University of Groningen

Colorectal AnastomosesBakker, Ilsalien

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INTRODUCTION

Chapter

1

GENERAL INTRODUCTION AND OUTLINE OF THESIS

Colorectal surgery with subsequent creation of colorectal anastomoses has been extensively

studied throughout the years. Various procedures and several materials have been examined

resulting in continuous improvements in surgical techniques. The introduction of stapling devices

in the 1970s allowed lower anastomoses leading to accumulating numbers of colorectal

anastomoses and improved application in laparoscopic surgery (1).

Colorectal cancer is the third most common cancer worldwide, with a persistent increasing

incidence (2). In the current multidisciplinary treatment approach, surgery is the only curative

treatment strategy for colon cancer. For rectal cancer however, non operative treatment is

currently focus of interest. Complete pathological response in patients treated with neoadjuvant

chemoradiation followed by a wait and see policy, seems to have good results without the

morbidity of surgery (3,4). Not all rectal tumours react with a complete response to neoadjuvant

therapy and at this moment there are no long term results. Hence, currently, surgical resection

remains the cornerstone of treatment for both colon and rectal cancer. In 2013 almost 10.000

colorectal cancer resections were performed in the Netherlands (5). Colorectal resections

however, are not only performed for a malignancy, but also for benign indications, resulting in a

significant higher nationwide total amount of annual colorectal surgical procedures.

Following colorectal resection, there are three surgical options, consisting of creation of bowel

continuity by means of a primary anastomosis, an anastomosis with a temporary defunctioning

stoma or the omission of bowel continuity by construction of a terminal ileo- or colostomy. Each

of these three surgical options is associated with their specific advantages and disadvantages and

corresponding outcome.

PRIMARY ANASTOMOSIS

Restoration of bowel continuity with a primary anastomosis is the first choice treatment for

patients undergoing an uncomplicated resection. An anastomosis however, bears the risk of

anastomotic leakage, one of the most common surgical complications after colorectal resection.

Anastomotic leakage, leads to high rates of morbidity, re-interventions, longer hospital stay and

mortality (6-8), and possibly a worse oncological outcome (9,10). The overall anastomotic leakage

incidence varies widely in the literature, ranging from 4 to 20% in colorectal anastomoses (7,11-

13) and 3 to 6.5% in colonic anastomoses (14-16). In the Netherlands 11% of the patients

operated on for rectal cancer developed anastomotic leakage and 7.2% of patients undergoing

Introduction

1

11

GENERAL INTRODUCTION AND OUTLINE OF THESIS

Colorectal surgery with subsequent creation of colorectal anastomoses has been extensively

studied throughout the years. Various procedures and several materials have been examined

resulting in continuous improvements in surgical techniques. The introduction of stapling devices

in the 1970s allowed lower anastomoses leading to accumulating numbers of colorectal

anastomoses and improved application in laparoscopic surgery (1).

Colorectal cancer is the third most common cancer worldwide, with a persistent increasing

incidence (2). In the current multidisciplinary treatment approach, surgery is the only curative

treatment strategy for colon cancer. For rectal cancer however, non operative treatment is

currently focus of interest. Complete pathological response in patients treated with neoadjuvant

chemoradiation followed by a wait and see policy, seems to have good results without the

morbidity of surgery (3,4). Not all rectal tumours react with a complete response to neoadjuvant

therapy and at this moment there are no long term results. Hence, currently, surgical resection

remains the cornerstone of treatment for both colon and rectal cancer. In 2013 almost 10.000

colorectal cancer resections were performed in the Netherlands (5). Colorectal resections

however, are not only performed for a malignancy, but also for benign indications, resulting in a

significant higher nationwide total amount of annual colorectal surgical procedures.

Following colorectal resection, there are three surgical options, consisting of creation of bowel

continuity by means of a primary anastomosis, an anastomosis with a temporary defunctioning

stoma or the omission of bowel continuity by construction of a terminal ileo- or colostomy. Each

of these three surgical options is associated with their specific advantages and disadvantages and

corresponding outcome.

