Analysis Of Short-term And Long-term Outcomes Following Sphincter-preserving Surgery For Rectal Cancer

Laparoscopic surgery has obvious minimally invasive advantages over traditional open surgery.In recent years,it has been greatly promoted and popularized in the treatment of rectal cancer.However,whether laparoscopic rectal cancer surgery can achieve the same or even better effect than laparotomy in terms of long-term outcomes has been widely debated.In addition,with the continuous development and application of laparoscopic minimally invasive surgery technology and the concept of enhanced recovery after surgery(ERAS),rectal cancer surgery has made great progress in standardization and minimally invasive surgery.Among them,sphincter-preserving surgery for rectal cancer can radically cure the tumor while reconstructing it.Bowel continuity is an ideal surgical approach for rectal cancer.However,postoperative complications such as anastomotic leakage and the permanent stoma developing from temporary stoma are still thorny problems that must be faced in clinical practice.We intend to evaluate the short-term and long-term outcomes of sphincter-preserving surgery for rectal cancer through a retrospective study,and analyze the relevant factors affecting the short-and long-term outcomes of sphincter-preserving surgery for rectal cancer,in order to provide reference for improving the surgical treatment effect of rectal cancer.This research contains the following three parts:Part Ⅰ Comparison of short-term and long-term outcomes of laparoscopic and open sphincter-preserving surgery for rectal cancerBackground Surgical resection is still the first choice for the treatment of rectal cancer,and it is also the core modality.In the past 20 years,laparoscopic surgery has been widely used in the surgical treatment of colorectal cancer.In colon cancer surgery,there is ample evidence that laparoscopic surgery not only has minimally invasive advantages in terms of short-term outcomes,but also has similar effects to open surgery in terms of long-term outcomes.As early as 2006,the National Comprehensive Cancer Network(NCCN)guidelines recommended laparoscopic surgery as the method of choice for colon cancer surgery.Nevertheless,the value of laparoscopy in the surgical treatment of rectal cancer has not been recommended by important international guidelines so far.Whether laparoscopic surgery can achieve the same or even better results than laparotomy in terms of long-term outcomes has not been well resolved,so the comparison of the efficacy of these two surgical methods in rectal cancer is still worthy of attention.Objective To compare the short-term and long-term outcomes of open and laparoscopic sphincter-preserving surgery for rectal cancer.Research methods The clinical data of patientelective sphincter-preserving surgery for rectal cancer in the department of general surgery of Daping Hospital of Chongqing from July2010 to June 2016 were retrospectively collected(the tumor is located within 15 cm of the anal verge).All patients were classified into laparoscopic surgery group and laparoscopic surgery group according to the surgical type,and the short-term and long-term surgical outcomes of the two groups were compared.Results1.Comparison of surgical conditions and short-term outcomesThe median intraoperative blood loss in the laparotomy group was 200 ml,which was significantly higher than 100 ml in the laparoscopy group(P < 0.001).and the preventive stoma rates for the laparotomy group and the laparoscopic surgery group were 29% and34.5%,respectively,no significant difference was observed in preventive stoma between the two groups(P=0.234).The 30-day postoperative complication rate in the open group was higher than that in the laparoscopy group(39.5% vs.26.6%),there was a statistically significant difference in the complication rates between the two groups(P=0.003).The incidence of anastomotic leakage in the two groups was 8.1% and 7.4%,respectively,and there was no statistical difference between the two groups in anastomotic leakage(P=0.78).The postoperative hospital stay in the laparotomy group was significantly longer than that in the laparoscopy group(14.3 days vs 10.3 days,P<0.001).The median operative time of the laparotomy group and the laparoscopic surgery group was 180 minutes and 150 minutes,respectively,and there was a statistically significant difference between the two groups(P<0.001).The postoperative readmission rates of the two groups of patients were 4% and 4.8%,respectively,and the difference was not statistically significant(P = 0.668).2.Comparison of long-term prognosis after operationThe 5-year overall survival rate was 78.3% in the laparotomy group and 81.3% in the laparoscopic group,respectively.There was no