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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 350-354

Risk factors for early complications after laparoscopic total mesorectal excision for locally advanced rectal cancer: A single center experience


Department of General Surgery, Chengdu Military General Hospital, Chengdu, People's Republic of China

Date of Web Publication13-Apr-2016

Correspondence Address:
Lijun Tang
Department of General Surgery, General Hospital of Chengdu Military Region, Chengdu - 610 083
People's Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.139273

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 > Abstract 


Background: Laparoscopic total mesorectal excision (TME) for rectal cancer has become a widely used surgical strategy in the treatment of rectal cancer. Laparoscopic rectal cancer surgery aims to provide patients with curative resection as well as minimize postoperative morbidity. This study was designed to analyze the foreseeable risk factors linked to postoperative morbidity in patients undergoing laparoscopic total mesorectal excision.
Materials and Methods: From February 2008 to May 2010, 306 consecutive patients underwent laparoscopic TME. Postoperative complications including wound infection, pneumonia, urethritis were recorded. Eleven potential risk factors for postoperative complications were analyzed.
Results: The overall postoperative complication rate was 22.3%, and the complications included wound infection (5.2%), pneumonia (4.5%), urethritis (3.9%), anastmosis bleed (1.9%), anastmosis leakage (3.2%), and obstruction (3.6%). The risk factors responsible for the complications were conversion (P = 0.002); operation time > 210 min (P = 0.047); age > 70 yr (P = 0.026); tumor size >4 cm (P = 0.005); preoperative chemoradiotherapy (P = 0.017); and a lower tumor location (P = 0.048). Conversion was positively related to wound infection and obstruction. Tumor size >4 cm and preoperative chemoradiotherapy were high-risk factors for urethritis. Operating time >210 min and age >70 year were associated with postoperative pneumonia. Lower tumor and age >70 yr were significant risk factors for anastmosis leakage.
Conclusions: Aged patients, large tumor, lower tumor location and conversion were risk factors in performing laparoscopic TME for locally advanced rectal cancer. Patients with these characteristics should be carefully considered before undergoing laparoscopic total mesorectal excision.

Keywords: Complication, laparoscopic surgery, rectal cancer, risk factor, total mesorectal excision


How to cite this article:
Liu L, Wang T, Zhang G, Dai R, Liang H, Tang L. Risk factors for early complications after laparoscopic total mesorectal excision for locally advanced rectal cancer: A single center experience. J Can Res Ther 2016;12:350-4

How to cite this URL:
Liu L, Wang T, Zhang G, Dai R, Liang H, Tang L. Risk factors for early complications after laparoscopic total mesorectal excision for locally advanced rectal cancer: A single center experience. J Can Res Ther [serial online] 2016 [cited 2019 Dec 11];12:350-4. Available from: http://www.cancerjournal.net/text.asp?2016/12/1/350/139273




 > Introduction Top


Substantial improvements have been made in the treatment of rectal cancer over the past two decades due to earlier diagnosis, improved efficacy and delivery of chemotherapy, and the adoption of advanced surgical techniques, such as laparoscopic total mesorectal excision (TME). Laparoscopic TME has several advantages, including a shorter recovery time, fewer complications, and a shorter duration of hospital stay when compared to the standard treatment.[1],[2] Postoperative complications, such as wound infection, pneumonia, and anastmosis leakage, still exist after laparoscopic TME, and it is important to facilitate the clinical application of laparoscopic techniques and improve the rehabilitation process through the analysis of risk factors for early complications after laparoscopic TME.

Although there were multicenter, randomized clinical trials reports on the risk factors in performing laparoscopic TME, data was still insufficient in our country. Therefore, we conducted this retrospective work in order to lay the foundation for further randomized clinical trial in our country.


 > Materials and Methods Top


Patients

Between February 2008 and May 2010, a total of 306 laparoscopic total mesorectal excision procedures were performed at our institution. The data on the patient demographics, oncologic details, and follow-up status were collected prospectively. The inclusion criteria required that the tumors were classified as TNM stage II to stage III. Patients who were admitted due to an emergency and patients with contraindications for laparoscopic surgery were excluded. Patients with moderately or severe obesity (body mass index <30) and previous abdominal surgery were also excluded.

Tumors were considered as primary rectal carcinoma if they were located in the lower third (0-5 cm from the anal verge), middle third (6-10 cm), or upper third of the rectum (11-15 cm) as measured by rigid rectosigmoidoscopy.

Before the operations, all cases were reviewed at a meeting attended by the staff surgeons, oncologists, anesthesiologists, and gastroenterologists. All patients gave their informed consent prior to the operation.