PRIMARY ANASTOMOSIS

Restoration of bowel continuity with a primary anastomosis is the first choice treatment for

patients undergoing an uncomplicated resection. An anastomosis however, bears the risk of

anastomotic leakage, one of the most common surgical complications after colorectal resection.

Anastomotic leakage, leads to high rates of morbidity, re-interventions, longer hospital stay and

mortality (6-8), and possibly a worse oncological outcome (9,10). The overall anastomotic leakage

incidence varies widely in the literature, ranging from 4 to 20% in colorectal anastomoses (7,11-

13) and 3 to 6.5% in colonic anastomoses (14-16). In the Netherlands 11% of the patients

operated on for rectal cancer developed anastomotic leakage and 7.2% of patients undergoing

Chapter 1

1

12

colon cancer resection (17). Variations in the definition of anastomotic leakage may in part

account for this difference, but patient selection and clinical practice may as well account to it.

The pathogenesis of the occurrence of anastomotic leakage is still not fully understood. It is

generally advised that a well-fashioned anastomosis should be made in an adequately vascularized

bowel in the absence of contamination. Tension on the anastomosis can result in insufficient

circulation leading to ischemia and inadequate anastomotic healing. Tension can also lead to

traction and a mechanical rupture of the anastomosis, especially when no defunctioning stoma is

made and (mass)peristalsis plays a role (18). Also intraoperative contamination results in worse

healing (16,19). Even though there are known risk factors including patient factors as

comorbidity, American Society of Anesthesiologist classification (19,20), tumour factors as stage

of disease, tumour localization (15,21) and treatment factors including emergency surgery (20,21),

and construction of a defunctioning stoma (7,13), it is still difficult to predict the anastomotic

leakage risk for the individual patient.

Improvements in surgical techniques as staple-line reinforcements (22), transanal stents (23) and

applications of intraluminal devices (24-27), aimed to diminish anastomotic leakage rates. Despite

these promising perspectives, clinical anastomotic leakage rates remain unaltered.

DEFUNCTIONING STOMA

In order to prevent the occurrence of anastomotic leakage and diminish its clinical consequences,

a temporary defunctioning stoma, could be made (7,13). Results of a Swedish randomized clinical

trial, randomizing rectal cancer patients undergoing low anterior resection between a

defunctioning stoma or a primary anastomosis, showed significant more anastomotic leakage in

patients without a defunctioning stoma, 28% vs 10.3% respectively (13). Despite the high overall

anastomotic leakage percentage in the control group, the outcome of this trial initiated a

defensive surgical strategy, translating in high defunctioning stoma rates. In the Netherlands a

defunctioning stoma is made in 70% of the patients with a colorectal anastomosis (5,17,28).

Leakage rates after rectal cancer surgery were significantly lower for patients with a defunctioning

stoma, compared to patients without a stoma, 10 and 13% respectively. The leakage incidence

after colonic anastomoses did not significantly differ, respectively 6% in patients with a

defunctioning stoma and 7% in patients without a stoma (17).

Even though a defunctioning stoma may result in lower leakage rates, anastomotic leakage still

occurs. Furthermore, stomas have there own drawbacks. The creation of a defunctioning stoma

is associated with more postoperative complications, stoma problems and higher hospital re-

admission rates (29-31). Also, patients with a defunctioning stoma need another operation to

reverse the stoma with subsequent associated postoperative complications, and in addition, these

patients still bear the risk for anastomotic leakage after stoma reversal (32,33). A high proportion

of temporary defunctioning stomas is not reversed at all and becomes permanent (34).

END-COLOSTOMY

Avoidance of an anastomosis after colorectal resection is often considered in high-risk patients.

