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Department of Surgery, CHU de Québec - Université Laval, Québec City, QC, Canada
© 2023 Korean Society of Coloproctology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Acknowledgments
The authors thank Shannon Wyszomierski for editing this manuscript.
Author contributions
Conceptualization: JF, SD, PB, AB, FL; Data curation: JF, GM, TQPN; Formal analysis: all authors; Visualization: JF; Writing–original draft: JF, GM, TQPN; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Demographic | Value (n=81) |
---|---|
Age (yr) | 63±9 |
BMI (kg/m2) | 30.3±5.7 |
Normal weight (<25.0) | 11 (13.6) |
Overweight (≥25.0, <30.0) | 31 (38.3) |
Obesity class I (≥30.0, <35.0) | 23 (28.4) |
Obesity class II (≥35.0, <40.0) | 10 (12.3) |
Obesity class III (≥40) | 6 (7.4) |
Sex | |
Male | 78 (96.3) |
Female | 3 (3.7) |
Charlson score | 4 (3–5) |
Preoperative histology on biopsy | |
Adenocarcinoma | 79 (97.5) |
Adenoma | 2 (2.5) |
Clinical tumor stagea | |
cT1 | 4 (5.1) |
cT2 | 24 (30.4) |
cT3 | 47 (59.5) |
cT4 | 2 (2.5) |
Unavailable | 2 (2.5) |
Positive nodal statusa | 37 (46.8) |
Distance from anal verge (cm) | 5 (4–6) |
Low rectum (≤5) | 45 (55.6) |
Mid rectum (>5 and ≤10) | 34 (42.0) |
High rectum (>10) | 1 (1.2) |
Neoadjuvant treatment | |
Neoadjuvant radiochemotherapy | 48 (59.3) |
Neoadjuvant radiotherapy only | 9 (11.1) |
None | 24 (29.6) |
Indication for transanal approachb | |
Distal lesions | 65 (80.2) |
BMI | 34 (42.0) |
Narrow pelvis | 7 (8.6) |
Post-TEM | 5 (6.2) |
Redo surgery | 4 (4.9) |
Recurrence | 3 (3.7) |
Giant rectal villous adenoma | 1 (1.2) |
Prostatomegaly | 1 (1.2) |
Characteristic | Value |
---|---|
Surgical approach | |
Laparoscopic | 80 (98.8) |
Open | 1 (1.2) |
Conversion to laparotomy | 0 (0) |
Surgical platform | |
Transanal endoscopic microsurgery | 58 (71.6) |
Transanal minimally invasive surgery | 23 (28.4) |
Type of resection | |
Lower anterior resection | 80 (98.8) |
Abdominoperineal resection | 1 (1.2) |
Surgical drain | 18 (22.2) |
Stoma at primary surgery | |
Diverting ileostomy | 64 (79.0) |
No stoma | 16 (19.8) |
Permanent colostomy | 1 (1.2) |
Anastomosis technique (n=80)a | |
Primary handsewn CAA | 52 (65.0) |
Primary stapled CAA | 10 (12.5) |
Delayed coloanal anastomosis | 18 (22.5) |
Operative time (min) | 300 (262–360) |
Blood loss (mL) | 100 (30–200) |
Variable | Value |
---|---|
Pathological diagnosis | |
Rectal adenocarcinoma | 70 (86.4) |
Absence of residual tumor | 10 (12.3) |
Epidermoid carcinoma | 1 (1.2) |
Pathological tumor stage | |
pT0 | 11 (13.6) |
pT1 | 12 (14.8) |
pT2 | 27 (33.3) |
pT3 | 31 (38.3) |
Pathological nodal stage | |
pN0 | 61 (75.3) |
pN1 | 16 (19.8) |
pN2 | 4 (4.9) |
Largest tumor dimension (cm) | 2.0 (1.5–3.5) |
Margin | |
Distal margin (mm) | 15 (8–25) |
Positive distal margin | 2 (2.5) |
Circumferential margin (mm) | 8 (5–13) |
Positive circumferential margin | 5 (6.2) |
Quality of TME | |
Complete | 64 (79.0) |
Near complete | 13 (16.0) |
Incomplete | 4 (4.9) |
Composite outcomea | 72 (88.9) |
Invasion | |
Perinervous | 13 (16.0) |
Lymphatic | 14 (17.3) |
Veinous | 17 (21.0) |
Tumor deposit | 7 (8.6) |
Tumor perforation | 1 (1.2) |
No. of LNs harvested | 25 (18–29) |
Positive LN | 15 (18.5) |
Adjuvant chemotherapy | 30 (37.0) |
Adjuvant radiotherapy | 1 (1.2) |
Recurrence | 13 (16.0) |
Locoregional recurrenceb | 4 (4.9) |
Distant recurrence | 11 (13.6) |
Values are presented as number (%) or median (interquartile range).
