International Journal of Surgery 12 (2014) 833e836
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Intraoperative complications have a negative impact on postoperative outcomes after rectal cancer surgery € ck b, Katharina Riss a, Praminthra Chitsabesan c, Stefan Riss a, *, Martina Mittlbo Anton Stift a €hringer Gürtel 18-20, A-1090 Vienna, Austria Medical University of Vienna, Austria, Department of General Surgery, Wa Center for Medical Statistics, Informatics, and Intelligent Systems, Austria c York Teaching Hospital NHS Foundation Trust, UK a
b
h i g h l i g h t s A meta-analysis showed increased intraoperative complications in laparoscopic colorectal surgery. The impact of intraoperative complications on the short term outcome is only poorly studied. Intraoperative complications increased the postoperative hospital length of stay in rectal cancer surgery. Intraoperative complications did not increase overall morbidity in rectal cancer surgery.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 April 2014 Received in revised form 16 May 2014 Accepted 5 July 2014 Available online 9 July 2014
Purpose: The impact of intraoperative complications on the postoperative outcome in rectal cancer surgery is only poorly studied in literature. Thus, the aim of the present study was to assess the frequency of intraoperative complications during rectal resections for malignancies and its influence on the short term outcome. Material and methods: We analyzed 605 consecutive patients, who had operations for rectal cancer at a single institution between 1995 and 2010. Retrospective data from the surgical procedure and postoperative course were obtained from the institutional colorectal database and individual chart reviews. Intraoperative complications were recorded and its influence on postoperative course was investigated. Results: Intraoperative complications occurred in 66 (10.9%) patients, with injury to the spleen (n ¼ 35 of 66, 53%) being the most frequent complication. Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7e92) compared to patients without complications (median: 12 days, range 2e135; p ¼ 0.0102). In addition, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (p ¼ 0.0536), whereas no impact on postoperative medical complications could be found (p ¼ 0.8043). Pulmonary disorders were the only predictive marker for intraoperative complications (p ¼ 0.0247) by univariate analysis. Conclusion: We found that intraoperative complications during rectal cancer surgery significantly prolonged hospital length stay. The overall morbidity rate was not affected. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Rectal cancer Surgery Complications Rectal resection
1. Introduction Colorectal cancer represents the third most common malignancy worldwide with a median age of diagnosis of 70 years in
* Corresponding author. E-mail address: [email protected] (S. Riss). http://dx.doi.org/10.1016/j.ijsu.2014.07.003 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
developed countries [1]. The treatment of patients with rectal cancer can often be challenging according to the extension and height of the tumor from the anal verge. In addition, neoadjuvant radiotherapy may be required in selected patients and can even increase the complexity of the operation. The surgeon must perform an adequate Total Mesorectal Excision (TME) while attempting to preserve the nerve supply to the pelvic organs to achieve an optimal oncological and functional outcome [2].
834
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836
Notably, rectal cancer surgery can be associated with a considerable overall postoperative morbidity rate of up to 40% [3,4]. Bennis et al. investigated risk factors to predict short-term complications after rectal resection for malignancy [5]. In a multivariate analysis, the authors reported male sex, circumferential tumor and transfusion to be independent parameters for postoperative complications. Surprisingly, there is a considerable lack of studies that examined the impact of intraoperative complications on postoperative outcome following rectal cancer surgery. Sammour et al. performed a meta-analysis comparing intraoperative complications between open and laparoscopic colorectal resections [6]. Although, a high number of randomized controlled trials did not record complications during surgery, the laparoscopic approach was associated with significantly higher rate of intraoperative adverse events in comparison to the open procedure. However, its impact on the postoperative outcome could not be evaluated. A recent study found an overall incidence of 8.4% of intraoperative complications during laparoscopic colorectal resections based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery [7]. Notably, in their series, intraoperative complications significantly increased the likelihood of a postoperative eventful course. In light of the paucity of data, the present study was designed to assess the frequency of intraoperative complications in patients undergoing open and laparoscopic rectal cancer resection and to evaluate its impact on the postoperative short-term outcome. 