In these patients an end-colostomy is contructed with closure of the rectal stump. This surgical

option protects against anastomotic leakage and its sequelae, and it also leads to better functional

results in patients with a low anastomosis (35). Further, patients with permanent stomas are

described to have a better quality of life than patients with temporary stomas (36). There is no

difference in quality of life between patients with a permanent end-colostomy compared to

patients without a permanent end-colostomy after rectal cancer resection (37). Construction of an

end-colostomy seems to be a good solution in high risk patients avoiding the sequelae of

anastomotic leakage, however, also creation of an end-colostomy has its disadvantages.

Construction of and end-colostomy is associated with stoma complications, more intra-

abdominal and pre-sacral abscesses due to stump necrosis, more re-interventions and a higher

hospital re-admission rate (38,39).

Although creation of defunctioning stomas reduces the anastomotic leakage rate, and end-

colostomies even prevent leakage, the drawbacks of stomas, both temporary defunctioning

stomas and end-colostomies, should be taken into account, prior to surgical resection. Outcome

of these three surgical options, together with the patient’s preference, should be considered for

good pre-operative clinical shared decision-making.

DUTCH SURGICAL COLORECTAL AUDIT

All aforementioned considerations of different surgical options and corresponding outcome,

together with existing scientific evidence, emphasize the importance of careful decision making in

anastomosis and stoma construction following colorectal resection. There is no uniform policy

concerning anastomosis and stoma creation. This decision process varies per country, per

hospital, per surgeon and per patient.

Currently, when quality indicators are a major topic in healthcare, there is increasing interest in

surgical outcome. The Dutch Surgical Colorectal Audit is a quality institution in which all Dutch

Hospitals participate. This audit is established in 2009 to monitor and improve surgical outcome

for patients with colorectal cancer. National audits provide insight in surgeries and their

Introduction

1

13

colon cancer resection (17). Variations in the definition of anastomotic leakage may in part

account for this difference, but patient selection and clinical practice may as well account to it.

The pathogenesis of the occurrence of anastomotic leakage is still not fully understood. It is

generally advised that a well-fashioned anastomosis should be made in an adequately vascularized

bowel in the absence of contamination. Tension on the anastomosis can result in insufficient

circulation leading to ischemia and inadequate anastomotic healing. Tension can also lead to

traction and a mechanical rupture of the anastomosis, especially when no defunctioning stoma is

made and (mass)peristalsis plays a role (18). Also intraoperative contamination results in worse

healing (16,19). Even though there are known risk factors including patient factors as

comorbidity, American Society of Anesthesiologist classification (19,20), tumour factors as stage

of disease, tumour localization (15,21) and treatment factors including emergency surgery (20,21),

and construction of a defunctioning stoma (7,13), it is still difficult to predict the anastomotic

leakage risk for the individual patient.

Improvements in surgical techniques as staple-line reinforcements (22), transanal stents (23) and

applications of intraluminal devices (24-27), aimed to diminish anastomotic leakage rates. Despite

these promising perspectives, clinical anastomotic leakage rates remain unaltered.

DEFUNCTIONING STOMA

In order to prevent the occurrence of anastomotic leakage and diminish its clinical consequences,

a temporary defunctioning stoma, could be made (7,13). Results of a Swedish randomized clinical

trial, randomizing rectal cancer patients undergoing low anterior resection between a

defunctioning stoma or a primary anastomosis, showed significant more anastomotic leakage in

patients without a defunctioning stoma, 28% vs 10.3% respectively (13). Despite the high overall

anastomotic leakage percentage in the control group, the outcome of this trial initiated a

defensive surgical strategy, translating in high defunctioning stoma rates. In the Netherlands a

defunctioning stoma is made in 70% of the patients with a colorectal anastomosis (5,17,28).

Leakage rates after rectal cancer surgery were significantly lower for patients with a defunctioning

stoma, compared to patients without a stoma, 10 and 13% respectively. The leakage incidence

after colonic anastomoses did not significantly differ, respectively 6% in patients with a

defunctioning stoma and 7% in patients without a stoma (17).