TME, total mesorectal excision; LN lymph node.
aDefined as a complete or near-complete TME, a negative circumferential resection margin (>1 mm), and a negative distal resection margin (>1 mm).
bAmong locoregional recurrences, 3 patients (75.0%) had multifocal local recurrences.
BMI, body mass index; pTN, pathologic assessment of the primary tumor and lymph node status; CRM, circumferential resection margin; TME, total mesorectal excision; CRT, chemoradiotherapy; CT, chemotherapy; LR, locoregional recurrence; DM, distant metastasis; MR, multifocal local recurrence; RT, radiotherapy.
Variable | Value |
---|---|
Length of stay (day) | 4 (3–8) |
Complication classificationa | |
None | 38 (46.9) |
I | 18 (22.2) |
II | 1 (1.2) |
IIIa | 4 (4.9) |
IIIb | 18 (22.2) |
IVa | 2 (2.5) |
IVb | 0 (0) |
Anastomotic leak (n=80)b | 21 (26.3) |
≤30 day | 15 (18.8) |
>30 day | 6 (7.5) |
Treatments needed for leakc | |
Transrectal drainage under general anesthesia | 14 (66.7) |
Laparoscopic surgery | 5 (23.8) |
Percutaneous drainage | 2 (9.5) |
Endoscopic drainage | 1 (4.8) |
Conservative management | 1 (4.8) |
Laparotomy | 0 (0) |
Anastomosis bleeding (n=80)b | 0 (0) |
Anastomosis stenosis (n=80)b | 9 (11.1) |
Ileusd | 10 (12.3) |
Small bowel obstructiond | 11 (13.6) |
Stoma site | 6 (7.4) |
Internal hernia | 5 (6.2) |
Reoperationd | 20 (24.7) |
Rehospitalizationd | 13 (16.0) |
Values are presented as median (interquartile range) or number (%).
aPostoperative complications in the first 30 postoperative days, according to the Clavien-Dindo classification system.
bExcluding the patient with abdominoperineal resection at primary surgery.
cSome patients had multiple treatments simultaneously.
dWithin 30 days postsurgery.
Demographic | Value (n=81) |
---|---|
Age (yr) | 63±9 |
BMI (kg/m2) | 30.3±5.7 |
Normal weight (<25.0) | 11 (13.6) |
Overweight (≥25.0, <30.0) | 31 (38.3) |
Obesity class I (≥30.0, <35.0) | 23 (28.4) |
Obesity class II (≥35.0, <40.0) | 10 (12.3) |
Obesity class III (≥40) | 6 (7.4) |
Sex | |
Male | 78 (96.3) |
Female | 3 (3.7) |
Charlson score | 4 (3–5) |
Preoperative histology on biopsy | |
Adenocarcinoma | 79 (97.5) |
Adenoma | 2 (2.5) |
Clinical tumor stage |
|
cT1 | 4 (5.1) |
cT2 | 24 (30.4) |
cT3 | 47 (59.5) |
cT4 | 2 (2.5) |
Unavailable | 2 (2.5) |
Positive nodal status |
37 (46.8) |
Distance from anal verge (cm) | 5 (4–6) |
Low rectum (≤5) | 45 (55.6) |
Mid rectum (>5 and ≤10) | 34 (42.0) |
High rectum (>10) | 1 (1.2) |
Neoadjuvant treatment | |
Neoadjuvant radiochemotherapy | 48 (59.3) |
Neoadjuvant radiotherapy only | 9 (11.1) |
None | 24 (29.6) |
Indication for transanal approach |
|
Distal lesions | 65 (80.2) |
BMI | 34 (42.0) |
Narrow pelvis | 7 (8.6) |
Post-TEM | 5 (6.2) |
Redo surgery | 4 (4.9) |
Recurrence | 3 (3.7) |
Giant rectal villous adenoma | 1 (1.2) |
Prostatomegaly | 1 (1.2) |
Characteristic | Value |
---|---|
Surgical approach | |
Laparoscopic | 80 (98.8) |
Open | 1 (1.2) |
Conversion to laparotomy | 0 (0) |
Surgical platform | |
Transanal endoscopic microsurgery | 58 (71.6) |
Transanal minimally invasive surgery | 23 (28.4) |
Type of resection | |
Lower anterior resection | 80 (98.8) |