2. Methods The investigation was approved by the local ethics committee. We included 605 patients, who were operated for rectal cancer at a single institution between 1995 and 2010. Data was retrospectively collected from the surgical operation note, from the institutional colorectal database and individual chart reviews. We routinely conducted a TME as previously described by Heald et al. [8] The type of resection was divided into intersphincteric or complete rectal resection with coloanal anastomosis and low anterior resection with colorectal anastomosis. In selected cases a Hartmann's procedure or an abdominoperineal resection was performed. Intraoperative complications were recorded for each case and its impact on the postoperative outcome was analyzed. The postoperative course was defined as the length of hospital stay and the occurrence of postoperative complications (medical and surgical). In addition, we aimed to assess parameters which were considered to have potential influence on intraoperative complications: body mass index (BMI), age, type of procedure, access to the abdomen, conversion to open surgery, type of anastomosis, type of neoadjuvant radio/chemotherapy, tumor height, stoma, smoking, Union Internationale Contre le Cancer stadium (UICC), neurological disorders, diabetes, cardiovascular and pulmonary disorders. 3. Statistical analysis Continuous data are shown median and minimumemaximum due to skew distribution. Differences of continuous data between patients with and without intraoperative complications are tested by Wilcoxon's rank sum test. Categorical variables are described with absolute numbers and percentages and associations between categorical variables are tested by chi-square test. All p-values are two-sided and p 0.05 was considered significant. All calculations were performed with the statistical analysis software SAS (SAS Institute Inc., Version 9.3, Cary, NC, USA).
4. Results The demographic data of all patients are outlined in Table 1. We performed 404 (66.8%) low anterior resections, 45 (7.4%) intersphincteric resections, 52 (8.6%) complete rectal resections, 71 (11.7%) abdominoperineal resections, 27 (4.5%) Hartmann procedures and in 6 (1%) patients other procedures. We conducted 36 laparoscopic assisted resections (6%), of whom 11 patients needed conversions to open. 4.1. Intraoperative complications Intraoperative complications occurred in 66 (10.9%) patients and are further described in Table 2. The most common complication was an injury to the spleen (n ¼ 35/66, 53%), which required a splenectomy in 5 (14.3%) patients due to significant bleeding not manageable by local hemostasis. Anastomotic leaks occurred in 3 (4.5%) patients and were detected by transanal installation of air. 4.2. Postoperative course In regard to the postoperative course, 222 (36.7%) patients developed early postoperative complications, of which 59 (9.8%) were medical and 185 (30.6%) surgical. According to the ClavieneDindo Classification of complications 82 (13.6%) patients showed grade I complications, 63 (10.4%) grade II, 16 (2.6%) grade IIIa, 55 (9.1%) grade IIIb, 2 (0.3%) grade IVa and 4 (0.7%) patients had complications grade V [9]. The hospital length of stay showed a median of 12 days (range 2e135). 4.3. Intraoperative complications and postoperative outcome Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7e92) compared to patients without intraoperative complications (median: 12 days, range 4e135; p ¼ 0.0102). In contrast, intraoperative complications
Table 1 Demographic characteristics of patients with rectal cancer resections.a Demographic characteristics Sex
Patients (%) Female Male
Age BMI Smoker Neurologic disorders Pulmonary disorders Diabetes mellitus Cardiologic disorders Neoadjuvant radio-(Chemo)therapy Tumor height High Middle Low Protective stoma Ileostomy Colostomy Anastomosis Stapled Hand-sewn No Type of reconstruction Colonpouch End-end End-side UICC Stadium 1 2 3 4 a
237 (39.2) 368 (60.8) 64 (range 18e92) 25.4 (range 15.2e54.9) 100 (16.5) 38 (6.3) 76 (12.6) 91 (15) 277 (45.8) 335 (55.4) 113 (18.7) 237 (39.2) 250 (41.3) 274 (45.3) 139 (23.0) 414 (68.4) 95 (15.7) 96 (15.9) 63 (10.4) 368 (60.8) 81 (13.4) 179 (29.6) 125 (20.7) 170 (28.1) 114 (18.8)
Categorical variables are described as absolute numbers with percentages.