Even though a defunctioning stoma may result in lower leakage rates, anastomotic leakage still

occurs. Furthermore, stomas have there own drawbacks. The creation of a defunctioning stoma

is associated with more postoperative complications, stoma problems and higher hospital re-

admission rates (29-31). Also, patients with a defunctioning stoma need another operation to

reverse the stoma with subsequent associated postoperative complications, and in addition, these

patients still bear the risk for anastomotic leakage after stoma reversal (32,33). A high proportion

of temporary defunctioning stomas is not reversed at all and becomes permanent (34).

END-COLOSTOMY

Avoidance of an anastomosis after colorectal resection is often considered in high-risk patients.

In these patients an end-colostomy is contructed with closure of the rectal stump. This surgical

option protects against anastomotic leakage and its sequelae, and it also leads to better functional

results in patients with a low anastomosis (35). Further, patients with permanent stomas are

described to have a better quality of life than patients with temporary stomas (36). There is no

difference in quality of life between patients with a permanent end-colostomy compared to

patients without a permanent end-colostomy after rectal cancer resection (37). Construction of an

end-colostomy seems to be a good solution in high risk patients avoiding the sequelae of

anastomotic leakage, however, also creation of an end-colostomy has its disadvantages.

Construction of and end-colostomy is associated with stoma complications, more intra-

abdominal and pre-sacral abscesses due to stump necrosis, more re-interventions and a higher

hospital re-admission rate (38,39).

Although creation of defunctioning stomas reduces the anastomotic leakage rate, and end-

colostomies even prevent leakage, the drawbacks of stomas, both temporary defunctioning

stomas and end-colostomies, should be taken into account, prior to surgical resection. Outcome

of these three surgical options, together with the patient’s preference, should be considered for

good pre-operative clinical shared decision-making.

DUTCH SURGICAL COLORECTAL AUDIT

All aforementioned considerations of different surgical options and corresponding outcome,

together with existing scientific evidence, emphasize the importance of careful decision making in

anastomosis and stoma construction following colorectal resection. There is no uniform policy

concerning anastomosis and stoma creation. This decision process varies per country, per

hospital, per surgeon and per patient.

Currently, when quality indicators are a major topic in healthcare, there is increasing interest in

surgical outcome. The Dutch Surgical Colorectal Audit is a quality institution in which all Dutch

Hospitals participate. This audit is established in 2009 to monitor and improve surgical outcome

for patients with colorectal cancer. National audits provide insight in surgeries and their

Chapter 1

1

14

corresponding outcome and can be useful in order to achieve improvements. Outcome of

national data has the benefit that it is less biased than outcome of clinical trials, often excluding

subpopulations as elderly, emergency patients and patients with metastatic disease. In the future

these results might contribute to establish a uniform policy according anastomosis and stoma

construction in colorectal surgery and possibly even custom made for groups or for the

individual patient.

OUTLINE OF THESIS

This thesis aims to describe surgical outcome of colorectal anastomoses and prevention of

anastomotic leakage. The majority of scientific clinical results are based on the combined

outcome of both colon and rectal surgical resections. The present thesis attempted to obtain

better insight in surgical outcome by differentiating between both colon and rectal surgery. The

first part focuses on surgical outcome of colorectal cancer resection in the Netherlands, using

population-based data from the Dutch Surgical Colorectal Audit. The second part of the thesis is

centered on the prevention of anastomotic leakage and its sequelae after colorectal resection.

Chapter 2 identifies risk factors for anastomotic leakage and mortality following anastomotic

leakage in patients undergoing colon cancer resection. In chapter 3 postoperative outcome of non-

elective colon cancer resections is focus of interest. Chapter 4 shows results of mid and high rectal

cancer resections, in which differences in outcome between primary anastomoses, defunctioning

stomas and end-colostomies were analyzed. Chapter 5 describes one-year surgical outcome after

low anterior resection for rectal cancer differentiating between the aforementioned three surgical

treatment strategies.