Abdominoperineal resection | 1 (1.2) |
Surgical drain | 18 (22.2) |
Stoma at primary surgery | |
Diverting ileostomy | 64 (79.0) |
No stoma | 16 (19.8) |
Permanent colostomy | 1 (1.2) |
Anastomosis technique (n=80) |
|
Primary handsewn CAA | 52 (65.0) |
Primary stapled CAA | 10 (12.5) |
Delayed coloanal anastomosis | 18 (22.5) |
Operative time (min) | 300 (262–360) |
Blood loss (mL) | 100 (30–200) |
Variable | Value |
---|---|
Pathological diagnosis | |
Rectal adenocarcinoma | 70 (86.4) |
Absence of residual tumor | 10 (12.3) |
Epidermoid carcinoma | 1 (1.2) |
Pathological tumor stage | |
pT0 | 11 (13.6) |
pT1 | 12 (14.8) |
pT2 | 27 (33.3) |
pT3 | 31 (38.3) |
Pathological nodal stage | |
pN0 | 61 (75.3) |
pN1 | 16 (19.8) |
pN2 | 4 (4.9) |
Largest tumor dimension (cm) | 2.0 (1.5–3.5) |
Margin | |
Distal margin (mm) | 15 (8–25) |
Positive distal margin | 2 (2.5) |
Circumferential margin (mm) | 8 (5–13) |
Positive circumferential margin | 5 (6.2) |
Quality of TME | |
Complete | 64 (79.0) |
Near complete | 13 (16.0) |
Incomplete | 4 (4.9) |
Composite outcome |
72 (88.9) |
Invasion | |
Perinervous | 13 (16.0) |
Lymphatic | 14 (17.3) |
Veinous | 17 (21.0) |
Tumor deposit | 7 (8.6) |
Tumor perforation | 1 (1.2) |
No. of LNs harvested | 25 (18–29) |
Positive LN | 15 (18.5) |
Adjuvant chemotherapy | 30 (37.0) |
Adjuvant radiotherapy | 1 (1.2) |
Recurrence | 13 (16.0) |
Locoregional recurrence |
4 (4.9) |
Distant recurrence | 11 (13.6) |
Patient no. | Distance from anal verge (cm) | BMI (kg/m2) | Neoadjuvant treatment | pTN | Distal margin (mm) | CRM margin (mm) | Quality of TME | Adjuvant treatment | Type of recurrence | Time to recurrence (mo) | Treatment |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 18.2 | CRT | pT3N1 | 25 | 65 | Near complete | CT | LR | 13.6 | Unknown |
2 | 6 | 32.1 | CRT | pT1N0 | 20 | 13 | Complete | CT | DM | 32.9 | Surgery |
3 | 5 | 24.9 | None | pT2N0 | 13 | 8 | Near complete | None | DM | 59.9 | Surgery |
4 | 10 | 39.8 | CRT | pT2N1 | 40 | 23 | Near complete | None | DM | 18.1 | Surgery+CT |
5 | 3 | 23.7 | CRT | pT3N1 | 15 | 5 | Complete | None | MR | 28.9 | Surgery+CRT |
6 | 6 | 37.4 | CRT | pT3N0 | 25 | 5 | Near complete | None | DM | 8.4 | Surgery+RT |
7 | 6 | 30.1 | CRT | pT3N1 | 27 | 12 | Complete | CT | MR+DM | 9.9 | Palliative CT |
8 | 6 | 43.7 | None | pT2N0 | 10 | 6 | Complete | None | DM | 25.9 | Surgery+CT |
9 | 3 | 27.1 | None | pT1N0 | 4 | 1 | Complete | None | MR+DM | 19.6 | Palliative CRT |
10 | 1 | 30.5 | None | pT3N1 | 0 | 0.5 | Complete | CRT | DM | 11.7 | Surgery+CT |
11 | 1 | 21.3 | CRT | pT2N1 | 8 | 2 | Complete | CT | DM | 17.3 | Surgery |
12 | 9 | 33.7 | RT | pT1N0 | 40 | 12 | Near complete | None | DM | 8.7 | Surgery |
13 | 3 | 26.7 | None | pT2N1 | 10 | 10 | Complete | None | DM | 8.6 | Unknown |
Variable | Value |
---|---|
Length of stay (day) | 4 (3–8) |
Complication classification |
|
None | 38 (46.9) |
I | 18 (22.2) |
II | 1 (1.2) |
IIIa | 4 (4.9) |
IIIb | 18 (22.2) |
IVa | 2 (2.5) |
IVb | 0 (0) |
Anastomotic leak (n=80) |
21 (26.3) |
≤30 day | 15 (18.8) |
>30 day | 6 (7.5) |
Treatments needed for leak |
|
Transrectal drainage under general anesthesia | 14 (66.7) |