significant difference in the overall survival rate between the two groups(P=0.464).The 5-year disease-free survival rate in the laparotomy group and the laparoscopic group were 73%,72.9%,respectively,and there was no significant difference in the 5-year disease-free survival rate between the two groups(P=0.924).Conclusion Compared with laparotomy,laparoscopy has the advantages of less blood loss,fewer postoperative complications,and shorter hospital stay,and has long-term outcomes comparable to laparotomy.The minimally invasive advantages of laparoscopic surgery are worthy of recognition,but the value of laparoscopic rectal cancer surgery in terms of long-term outcomes still needs to be further evaluated by randomized controlled studies with a larger sample size and a more scientific design.Part Ⅱ Analysis of risk factors for anastomotic leakage after sphincter-preserving surgery for rectal cancer and the value of postoperative albumin drop fraction in predicting anastomotic leakageBackground Previous studies have shown that the early postoperative albumin drop fraction(ΔALB)is related to the clinical outcomes,but no study has reported the correlation between ΔALB and postoperative anastomotic leakage.Objective: To investigate the relationship between ΔALB and anastomotic leakage,and to evaluate the risk factors affecting anastomotic leakage.Methods Early albumin decline rate was defined as ΔALB=(preoperative albumin levelpostoperative albumin level)/preoperative albumin level × 100%.The receiver operating characteristic(ROC)curve was used to evaluate the predictive effect of ΔALB on anastomotic leakage and to determine the cut-off value of ΔALB.Multivariate analysis was performed using Logistic regression models to identify independent risk factors for anastomotic leakage.Results A total of 499 patients were eventually included in this study,of which 40 patients developed anastomotic leakage postoperatively.The ROC analysis showed that the area under the curve for ΔALB was 0.605(P=0.027),the cutoff value was 33.6%,and the negative predictive value was 94%.Multivariate analysis showed that ΔALB≥33.6% and intraoperative blood loss>300ml were independent risk factors for anastomotic leakage in this study.Conclusion In patients with normal preoperative albumin levels,a significant reduction in albumin early postoperatively was also associated with an increased risk of anastomotic leakage.Part Ⅲ Influence of the severity of postoperative complications on temporary stoma reversal after sphincter-preserving surgery for rectal cancerBackground Previous literature has reported the relationship between the severity of postoperative complications after rectal cancer surgery and the long-term prognosis of patients,but no study has explored the effect of the severity of postoperative complications on temporary stoma reversal.Objective To investigate the relationship between the severity of complications and temporary stoma reversal.Research methods: The clinical data of patients who underwent elective rectal cancer sphincter-preserving surgery and temporary stoma procedure in the department of general surgery of Daping Hospital of Chongqing from July 2010 to June 2016 were retrospectively collected.According to previous literature,the Kaplan-Meier method was used to evaluate the results of temporary stoma reversal and long-term prognosis,and the COX regression model was used to evaluate the risk factors affecting temporary stoma reversal.Results Finally,380 patients with temporary stoma who met the inclusion criteria were included in the analysis,the median follow-up was 60 months(IQR,26-79 months).The 380 patients with temporary stoma included 335 with primary stoma and 45 with secondary stoma for postoperative anastomotic leakage.A total of 139 patients developed complications within30 days after sphincter-preserving surgery for rectal cancer,leading to a complication rate of36.6%(139/380).At the end of follow-up,the rate of temporary stoma unclosed rate was24.7%(95% CI,19.8%,29.6%)among 380 patients,and the median time to stoma reversal was 197 days(95% CI 180,214 days).Among the 335 primary stoma cases,the stoma unclosed rate was 23.3%(95%CI,18.2%,28.4%),and the median stoma reversal time was 194 days(95%CI,179,209 days).Postoperative tumor metastasis,anastomotic stenosis,and postoperative complications are all independent risk factors that affect stoma recovery.In addition,the multivariate analysis still found that the likelihood of stoma reversal decreased with the severity of postoperative complications.Conclusion Complications at any level after sphincter-preserving surgery for rectal cancer may adversely affect stoma reversal,and the severer the complication severity,the lower the likelihood of postoperative stoma reversal.