Chapter 6 reveals the study protocol of the C-seal trial. The C-seal is designed to prevent

anastomotic leakage. It is an intraluminal biodegradable drain, which is fixed proximal to the

anastomosis with a circular stapler. This randomized clinical trial examined the influence of the

C-seal on the occurrence of clinical anastomotic leakage after colorectal resection. The results of

the C-seal trial are presented in Chapter 7. Chapter 8 focuses on techniques used in Dutch

colorectal anastomoses after colorectal resection.

Introduction

1

15

corresponding outcome and can be useful in order to achieve improvements. Outcome of

national data has the benefit that it is less biased than outcome of clinical trials, often excluding

subpopulations as elderly, emergency patients and patients with metastatic disease. In the future

these results might contribute to establish a uniform policy according anastomosis and stoma

construction in colorectal surgery and possibly even custom made for groups or for the

individual patient.

OUTLINE OF THESIS

This thesis aims to describe surgical outcome of colorectal anastomoses and prevention of

anastomotic leakage. The majority of scientific clinical results are based on the combined

outcome of both colon and rectal surgical resections. The present thesis attempted to obtain

better insight in surgical outcome by differentiating between both colon and rectal surgery. The

first part focuses on surgical outcome of colorectal cancer resection in the Netherlands, using

population-based data from the Dutch Surgical Colorectal Audit. The second part of the thesis is

centered on the prevention of anastomotic leakage and its sequelae after colorectal resection.

Chapter 2 identifies risk factors for anastomotic leakage and mortality following anastomotic

leakage in patients undergoing colon cancer resection. In chapter 3 postoperative outcome of non-

elective colon cancer resections is focus of interest. Chapter 4 shows results of mid and high rectal

cancer resections, in which differences in outcome between primary anastomoses, defunctioning

stomas and end-colostomies were analyzed. Chapter 5 describes one-year surgical outcome after

low anterior resection for rectal cancer differentiating between the aforementioned three surgical

treatment strategies.

Chapter 6 reveals the study protocol of the C-seal trial. The C-seal is designed to prevent

anastomotic leakage. It is an intraluminal biodegradable drain, which is fixed proximal to the

anastomosis with a circular stapler. This randomized clinical trial examined the influence of the

C-seal on the occurrence of clinical anastomotic leakage after colorectal resection. The results of

the C-seal trial are presented in Chapter 7. Chapter 8 focuses on techniques used in Dutch

colorectal anastomoses after colorectal resection.

Chapter 1

1

16

REFERENCES

(1) Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012 Feb 15;2:CD003144.

(2) International Agency for research on cancer. WorldHealthOrganisation.http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed 30-11-2015.

(3) Smith JD, Ruby JA, Goodman KA, Saltz LB, Guillem JG, Weiser MR, et al. Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg 2012 Dec;256(6):965-972.

(4) Dedemadi G, Wexner SD. Complete response after neoadjuvant therapy in rectal cancer: to operate or not to operate? Dig Dis 2012;30 Suppl 2:109-117.

(5) Dutch Institute for Clinical Auditing, rapportages 2013.http://www.clinicalaudit.nl/jaarrapportage/2013/. Accessed 30-11-2015.

(6) den Dulk M, Marijnen CA, Collette L, Putter H, Pahlman L, Folkesson J, et al. Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 2009 Sep;96(9):1066-1075.

(7) Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 2005 Feb;92(2):211-216.

(8) Snijders HS, Wouters MW, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, et al. Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 2012 Nov;38(11):1013-1019.

(9) Petersen S, Freitag M, Hellmich G, Ludwig K. Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer. Int J Colorectal Dis 1998;13(4):160-163.

(10) Law WL, Choi HK, Lee YM, Ho JW, Seto CL. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007 Jan;11(1):8-15.

(11) Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005 Nov;48(11):2076-2079.