Laparoscopic surgery | 5 (23.8) |
Percutaneous drainage | 2 (9.5) |
Endoscopic drainage | 1 (4.8) |
Conservative management | 1 (4.8) |
Laparotomy | 0 (0) |
Anastomosis bleeding (n=80) |
0 (0) |
Anastomosis stenosis (n=80) |
9 (11.1) |
Ileus |
10 (12.3) |
Small bowel obstruction |
11 (13.6) |
Stoma site | 6 (7.4) |
Internal hernia | 5 (6.2) |
Reoperation |
20 (24.7) |
Rehospitalization |
13 (16.0) |
Variable | No AL (n=59) | AL (n=21) | P-value |
---|---|---|---|
Body mass index (kg/m2) | 29.6±5.3 | 31.5±6.3 | 0.194 |
Distance from anal verge (cm) | 5.0 (4.0–6.0) | 6.0 (4.0–7.0) | 0.197 |
Neoadjuvant treatment | 0.152 | ||
Neoadjuvant radiochemotherapy | 34 (57.6) | 14 (66.7) | |
Neoadjuvant radiotherapy only | 5 (8.5) | 4 (19.0) | |
None | 20 (33.9) | 3 (14.3) | |
Anastomosis technique | 0.010 | ||
Primary handsewn CAA | 44 (74.6) | 8 (38.1) | |
Primary stapled CAA | 5 (8.5) | 5 (23.8) | |
DCA | 10 (16.9) | 8 (38.1) | |
Operative time (min) | 300 (257–345) | 330 (268–360) | 0.286 |
Blood loss (mL) | 75 (25–150) | 150 (50–250) | 0.031 |
Variable | OR (95% CI) | P-value |
---|---|---|
Anastomosis technique | 0.085 | |
Primary stapled CAA vs. primary handsewn CAA | 3.76 (0.80–17.63) | |
DCA vs. primary handsewn CAA | 3.41 (0.97–11.94) | |
Blood loss (mL) | 1.002 (1.000–1.005) | 0.092 |
Values are presented as mean±standard deviation, number (%), or median (interquartile range). BMI, body mass index; TEM, transanal endoscopic microsurgery. Assessed in 79 patients with adenocarcinoma on preoperative biopsy. Some patients had multiple indications.
Values are presented as number (%) or median (interquartile range). CAA, coloanal anastomosis. Excluding the patient with abdominoperineal resection at primary surgery.
Values are presented as number (%) or median (interquartile range). TME, total mesorectal excision; LN lymph node. Defined as a complete or near-complete TME, a negative circumferential resection margin (>1 mm), and a negative distal resection margin (>1 mm). Among locoregional recurrences, 3 patients (75.0%) had multifocal local recurrences.
BMI, body mass index; pTN, pathologic assessment of the primary tumor and lymph node status; CRM, circumferential resection margin; TME, total mesorectal excision; CRT, chemoradiotherapy; CT, chemotherapy; LR, locoregional recurrence; DM, distant metastasis; MR, multifocal local recurrence; RT, radiotherapy.
Values are presented as median (interquartile range) or number (%). Postoperative complications in the first 30 postoperative days, according to the Clavien-Dindo classification system. Excluding the patient with abdominoperineal resection at primary surgery. Some patients had multiple treatments simultaneously. Within 30 days postsurgery.
Values are presented as mean±standard deviation, median (interquartile range), or number (%). AL, anastomotic leak; CAA, coloanal anastomosis; DCA, delayed coloanal anastomosis. Excluding the patient with abdominoperineal resection at primary surgery.
OR, odds ratio; CI, confidence interval; CAA, coloanal anastomosis; DCA, delayed coloanal anastomosis. Excluding the patient with abdominoperineal resection at primary surgery.