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836 Table 2 Intraoperative complications during rectal cancer surgery.a Intraoperative complications
Total (%)
Management
Bleeding Ureteric Injury Bladder injury Splenic injury
9 4 2 35
(13.6) (6.1) (3) (53)
1 3 1 1 4 3 1 1
(1.5) (4.5) (1.5) (1.5) (6.1) (4.5) (1.5) (1.5)
Surgical hemostasis Surgical repair Surgical repair Splenectomy (n ¼ 5) Local hemostasis (n ¼ 30) Surgical reconstruction Surgical repair (over-sewn) Surgical resection ERCP (after operation) Surgical repair Lavage Re-laparotomy Conservative
Sphincter damage Anastomotic leak Ischemic colon Common bile duct injury Bowel injury Tumor perforation Towel in abdomen Hemodynamic instability unknown origin Hypogastric nerve injury a
1 (1.5)
None
Categorical variables are described as absolute numbers with percentages.
showed no significant correlation with postoperative complications (35.6% without and 45.5% with intraoperative complications; p ¼ 0.1177). However, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (29.3% without and 40.9% with intraoperative complications; p ¼ 0.0536), whereas no impact on postoperative medical complications could be found (9.7% without and 10.6% with intraoperative complications; p ¼ 0.8043). Postoperative surgical complications following intraoperative complications were anastomotic leak n ¼ 6 (23.1%), small bowel obstruction n ¼ 6 (23.1%), wound infection n ¼ 4 (15.4%), bleeding n ¼ 4 (15.4%), sepsis n ¼ 2 (7.7%), large bowel leak n ¼ 1 (3.8%), common bile duct leak n ¼ 1 (3.8%) and urinary retention requiring intervention n ¼ 2 (7.7%). 4.4. Risk factors for intraoperative complications Patients with pulmonary disorders were found to have a significant higher risk for intraoperative complications (9.8% without and 18.4% with pulmonary disorder; p ¼ 0.0247) by univariate analysis. No other risk factors could be detected. 5. Discussion In the present study we could demonstrate that intraoperative complications during rectal cancer surgery significantly prolonged postoperative hospital stay. In addition, complications during surgery also showed a tendency towards an increased risk for postoperative surgical complications, whereas the overall morbidity rate was not affected. We cannot give a clear explanation why surgical but not medical complications were more common following intraoperative complications. However, intraoperative complications can have a negative impact on the entire immune system and subsequently affect the postoperative recovery and healing process. This can possibly lead to surgical complications. The occurrence and impact of intraoperative complications in rectal cancer surgery is only poorly studied in literature. In a large series including general laparoscopic colorectal operations the overall incidence of intraoperative complications was 8.4% [7]. The most common complications were injuries of solid organs and bleeding. In the present study, we found a slightly higher rate of intraoperative adverse events. However, it needs to be taken into consideration, that we focused on rectal cancer resections only, and analyzed both laparoscopic and open procedures. Bleeding
835
represented the most frequent complication in our cohort too, but was mainly linked to an injury of the spleen, which required splenectomy in a small number of patients. This is certainly a result of the constant mobilization of the left flexure in order to achieve a tension free colorectal or coloanal anastomosis. A multicenter study assessed the outcome of patients who underwent colorectal surgery and required a splenectomy because of an iatrogenic injury of the spleen [10]. The authors revealed a cancer-specific survival at five years of 70% in contrast to 47% of patients in those who had an unplanned splenectomy. We did not comment on the prognosis of patients with intraoperative complications, as the primary aim of the current study was to evaluate its influence on the short-term outcome. Iatrogenic ureteral injury represents another feared complication in colorectal surgery, which usually requires immediate surgical reconstruction. In a nationwide inpatient administrative data-base in the United States the overall incidence of ureteral injuries was 0.28% out of 2,165,848 colorectal surgical procedures between 2001 and 2010 [11]. Notably, the occurrence of ureteral complications was associated with a significantly increased morbidity, mortality rate and length of hospital stay postoperatively. Furthermore, several risk factors for ureteral injury were detected by multivariate analysis with rectal cancer being one of them. In our series ureteral complications were observed in 4 patients (0.66%), all of whom needed reconstruction by urologists. We also aimed to identify risk factors for developing intraoperative complications in rectal cancer surgery. Interestingly, only patients with pulmonary disease were found to increase the risk for an intraoperative eventful course. Generally, patients with pulmonary disorders have an increased anesthetic risk undergoing surgical