(12) Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 2004 Aug;240(2):260-268.

(13) Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007 Aug;246(2):207-214.

(14) Kube R, Mroczkowski P, Granowski D, Benedix F, Sahm M, Schmidt U, et al. Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival. Eur J Surg Oncol 2010 Feb;36(2):120-124.

(15) Krarup PM, Jorgensen LN, Andreasen AH, Harling H, on behalf of the Danish Colorectal Cancer Group. A nationwide study on anastomotic leakage after colonic cancer surgery. Colorectal Dis 2012 Oct;14(10):e661-7.

(16) Leichtle SW, Mouawad NJ, Welch KB, Lampman RM, Cleary RK. Risk factors for anastomotic leakage after colectomy. Dis Colon Rectum 2012 May;55(5):569-575.

(17) Dutch Institute for Clinical Auditing, rapportages2011.http://www.clinicalaudit.nl/jaarrapportage/archief/DICA%20Jaarrapportage%202011.pdf. Accessed 30-11-2015.

(18) Holdstock DJ, Misiewicz JJ, Smith T, Rowlands EN. Propulsion (mass movements) in the human colon and its relationship to meals and somatic activity. Gut 1970 Feb;11(2):91-99.

(19) Alves A, Panis Y, Trancart D, Regimbeau JM, Pocard M, Valleur P. Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 patients. World J Surg 2002 Apr;26(4):499-502.

(20) Buchs NC, Gervaz P, Bucher P, Huber O, Mentha G, Morel P. Lessons learned from one thousand consecutive colonic resections in a teaching hospital. Swiss Med Wkly 2007 May 5;137(17-18):259-264.

(21) Bakker IS, Grossmann I, Henneman D, Havenga K, Wiggers T. Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 2014 Mar;101(4):424-32; discussion 432.

(22) Franklin ME,Jr, Berghoff KE, Arellano PP, Trevino JM, Abrego-Medina D. Safety and efficacy of

the use of bioabsorbable seamguard in colorectal surgery at the Texas endosurgery institute. Surg Laparosc Endosc Percutan Tech 2005 Feb;15(1):9-13.

(23) Amin AI, Ramalingam T, Sexton R, Heald RJ, Leppington-Clarke A, Moran BJ. Comparison of transanal stent with defunctioning stoma in low anterior resection for rectal cancer. Br J Surg 2003 May;90(5):581-582.

(24) Rack RJ. Advantages of an indwelling rectal tube in anterior resection and anastomosis for lesions involving the terminal portion of the colon. Dis Colon Rectum 1966 Jan-Feb;9(1):42-48.

(25) Ger R, Ravo B. Prevention and treatment of intestinal dehiscence by an intraluminal bypass graft. Br J Surg 1984 Sep;71(9):726-729.

(26) Yoon WH, Song IS, Chang ES. Intraluminal bypass technique using a condom for protection of coloanal anastomosis. Dis Colon Rectum 1994 Oct;37(10):1046-1047.

(27) Morks AN, Havenga K, Ten Cate Hoedemaker HO, Leijtens JW, Ploeg RJ, For the C-seal Study Group. Thirty-seven patients treated with the C-seal: protection of stapled colorectal anastomoses with a biodegradable sheath. Int J Colorectal Dis 2013 Oct;28(10):1433-8. (28) Dutch Surgical Colorectal Audit, Jaarrapportage 2010.http://www.clinicalaudit.nl/jaarrapportage/2013/archief/DSCA%20Jaarrapportage%202010.pdf. Accessed 30-11-2015.

(29) Formijne Jonkers HA, Draaisma WA, Roskott AM, van Overbeeke AJ, Broeders IA, Consten EC. Early complications after stoma formation: a prospective cohort study in 100 patients with 1-year follow-up. Int J Colorectal Dis 2012 Aug;27(8):1095-1099.

(30) Mala T, Nesbakken A. Morbidity related to the use of a protective stoma in anterior resection for rectal cancer. Colorectal Dis 2008 Oct;10(8):785-788.

