Selective approach for splenic flexure mobilization in total mesorectal excision followed by low colorectal anastomoses

Tulina, Inna; Zhurkovsky, V I; Bredikhin, Mikhail; Tsugulya, Petr; Tsarkov, Petr

doi:10.17116/hirurgia2018741

Cited by 6 publications

(2 citation statements)

References 15 publications

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“…Thus far, many risk factors have been associated with AL and a complex multifactorial pathophysiology has emerged [ 1 , 5 – 7 , 9 ]. Most interventional studies up till now only evaluated the impact of a single risk factor on AL [ 16 , 17 , 32 , 33 ]. The IMARI trial addresses three modifiable risk factors to ensure a tension-free, adequate perfused anastomosis, under optimal condition of the microbiome: (1) MBP/AB that could lead to a reduction in AL by reduction of the fecal bulk and bacterial load [ 13 – 16 ]; (2) Splenic flexure mobilization to optimise a tension-free anastomosis, particularly for low rectal cancer [ 17 , 34 ]; (3) Intraoperative real-time FA using ICG to assesses adequate perfusion of the afferent colon and anastomosis.…”

Section: Discussionmentioning

confidence: 99%

IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol

et al. 2020

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Background Anastomotic leakage (AL) is still a common and feared complication after low anterior resection (LAR) for rectal cancer. The multifactorial pathophysiology of AL and lack of standardised treatment options requires a multi-modal approach to improve long-term anastomotic integrity. The objective of the IMARI-trial is to determine whether the one-year anastomotic integrity rate in patients undergoing LAR for rectal cancer can be improved using a multi-interventional program. Methods IMARI is a multicentre prospective clinical effectiveness trial, whereby current local practice (control cohort) will be evaluated, and subsequently compared to results after implementation of the multi-interventional program (intervention cohort). Patients undergoing LAR for rectal cancer will be included. The multi-interventional program includes three preventive interventions (mechanical bowel preparation with oral antibiotics, tailored full splenic flexure mobilization and intraoperative fluorescence angiography using indocyanine green) combined with a standardised pathway for early detection and active management of AL. The primary outcome is anastomotic integrity, confirmed by CT-scan at one year postoperatively. Secondary outcomes include incidence of AL, protocol compliance and association with AL, temporary and permanent stoma rate, reintervention rate, quality of life and functional outcome. Microbiome analysis will be conducted to investigate the role of the rectal microbiome in AL. In a Dutch nationwide study, the AL rate was 20%, with anastomotic integrity of 90% after one year. Based on an expected reduction of AL due to the preventive approaches of 50%, and increase of anastomotic integrity by a standardised pathway for early detection and active management of AL, we hypothesised that the anastomotic integrity rate will increase from 90 to 97% at one year. An improvement of 7% in anastomotic integrity at one year was considered clinically relevant. A total number of 488 patients (244 per cohort) are needed to detect this difference, with 80% statistical power. Discussion The IMARI-trial is designed to evaluate whether a multi-interventional program can improve long-term anastomotic integrity after rectal cancer surgery. The uniqueness of IMARI lies in the multi-modal design that addresses the multifactorial pathophysiology for prevention, and a standardised pathway for early detection and active treatment of AL. Trial registration Trialregister.nl (NL8261), January 2020.

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Section: Discussionmentioning

confidence: 99%

IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol

et al. 2020

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“…After screening the records of 385 studies, 19 studies [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] published between 2007 and 2023 were included (Figure 1). The studies were all cohort studies (16 retrospective and 2 prospective) except for one RCT [16].…”

Section: Re Sults Descriptionofstudiesandpatientsmentioning

confidence: 99%

Splenic flexure mobilization in left‐sided colonic and rectal resections: A meta‐analysis and meta‐regression of factors associated with anastomotic leak and complications

Emile,

Dourado,

Rogers

et al. 2024

Colorectal Disease

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AimSplenic flexure mobilization (SFM) is commonly performed during left‐sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left‐sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL).MethodThis study was a PRISMA‐compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes.ResultsNineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47–34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06–1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group.ConclusionsSFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.

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Assessment of the efficiency and safety of the modified combined approach for laparoscopic splenic flexure mobilization

et al. 2019

Khir. Z. im. N.I. Pirogova

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Мобилизация селезеночного изгиба ободочной кишки (МСИОК)-один из самых важных и в то же время самых сложных и трудоемких этапов операций в колоректальной хирургии. МСИОК сопряжена с высоким риском развития жизнеугрожающих интра-и послеоперационных осложнений. К сожалению, стандартизованной методики МСИОК в настоящее время нет. В нашей клинике предложен новый способ МСИОК-модифицированная комбинированная МСИОК, не описанный ранее в литературе, включающий вход в сальниковую через брыжейку поперечной ободочной кишки. Цель исследования-оценка эффективности и безопасности предложенного модифицированного комбинированного доступа при лапароскопической мобилизации селезеночного изгиба ободочной кишки (МСИОК). Материал и методы. Проведено многоцентровое нерандомизированное сравнительное исследование по оценке эффективности и безопасности предложенного способа МСИОК. Основную группу составили 12 пациентов, которым была выполнена лапароскопическая модифицированная комбинированная МСИОК с декабря 2018 г. по май 2019 г., группу сравнения-12 пациентов, которым была выполнена лапароскопическая традиционная комбинированная МСИОК в период с 2013 по 2018 г. При сравнении учитывали следующие показатели: общая продолжительность операции, продолжительность МСИОК, объем кровопотери, конверсии, интраоперационные осложнения, послеоперационные осложнения, продолжительность послеоперационного периода. Результаты. Получены достоверные различия по средней продолжительности МСИОК. Средняя продолжительность МСИОК в основной группе составила 37,4±12,2 мин, в группе сравнения-59,5±19,1 мин (p=0,03). Средний объем кровопотери в основной группе достигал 52,5±12,3 мл, в группе сравнения-115,6±20,7 мл (p=0,02). В основной группе не отмечено интраоперационных осложнений, в то время как в группе сравнения выявлены 1 случай ранения селезенки, что потребовало конверсии, и 1 случай повреждения хвоста поджелудочной железы. Данные различия не достоверны в связи с малой выборкой. Выводы. Применение предложенного модифицированного комбинированного доступа при лапароскопической МСИОК значительно сокращает длительность операции и сопровождается снижением частоты развития интраоперационных осложнений. Однако необходимы дальнейшие рандомизированные исследования с более значительной выборкой. Ключевые слова: опухоль толстой кишки, мобилизация селезеночного изгиба, селезеночный изгиб, комбинированный способ мобилизации толстой кишки.

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Selective approach for splenic flexure mobilization in total mesorectal excision followed by low colorectal anastomoses

Abstract: Selective SFM in TME followed by advanced paraaortic lymph node dissection and left colic artery preservation is safe and may be considered as a viable option to routine SFM in rectal cancer surgery.

Cited by 6 publications

References 15 publications

IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol

IMARI: multi-Interventional program for prevention and early Management of Anastomotic leakage after low anterior resection in Rectal cancer patIents: rationale and study protocol

Splenic flexure mobilization in left‐sided colonic and rectal resections: A meta‐analysis and meta‐regression of factors associated with anastomotic leak and complications

Assessment of the efficiency and safety of the modified combined approach for laparoscopic splenic flexure mobilization

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