interventions. However, whether this has an effect on intraoperative complications needs to be proven by further studies. From the clinical point of view, there is no obvious correlation between intraoperative surgical complications and pulmonary disorders. In contrast, Kirchhoff et al. analyzed predictive markers for intra and postoperative complications in patients who underwent laparoscopic sigmoid resections due to recurrent diverticulitis [12]. Intraoperative problems occurred in 5.3% and were mainly bowel injuries, anastomotic and anesthetic problems and bleeding. Only age >75 years was associated with a higher chance of intraoperative complications. Sammour et al. revealed a higher intraoperative complication rate during laparoscopic colorectal resections compared with conventional open resection by analyzing 10 randomized controlled trials [6]. The authors of the study could not provide data whether this affected the postoperative outcome negatively. Notably, several large randomized controlled trials found no difference in the postoperative complication rate between open and laparoscopic colorectal operations. Yang et al. reported that an unplanned conversion due to intraoperative adverse events during laparoscopic colorectal surgery for benign and malignant disease was associated with a greater risk of developing postoperative complications [13]. In our series, laparoscopic rectal resections or even conversion to open did not elevate the intraoperative complication rate. We need to address that the main limitation of the study is its retrospective design. However, consecutive data were collected from an institutional database and all operation notes were proofread to adequately record the occurrence of intraoperative complications. As the study was conducted to assess short term outcome only, we cannot provide data of the effect of intraoperative complications on diseases free survival. Nevertheless, we believe that the present study is of relevant clinical interest as the data on intraoperative complications and its impact on the postoperative outcome in rectal cancer surgery is lacking.
836
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836
6. Conclusion
References
In the present analysis we found that intraoperative adverse events during rectal cancer resections prolonged postoperative length of stay significantly. In addition, intraoperative complications seemed to increase postoperative surgical complications without reaching statistical significance. These data underline the importance of maintaining an impeccable approach to surgical procedures to minimize intraoperative complications and their effect on postoperative outcome.
[1] H. Brenner, M. Kloor, C.P. Pox, Colorectal cancer, Lancet 383 (2014) 1490e1502. [2] S. Riss, S. Stremitzer, K. Riss, M. Mittlbock, M. Bergmann, A. Stift, Pelvic organ function and quality of life after anastomotic leakage following rectal cancer surgery, Wien. klin. Wochenschr. 123 (2011) 53e57. [3] F. Penninckx, A. Kartheuser, J. Van de Stadt, et al., Outcome following laparoscopic and open total mesorectal excision for rectal cancer, Br. J. Surg. 100 (2013) 1368e1375. [4] P. Piso, M.H. Dahlke, P. Mirena, et al., Total mesorectal excision for middle and lower rectal cancer: a single institution experience with 337 consecutive patients, J. Surg. Oncol. 86 (2004) 115e121. [5] M. Bennis, Y. Parc, J.H. Lefevre, N. Chafai, E. Attal, E. Tiret, Morbidity risk factors after low anterior resection with total mesorectal excision and coloanal anastomosis: a retrospective series of 483 patients, Ann. Surg. 255 (2012) 504e510. [6] T. Sammour, A. Kahokehr, S. Srinivasa, I.P. Bissett, A.G. Hill, Laparoscopic colorectal surgery is associated with a higher intraoperative complication rate than open surgery, Ann. Surg. 253 (2011) 35e43. [7] P. Kambakamba, D. Dindo, A. Nocito, et al., Intraoperative adverse events during laparoscopic colorectal resectionebetter laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients, Langenbeck's Arch. Surg./Dtsch. Ges. Chir. 399 (2014) 297e305. [8] R.J. Heald, B.J. Moran, R.D. Ryall, R. Sexton, J.K. MacFarlane, Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997, Arch. Surg. 133 (1998) 894e899. [9] D. Dindo, N. Demartines, P.A. Clavien, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey, Ann. Surg. 240 (2004) 205e213. [10] C.J. Wakeman, B.R. Dobbs, F.A. Frizelle, et al., The impact of splenectomy on outcome after resection for colorectal cancer: a multicenter, nested, paired cohort study, Dis. Colon Rectum 51 (2008) 213e217. [11] W.J. Halabi, M.D. Jafari, V.Q. Nguyen, et al., Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States, Dis. Colon Rectum 57 (2014) 179e186. [12] P. Kirchhoff, D. Matz, S. Dincler, P. Buchmann, Predictive risk factors for intraand postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis: a multivariate analysis, World J. Surg. 35 (2011) 677e683. [13] C. Yang, S.D. Wexner, B. Safar, et al., Conversion in laparoscopic surgery: does intraoperative complication influence outcome? Surg. Endosc. 23 (2009) 2454e2458.