(31) Akesson O, Syk I, Lindmark G, Buchwald P. Morbidity related to defunctioning loop ileostomy in low anterior resection. Int J Colorectal Dis 2012 Dec;27(12):1619-1623.

(32) Saha AK, Tapping CR, Foley GT, Baker RP, Sagar PM, Burke DA, et al. Morbidity and mortality after closure of loop ileostomy. Colorectal Dis 2009 Oct;11(8):866-871.

(33) Peacock O, Law CI, Collins PW, Speake WJ, Lund JN, Tierney GM. Closure of loop ileostomy:

potentially a daycase procedure? Tech Coloproctol 2011 Dec;15(4):431-437.

(34) den Dulk M, Smit M, Peeters KC, Kranenbarg EM, Rutten HJ, Wiggers T, et al. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol 2007 Apr;8(4):297-303.

(35) Rasmussen OO, Petersen IK, Christiansen J. Anorectal function following low anterior resection. Colorectal Dis 2003 May;5(3):258-261.

(36) Smith DM, Loewenstein G, Jankovic A, Ubel PA. Happily hopeless: adaptation to a permanent, but not to a temporary, disability. Health Psychol 2009 Nov;28(6):787-791.

(37) Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database Syst Rev 2012 Dec 12;12:CD004323.

(38) Molina Rodriguez JL, Flor-Lorente B, Frasson M, Garcia-Botello S, Esclapez P, Espi A, et al. Low rectal cancer: abdominoperineal resection or low Hartmann resection? A postoperative outcome analysis. Dis Colon Rectum 2011 Aug;54(8):958-962.

(39) Tottrup A, Frost L. Pelvic sepsis after extended Hartmann's procedure. Dis Colon Rectum 2005 Feb;48(2):251-255.

Introduction

1

17

REFERENCES

(1) Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012 Feb 15;2:CD003144.

(2) International Agency for research on cancer. WorldHealthOrganisation.http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. Accessed 30-11-2015.

(3) Smith JD, Ruby JA, Goodman KA, Saltz LB, Guillem JG, Weiser MR, et al. Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg 2012 Dec;256(6):965-972.

(4) Dedemadi G, Wexner SD. Complete response after neoadjuvant therapy in rectal cancer: to operate or not to operate? Dig Dis 2012;30 Suppl 2:109-117.

(5) Dutch Institute for Clinical Auditing, rapportages 2013.http://www.clinicalaudit.nl/jaarrapportage/2013/. Accessed 30-11-2015.

(6) den Dulk M, Marijnen CA, Collette L, Putter H, Pahlman L, Folkesson J, et al. Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 2009 Sep;96(9):1066-1075.

(7) Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, et al. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 2005 Feb;92(2):211-216.

(8) Snijders HS, Wouters MW, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, et al. Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 2012 Nov;38(11):1013-1019.

(9) Petersen S, Freitag M, Hellmich G, Ludwig K. Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer. Int J Colorectal Dis 1998;13(4):160-163.

(10) Law WL, Choi HK, Lee YM, Ho JW, Seto CL. Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 2007 Jan;11(1):8-15.

(11) Wong NY, Eu KW. A defunctioning ileostomy does not prevent clinical anastomotic leak after a low anterior resection: a prospective, comparative study. Dis Colon Rectum 2005 Nov;48(11):2076-2079.

(12) Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 2004 Aug;240(2):260-268.

(13) Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 2007 Aug;246(2):207-214.

(14) Kube R, Mroczkowski P, Granowski D, Benedix F, Sahm M, Schmidt U, et al. Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival. Eur J Surg Oncol 2010 Feb;36(2):120-124.

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PART I

SURGICAL OUTCOME OF COLORECTAL CANCER

RESECTION IN THE NETHERLANDS

PART I

SURGICAL OUTCOME OF COLORECTAL CANCER

RESECTION IN THE NETHERLANDS