All patients underwent preoperative tumor staging by rectoscopy and colonoscopy with biopsies of the tumor, endorectal ultrasonography, contrast medium enema, abdominal computed tomography (CT) scan, abdominal ultrasound, and chest X-ray. In all cases, magnetic resonance imaging (MRI) of the pelvis was performed in order to rule out the suspicion of tumor invasion into adjacent organs.

Studied data

The following data were collected prospectively: age; sex; preoperative chemoradiotherapy; tumor location, size, stage, and type; and the type of surgery [Table 1].
Table 1: Patient characteristics and surgical treatment

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Wound infection was defined by a positive wound secretion culture sample. Pneumonia was defined by chest X-ray and a positive bronchial culture. If bloody drainage from anal drainage was observed after operation and the volume was over 30ml per hour, lower endoscopy would be taken to determine whether anastomotic bleeding existed. Urethritis was defined as a positive middle urine culture and bacterial colonies ≥10 cfu/ml. If the stool-like liquid was found in pelvic drainage tube and clinical suspicion existed, anoscope would be performed to identify whether anastomosis leakage happened. Obstruction was detected by clinical symptoms and abdominal X-ray.

Statistical analysis

Statistical analyses, including the Chi-squared test and Student's t-test, were performed when appropriate. A P value less than 0.05 was considered statistically significant. For the multivariate analysis, a Cox regression was used to evaluate the risk factors. Statistical Package for the Social Sciences (SPSS) software (version 13.0 for windows, SPSS, Chicago, IL, USA) was used for the statistical analyses.

Surgical technique

All patients were operated by two of our qualified and experienced surgeons. The patients were placed in a steep Trendelenburg position with the head down and right-side downward tilting. In this position, the surgeon stands on the patient's right side. Laparoscopic exploration is performed by creating a pneumoperitoneum using CO2 to a maximum of 14 mmHg. A 5-port technique is used under the vision of a flexible video scope. Scissors and a Ligasure or harmonic scalpel are used for dissection. We first dissect the inferior mesenteric artery (IMA) around the origin, and the preaortic sympathetic neural plexus is protected. The dissection is extended to the inferior mesenteric vein (IMV), and the IMA and IMV are ligated close to their origin using a linear vascular stapler or clips. We then incise the right loop of the sigmoid mesocolon and enter the avascular plane between the visceral and parietal pelvic fascia. Along this plane, the left gonadal vessels and ureter are safely explored and protected. For tumors in the middle or lower third of the rectum, the rectum and its mesentery are sharply dissected along the anatomic space between the visceral and parietal endopelvic fascia to the anal hiatus at the level of the pelvic diaphragm. At the same time, the pelvic autonomic nerves, including the superior hypogastric nerves, the autonomic branches of S2–S4, and the pelvic autonomic nerve plexus are identified and preserved. For tumors in the upper third of the rectum, the mesorectum is separated up to 5 cm below the lesion. When the dissection of pelvic is complete, the distal end is cut using endoscopic linear staplers and an Endo-GIA-type mechanical suturing device.

The specimen is extracted through a plastic wound protector inserted in a small incision at the left lower quadrant site. Proximal bowel transection is performed extra-corporeally. A standard double-stapling technique is used to perform tension-free anastomosis. In cases of very low-lying cancer, a colo-anal hand-sewn anastomosis is performed. For abdominoperineal resection, the sigmoid colon is divided, and TME is completed during the abdominal phase of the rectal dissection. The specimen is extracted through the perineum after perineal dissection in the usual fashion. Finally, an end colostomy is constructed at the preplanned site.


 > Results Top


The overall postoperative complication rate was 22.3%, and the complications included wound infection (5.2%), pneumonia (4.5%), urethritis (3.9%), anastmosis bleeding (1.9%), anastmosis leakage (3.2%), and obstruction (3.6%). No mortality was observed [Table 2].
Table 2: Early complications after laparoscopic total mesorectal excision

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The multivariate analysis [Table 3] and [Table 4] indicated the following: The variable associated with wound infection was conversion; the variables associated with pneumonia were age <70 year and operating time <210 min; the variables associated with urethritis were preoperative chemoradiotherapy and tumor size <4 cm; the variables associated with anastomosis leakage were age <70 year and a lower tumor location; and the variable associated with obstruction was conversion.
Table 3: Logistic regression analysis of factors associated with complications

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Table 4: Hazard ratios and 95% CIs of the risk factors associated with complications

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 > Discussion Top


Colorectal cancer is a common gastrointestinal malignancy. Each year, approximately 70,000 new patients are diagnosed and 50,000 people or more die from the disease. Only 61% of patients survive for five years.[3] Surgical treatment is still the best means for colorectal cancer patients to achieve a clinical cure. However, postoperative complications are inevitable, and they may affect the postoperative recovery and quality of life; they may even endanger patient lives.