Ethical approval Medical University of Vienna, 456499. Funding None. Author contribution € ck, Katharina Riss, Praminthra Stefan Riss, Martina Mittlbo Chitsabesan and Anton Stift contributed to conception, design, acquisition and interpretation of data. All authors revised the article and approved the final version. Conflict of interest € ck, Katharina Riss, Praminthra Stefan Riss, Martina Mittlbo Chitsabesan and Anton Stift have no conflicts of interest, sources of financial support, corporate involvement, patent holdings, etc. involved in the research and preparation of this manuscript.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Intraoperative complications have a negative impact on postoperative outcomes after rectal cancer surgery € ck b, Katharina Riss a, Praminthra Chitsabesan c, Stefan Riss a, *, Martina Mittlbo Anton Stift a €hringer Gürtel 18-20, A-1090 Vienna, Austria Medical University of Vienna, Austria, Department of General Surgery, Wa Center for Medical Statistics, Informatics, and Intelligent Systems, Austria c York Teaching Hospital NHS Foundation Trust, UK a
b
h i g h l i g h t s A meta-analysis showed increased intraoperative complications in laparoscopic colorectal surgery. The impact of intraoperative complications on the short term outcome is only poorly studied. Intraoperative complications increased the postoperative hospital length of stay in rectal cancer surgery. Intraoperative complications did not increase overall morbidity in rectal cancer surgery.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 April 2014 Received in revised form 16 May 2014 Accepted 5 July 2014 Available online 9 July 2014
Purpose: The impact of intraoperative complications on the postoperative outcome in rectal cancer surgery is only poorly studied in literature. Thus, the aim of the present study was to assess the frequency of intraoperative complications during rectal resections for malignancies and its influence on the short term outcome. Material and methods: We analyzed 605 consecutive patients, who had operations for rectal cancer at a single institution between 1995 and 2010. Retrospective data from the surgical procedure and postoperative course were obtained from the institutional colorectal database and individual chart reviews. Intraoperative complications were recorded and its influence on postoperative course was investigated. Results: Intraoperative complications occurred in 66 (10.9%) patients, with injury to the spleen (n ¼ 35 of 66, 53%) being the most frequent complication. Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7e92) compared to patients without complications (median: 12 days, range 2e135; p ¼ 0.0102). In addition, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (p ¼ 0.0536), whereas no impact on postoperative medical complications could be found (p ¼ 0.8043). Pulmonary disorders were the only predictive marker for intraoperative complications (p ¼ 0.0247) by univariate analysis. Conclusion: We found that intraoperative complications during rectal cancer surgery significantly prolonged hospital length stay. The overall morbidity rate was not affected. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Rectal cancer Surgery Complications Rectal resection
1. Introduction Colorectal cancer represents the third most common malignancy worldwide with a median age of diagnosis of 70 years in
* Corresponding author. E-mail address: [email protected] (S. Riss). http://dx.doi.org/10.1016/j.ijsu.2014.07.003 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
developed countries [1]. The treatment of patients with rectal cancer can often be challenging according to the extension and height of the tumor from the anal verge. In addition, neoadjuvant radiotherapy may be required in selected patients and can even increase the complexity of the operation. The surgeon must perform an adequate Total Mesorectal Excision (TME) while attempting to preserve the nerve supply to the pelvic organs to achieve an optimal oncological and functional outcome [2].
