeding under direct vision. It minimizes extra injuries and complications to the bleeding managements. Finally, it avoids lengthy hospitalization and extra expenses due to surgical interventions.18 Furthermore, it is safe and effective to utilize endoscopic management to treat anastomotic bleeding after anterior resection. This procedure should be considered before surgical intervention as the treatment to the bleeding cases under regular bases. On the basis of the experiences obtained from the current study, several suggestions are drawn regarding the endoscopic management. The management is the choice right after the failure of the nonconservative treatments for the postoperative anastomotic bleeding. During the management, patient’s general conditions are the first concern. The endoscopic doctor should only swiftly proceed the management under the circumstances that the patient owns volumic stability and the establishment of intraveneous administration. Complete suction of the blood or clotting in the lumen to gain a vivid field is the key to an effective identification of the bleeding site. Once the site is found, respective treatments could be applied accordingly. For
TABLE 3. Analysis of Multivariate Logistic Regression on Postlaparoscopic Anterior Resection Anastomotic Bleeding
Parameters Intraoperative endoscopy Distance to anal verge Constant
Regression Coefficient 1.085 1.564 3.903
SD
Wald v2
Degree of Freedom
P
Exp (B)
0.546 0.764 1.652
3.952 4.184 5.583
1 1 1
0.047* 0.041* 0.018
0.338 4.776 0.020
*P < 0.05.
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small amount of bleeding, transendoscopic irrigation of epinephrine solution is suitable. Electrocautery is also an effective alternative. This causes tissue edema through heat conduction to establish necessary vessel pressing. For larger amount of bleeding, especially pulse bleeding or arteriole bleeding, titanium clipping should be utilized after the irrigation of the epinephrine solution. However, during the surgery, IOE is the “protective” factor to the postoperative anastomotic bleeding after LAR. IOE can effectively prevent postoperative anastomotic bleeding. Besides, the location of the tumor is the independent “risk” factor for the bleeding. Postoperative endoscopic hemostasis is an effective treatment for an anastomotic bleeding after LAR for rectal cancer using a stapling technique.
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Endoscopy for Rectal Anastomotic Bleeding
7. Leung KL, Kwok SP, Lam SC, et al. Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial. [J] Lancet. 2004;363:1187–1192. 8. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. [J] N Engl J Med. 2004;350:2050–2059. 9. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25:3061–3068. 10. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection in rectal cancer patients: outcome and cost-benefit analysis. Dis Colon Rectum. 2007;50:464–471. 11. Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol. 2009;10:44–52. 12. Yan SL, Xu ZB, Chi P, et al. Comparing the influencing factors of anastomotic bleeding in rectal carcinoma resection between laparoscopic and open radical approaches. Zhonghua Wei Chang Wai Ke Za Zhi. 2007;10:157–159. 13. Milsom JW, Pavoor RS, Shukla PJ. Evaluating the vascularity of intestinal anastomoses—can narrow band imaging play a role? Med Hypotheses. 2011;77:290–293. 14. Shamiyeh A, Szabo K, Ulf Wayand W, et al. Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech. 2012;22:65–67. 15. Wilhelm D, von Delius S, Weber L, et al. Combined laparoscopic-endoscopic resections of colorectal polyps: 10year experience and follow-up. Surg Endosc. 2009;23:688–693. 16. Yan J, Trencheva K, Lee SW, et al. Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach. Dis Colon Rectum. 2011; 54:753–758. 17. Lipska MA, Bissett IP, Parry BR, et al. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J. Surg. 2006;76:579–585. 18. Martı´ nez-Serrano MA, Pare´s D, Pera M, et al. Management of lower gastrointestinal bleeding after colorectal resection and stapled anastomosis. Tech Coloproctol. 2009;13:49–53.
Erratum Bilateral Axillo-breast Approach (BABA) Endoscopic Sistrunk Operation in Patients With Thyroglossal Duct Cyst: Technical Report of the Novel Endoscopic Sistrunk Operation: Erratum In the article that appeared on pages e95–e98 in the June issue of SLEPT, several author affiliations appeared incorrectly. The correct author affiliations are below. Se Hyun Paek, MD is affiliated with the Department of Surgery, Chung-Ang University Hospital, Seoul, Korea. June Young Choi, MD is affiliated with the Department of Surgery, Seoul National University College of Medicine, Seoul, Korea and the Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea. Kyu-Eun Lee, MD and Yeo-Kyu Youn are affiliated with the Department of Surgery, Seoul National University College of Medicine, Seoul, Korea and the Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea. The Publisher apologizes for these errors. REFERENCE Paek SH, Choi JY, Lee KE, et al. Bilateral axillo-breast approach (BABA) endoscopic Sistrunk operation in patients with thyroglossal duct cyst: technical report of the novel endoscopic Sistrunk operation. Surg Laparosc Endosc Percutan Tech. 2014;24:e95–e98.
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