Laparoscopic surgery is not, strictly speaking, a new surgical technique, but its use in the surgical treatment of colorectal cancer is recent. Therefore, complications after a laparoscopic total mesorectal excision may include similar complications to those observed with open surgery and unique complications associated with the laparoscopic technique. It was reported that the two main complications observed with the laparoscopic technique were hypercapnia and Trocar metastasis, but the incidence of both were low.[4] Postoperative hypercapnia was not observed in our study. In fact, the distribution of complications, such as the rate of wound infection and the occurrence of pneumonia, after TME using either the laparoscopic or the open technique was different. Our study suggests that these differences tend to be indirectly caused by the laparoscopic technique or by improper patient selection.

Laparoscopic TME requires a longer operation time than open surgery.[5] Our study indicates that an operative time greater than 210 minutes was significantly related to the occurrence of pneumonia. This may be related to the longer period of anesthesia and the use of the ventilator. However, regardless of the direct cause of postoperative pneumonia, the surgeon should do as much as possible to shorten the operation time. This requires that a surgeon has a skillful laparoscopic technique. Furthermore, obesity, the presence of a large tumor, tumor invasion into adjacent organs, and other factors that will increase the difficulty of the operation should be avoided. Another risk factor for postoperative pneumonia was age <70 yr, which was also a risk factor for anastomotic leakage. It was reported that immunity, resistance to infection, and the stress capacity of elderly individuals was lower relative to younger individuals.[6],[7] At the same time, the function and reparative ability of the vital organs had a different degree of recession, and elderly patients had a slower wound healing speed than younger people. Each of these factors together may explain why elderly patients are prone to postoperative pneumonia and anastomotic leakage. Therefore, laparoscopic TME in older patients should be performed carefully, and the surgeon should ensure a good anastomotic blood supply, a tension-free anastomosis, and the absence of bowel reversal during the operation. Finally, more attention should be paid to the prevention of postoperative pneumonia.

The position of primary rectal cancer has long been considered a key factor influencing anastomotic leakage.[8],[9] The lower the location of the tumor, the greater the difficulty of the operation and the greater the risk of anastomotic leakage.[10] Our study had similar results. It was reported that the anastomotic leakage rates were 1.0% and 7.7% at locations 7 cm above and below the anal margin, respectively.[11] We believe that because the operative space is small in cancer of the lower rectum, total mesorectal excision will be difficult and the operation time will be long. These factors affect the establishment of good anastomotic blood supply and appropriate anastomotic tension, and therefore, the probability of anastomotic leakage may increase. The anastomotic leakage rate and the postoperative mortality rate can be reduced by protective proximal intestinal stoma in cases of tumors at a lower location.[12] However, whether this technique should be routinely used has been controversial.

Conversion is a risk factor not only for postoperative wound infection but also for postoperative intestinal obstruction. The CLASICC trial indicates that conversion to open surgery tends to produce wound infection and adhesive intestinal obstruction.[13] Mroczkowski [14] reported that a conversion group suffered more postoperative complications (32.3% vs. 18.9% for completed laparoscopies and 25.8% for open operations, [P < 0.0001]). A recent meta-analysis showed that laparoscopy is associated with earlier return of bowel function, lower rates of wound infection, late intestinal adhesion obstruction and other late morbidity.[15] Conversion is similar to open surgery. The following points may explain why conversion has high wound infection and intestinal adhesion obstruction rates compared with total laparoscopic surgery. First, the bowel, omentum, and peritoneum are less exposed in total laparoscopy than in conversion, and the inflammatory response after total laparoscopic surgery is low compared to open surgery.[16],[17] Therefore, the risk of postoperative inflammatory ileus may be reduced after total laparoscopic TME. Second, patients can get out of bed sooner and exhibit a more rapid return of bowel function after laparoscopic TME.[18],[19] Consequently, they present a lower intestinal adhesion obstruction rate. Third, laparoscopic surgery offers a smaller incision and has less impact on immune function than the open technique, and the incidence of wound infection is reduced. However, conversion eliminates these advantages of laparoscopy. Once again, considering the benefits of reducing the conversion rate, laparoscopic total mesorectal excision should be performed on selected patients.