834
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836
Notably, rectal cancer surgery can be associated with a considerable overall postoperative morbidity rate of up to 40% [3,4]. Bennis et al. investigated risk factors to predict short-term complications after rectal resection for malignancy [5]. In a multivariate analysis, the authors reported male sex, circumferential tumor and transfusion to be independent parameters for postoperative complications. Surprisingly, there is a considerable lack of studies that examined the impact of intraoperative complications on postoperative outcome following rectal cancer surgery. Sammour et al. performed a meta-analysis comparing intraoperative complications between open and laparoscopic colorectal resections [6]. Although, a high number of randomized controlled trials did not record complications during surgery, the laparoscopic approach was associated with significantly higher rate of intraoperative adverse events in comparison to the open procedure. However, its impact on the postoperative outcome could not be evaluated. A recent study found an overall incidence of 8.4% of intraoperative complications during laparoscopic colorectal resections based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery [7]. Notably, in their series, intraoperative complications significantly increased the likelihood of a postoperative eventful course. In light of the paucity of data, the present study was designed to assess the frequency of intraoperative complications in patients undergoing open and laparoscopic rectal cancer resection and to evaluate its impact on the postoperative short-term outcome. 2. Methods The investigation was approved by the local ethics committee. We included 605 patients, who were operated for rectal cancer at a single institution between 1995 and 2010. Data was retrospectively collected from the surgical operation note, from the institutional colorectal database and individual chart reviews. We routinely conducted a TME as previously described by Heald et al. [8] The type of resection was divided into intersphincteric or complete rectal resection with coloanal anastomosis and low anterior resection with colorectal anastomosis. In selected cases a Hartmann's procedure or an abdominoperineal resection was performed. Intraoperative complications were recorded for each case and its impact on the postoperative outcome was analyzed. The postoperative course was defined as the length of hospital stay and the occurrence of postoperative complications (medical and surgical). In addition, we aimed to assess parameters which were considered to have potential influence on intraoperative complications: body mass index (BMI), age, type of procedure, access to the abdomen, conversion to open surgery, type of anastomosis, type of neoadjuvant radio/chemotherapy, tumor height, stoma, smoking, Union Internationale Contre le Cancer stadium (UICC), neurological disorders, diabetes, cardiovascular and pulmonary disorders. 3. Statistical analysis Continuous data are shown median and minimumemaximum due to skew distribution. Differences of continuous data between patients with and without intraoperative complications are tested by Wilcoxon's rank sum test. Categorical variables are described with absolute numbers and percentages and associations between categorical variables are tested by chi-square test. All p-values are two-sided and p 0.05 was considered significant. All calculations were performed with the statistical analysis software SAS (SAS Institute Inc., Version 9.3, Cary, NC, USA).
4. Results The demographic data of all patients are outlined in Table 1. We performed 404 (66.8%) low anterior resections, 45 (7.4%) intersphincteric resections, 52 (8.6%) complete rectal resections, 71 (11.7%) abdominoperineal resections, 27 (4.5%) Hartmann procedures and in 6 (1%) patients other procedures. We conducted 36 laparoscopic assisted resections (6%), of whom 11 patients needed conversions to open. 4.1. Intraoperative complications Intraoperative complications occurred in 66 (10.9%) patients and are further described in Table 2. The most common complication was an injury to the spleen (n ¼ 35/66, 53%), which required a splenectomy in 5 (14.3%) patients due to significant bleeding not manageable by local hemostasis. Anastomotic leaks occurred in 3 (4.5%) patients and were detected by transanal installation of air. 4.2. Postoperative course In regard to the postoperative course, 222 (36.7%) patients developed early postoperative complications, of which 59 (9.8%) were medical and 185 (30.6%) surgical. According to the ClavieneDindo Classification of complications 82 (13.6%) patients showed grade I complications, 63 (10.4%) grade II, 16 (2.6%) grade IIIa, 55 (9.1%) grade IIIb, 2 (0.3%) grade IVa and 4 (0.7%) patients had complications grade V [9]. The hospital length of stay showed a median of 12 days (range 2e135). 4.3. Intraoperative complications and postoperative outcome Patients with intraoperative complications had a significant longer hospital stay (median: 13 days, range 7e92) compared to patients without intraoperative complications (median: 12 days, range 4e135; p ¼ 0.0102). In contrast, intraoperative complications
Table 1 Demographic characteristics of patients with rectal cancer resections.a Demographic characteristics Sex
Patients (%) Female Male
Age BMI Smoker Neurologic disorders Pulmonary disorders Diabetes mellitus Cardiologic disorders Neoadjuvant radio-(Chemo)therapy Tumor height High Middle Low Protective stoma Ileostomy Colostomy Anastomosis Stapled Hand-sewn No Type of reconstruction Colonpouch End-end End-side UICC Stadium 1 2 3 4 a
237 (39.2) 368 (60.8) 64 (range 18e92) 25.4 (range 15.2e54.9) 100 (16.5) 38 (6.3) 76 (12.6) 91 (15) 277 (45.8) 335 (55.4) 113 (18.7) 237 (39.2) 250 (41.3) 274 (45.3) 139 (23.0) 414 (68.4) 95 (15.7) 96 (15.9) 63 (10.4) 368 (60.8) 81 (13.4) 179 (29.6) 125 (20.7) 170 (28.1) 114 (18.8)
Categorical variables are described as absolute numbers with percentages.
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836 Table 2 Intraoperative complications during rectal cancer surgery.a Intraoperative complications
Total (%)
Management
Bleeding Ureteric Injury Bladder injury Splenic injury
9 4 2 35
(13.6) (6.1) (3) (53)
1 3 1 1 4 3 1 1
(1.5) (4.5) (1.5) (1.5) (6.1) (4.5) (1.5) (1.5)
Surgical hemostasis Surgical repair Surgical repair Splenectomy (n ¼ 5) Local hemostasis (n ¼ 30) Surgical reconstruction Surgical repair (over-sewn) Surgical resection ERCP (after operation) Surgical repair Lavage Re-laparotomy Conservative
Sphincter damage Anastomotic leak Ischemic colon Common bile duct injury Bowel injury Tumor perforation Towel in abdomen Hemodynamic instability unknown origin Hypogastric nerve injury a
1 (1.5)
None
Categorical variables are described as absolute numbers with percentages.
showed no significant correlation with postoperative complications (35.6% without and 45.5% with intraoperative complications; p ¼ 0.1177). However, intraoperative complications showed a tendency towards an increased risk for postoperative surgical complications (29.3% without and 40.9% with intraoperative complications; p ¼ 0.0536), whereas no impact on postoperative medical complications could be found (9.7% without and 10.6% with intraoperative complications; p ¼ 0.8043). Postoperative surgical complications following intraoperative complications were anastomotic leak n ¼ 6 (23.1%), small bowel obstruction n ¼ 6 (23.1%), wound infection n ¼ 4 (15.4%), bleeding n ¼ 4 (15.4%), sepsis n ¼ 2 (7.7%), large bowel leak n ¼ 1 (3.8%), common bile duct leak n ¼ 1 (3.8%) and urinary retention requiring intervention n ¼ 2 (7.7%). 4.4. Risk factors for intraoperative complications Patients with pulmonary disorders were found to have a significant higher risk for intraoperative complications (9.8% without and 18.4% with pulmonary disorder; p ¼ 0.0247) by univariate analysis. No other risk factors could be detected. 5. Discussion In the present study we could demonstrate that intraoperative complications during rectal cancer surgery significantly prolonged postoperative hospital stay. In addition, complications during surgery also showed a tendency towards an increased risk for postoperative surgical complications, whereas the overall morbidity rate was not affected. We cannot give a clear explanation why surgical but not medical complications were more common following intraoperative complications. However, intraoperative complications can have a negative impact on the entire immune system and subsequently affect the postoperative recovery and healing process. This can possibly lead to surgical complications. The occurrence and impact of intraoperative complications in rectal cancer surgery is only poorly studied in literature. In a large series including general laparoscopic colorectal operations the overall incidence of intraoperative complications was 8.4% [7]. The most common complications were injuries of solid organs and bleeding. In the present study, we found a slightly higher rate of intraoperative adverse events. However, it needs to be taken into consideration, that we focused on rectal cancer resections only, and analyzed both laparoscopic and open procedures. Bleeding
835
represented the most frequent complication in our cohort too, but was mainly linked to an injury of the spleen, which required splenectomy in a small number of patients. This is certainly a result of the constant mobilization of the left flexure in order to achieve a tension free colorectal or coloanal anastomosis. A multicenter study assessed the outcome of patients who underwent colorectal surgery and required a splenectomy because of an iatrogenic injury of the spleen [10]. The authors revealed a cancer-specific survival at five years of 70% in contrast to 47% of patients in those who had an unplanned splenectomy. We did not comment on the prognosis of patients with intraoperative complications, as the primary aim of the current study was to evaluate its influence on the short-term outcome. Iatrogenic ureteral injury represents another feared complication in colorectal surgery, which usually requires immediate surgical reconstruction. In a nationwide inpatient administrative data-base