Our study indicates that preoperative chemoradiotherapy and large tumors (tumor size > 4 cm) may increase the possibility of urethritis. We are not sure why, but we suspect the possible reasons may include preoperative chemoradiotherapy impacts on immune function and the potential for greater stimulation of the urinary system following the removal of large tumors. More work is needed to clarify the specific mechanism.

In summary, aged patients, large tumor, lower tumor location and conversion were risk factors in performing laparoscopic TME for locally advanced rectal cancer. Patients with these characteristics should be carefully considered before undergoing laparoscopic total mesorectal excision. This was a retrospective study, selection bias was unavoidable, and a control population was absent. Longer follow-up and further randomized trial studies are needed for a more definite conclusion.

 
 > References Top

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Denoya P, Wang H, Sands D, Nogueras J, Weiss E, Wexner SD. Short-term outcomes of laparoscopic total mesorectal excision following neoadjuvant chemoradiotherapy. Surg Endosc 2010;24:933-8.  Back to cited text no. 2
    
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Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 2010;97:1638-45.  Back to cited text no. 3
    
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Chen Y, Xu H, Li Y, Wang D, Li J, Yuan J, et al. The outcome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: A prospective analysis of 295 patients. Ann Surg Oncol 2008;15:2847-55.  Back to cited text no. 4
    
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Chen WF, Liu SL, Gao XM, Pang XW. The capacity of lymphokine production by peripheral blood lymphocytes from aged humans. Immunol Invest 1968;15:575-83.  Back to cited text no. 7
    
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Warschkow R, Steffen T, Thierbach J, Bruckner T, Lange J, Tarantino I. Risk factors for anastomotic leakage after rectal cancer resection and reconstruction with colorectostomy. A retrospective study with bootstrap analysis. Ann Surg Oncol 2011;18:2772-82.  Back to cited text no. 8
    
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Jestin P, Pahlman L, Gunnarsson U. Risk factors for anastomotic leakage after rectal cancer surgery: A case-control study. Colorectal Dis 2008;10:715-21.  Back to cited text no. 9
    
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Bertelsen CA, Andreasen AH, Jørgensen T, Harling H. Danish Colorectal Cancer Group. Anastomotic leakage after anterior resection for rectal cancer: Risk factors. Colorectal Dis 2010;12:37-43.  Back to cited text no. 10
    
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Konishi T, Watanabe T, Kishimoto J, Balani A, de Manzini N. Risk factors for anastomotic leakage after surgery for colorectal cancer: Results of prospective surveillance. J Am Coll Surg 2006;202:439-44.  Back to cited text no. 11
    
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Palmisano S, Piccinni G, Casagranda B, Balani A, de Manzini N. The reversal of a protective stoma is feasible before the complete healing of a colorectal anastomotic leak. Am Surg 2011;77:1619-23.  Back to cited text no. 12
    
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Taylor GW, Jayne DG, Brown SR, Thorpe H, Brown JM, Dewberry SC, et al. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010;97:70-8.  Back to cited text no. 13
    
14.
Mroczkowski P, Hac S, Smith B, Schmidt U, Lippert H, Kube R. Laparoscopy in the surgical treatment of rectal cancer in Germany 2000-2009. Colorectal Dis 2012;14:1473-8.  Back to cited text no. 14
    
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Huang MJ, Liang JL, Wang H, Kang L, Deng YH, Wang JP. Laparoscopic-assisted versus open surgery for rectal cancer: A meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes. Int J Colorectal Dis 2011;26:415-21.  Back to cited text no. 15
    
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Natsume T, Kawahira H, Hayashi H, Nabeya Y, Akai T, Horibe D, et al. Low peritoneal and systemic inflammatory response after laparoscopy-assisted gastrectomy compared to open gastrectomy. Hepatogastroenterology 2011;58:659-62.  Back to cited text no. 16
    
17.
Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, et al. Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: A randomized trial. Ann Surg 2012;255:216-21.  Back to cited text no. 17
    
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McKay GD, Morgan MJ, Wong SK, Gatenby AH, Fulham SB, Ahmed KW, et al. Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: A multicenter study. Dis Colon Rectum 2012;55:42-50.  Back to cited text no. 18
    
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Orcutt ST, Marshall CL, Robinson CN, Balentine CJ, Anaya DA, Artinyan A, et al. Minimally invasive surgery in colon cancer patients leads to improved short-term outcomes and excellent oncologic results. Am J Surg 2011;202:528-31.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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