in the United States the overall incidence of ureteral injuries was 0.28% out of 2,165,848 colorectal surgical procedures between 2001 and 2010 [11]. Notably, the occurrence of ureteral complications was associated with a significantly increased morbidity, mortality rate and length of hospital stay postoperatively. Furthermore, several risk factors for ureteral injury were detected by multivariate analysis with rectal cancer being one of them. In our series ureteral complications were observed in 4 patients (0.66%), all of whom needed reconstruction by urologists. We also aimed to identify risk factors for developing intraoperative complications in rectal cancer surgery. Interestingly, only patients with pulmonary disease were found to increase the risk for an intraoperative eventful course. Generally, patients with pulmonary disorders have an increased anesthetic risk undergoing surgical interventions. However, whether this has an effect on intraoperative complications needs to be proven by further studies. From the clinical point of view, there is no obvious correlation between intraoperative surgical complications and pulmonary disorders. In contrast, Kirchhoff et al. analyzed predictive markers for intra and postoperative complications in patients who underwent laparoscopic sigmoid resections due to recurrent diverticulitis [12]. Intraoperative problems occurred in 5.3% and were mainly bowel injuries, anastomotic and anesthetic problems and bleeding. Only age >75 years was associated with a higher chance of intraoperative complications. Sammour et al. revealed a higher intraoperative complication rate during laparoscopic colorectal resections compared with conventional open resection by analyzing 10 randomized controlled trials [6]. The authors of the study could not provide data whether this affected the postoperative outcome negatively. Notably, several large randomized controlled trials found no difference in the postoperative complication rate between open and laparoscopic colorectal operations. Yang et al. reported that an unplanned conversion due to intraoperative adverse events during laparoscopic colorectal surgery for benign and malignant disease was associated with a greater risk of developing postoperative complications [13]. In our series, laparoscopic rectal resections or even conversion to open did not elevate the intraoperative complication rate. We need to address that the main limitation of the study is its retrospective design. However, consecutive data were collected from an institutional database and all operation notes were proofread to adequately record the occurrence of intraoperative complications. As the study was conducted to assess short term outcome only, we cannot provide data of the effect of intraoperative complications on diseases free survival. Nevertheless, we believe that the present study is of relevant clinical interest as the data on intraoperative complications and its impact on the postoperative outcome in rectal cancer surgery is lacking.
836
S. Riss et al. / International Journal of Surgery 12 (2014) 833e836
6. Conclusion
References
In the present analysis we found that intraoperative adverse events during rectal cancer resections prolonged postoperative length of stay significantly. In addition, intraoperative complications seemed to increase postoperative surgical complications without reaching statistical significance. These data underline the importance of maintaining an impeccable approach to surgical procedures to minimize intraoperative complications and their effect on postoperative outcome.
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Ethical approval Medical University of Vienna, 456499. Funding None. Author contribution € ck, Katharina Riss, Praminthra Stefan Riss, Martina Mittlbo Chitsabesan and Anton Stift contributed to conception, design, acquisition and interpretation of data. All authors revised the article and approved the final version. Conflict of interest € ck, Katharina Riss, Praminthra Stefan Riss, Martina Mittlbo Chitsabesan and Anton Stift have no conflicts of interest, sources of financial support, corporate involvement, patent holdings, etc. involved in the research and preparation of this manuscript.
