INTRODUCTION

Colorectal resections can be performed through malignant or benign pathologies, with anastomosis or ostomy confection. The anastomosis types include the term-terminal, term-lateral, or lateral-lateral type, with mechanical (staple) or manual suture. The surgical options include ileus-colic resection, right, transverse, or left colectomies, sigmoidectomy, and protocolectomy, among others. Conventional or minimally invasive handlings can be used, and in the latter group the manually or robotically assisted laparoscopic handling are included¹.

The colorectal carcinoma is the most common neoplasia of the digestive tube, and its treatment has surgical, curative or palliative indication, even with the existence of metastasis^2), because it decreases the tumoral load and prevents possible complications^3). Among the most important risk factors ageing is included, given that 90% of patients who suffer from it are older than 50 years old, however, it’s also prevalent in patients younger than 50 years old hence a colonoscopy is key for diagnosing^4). The surgery’s individualization in elderly patients looks to reduce complications. Minimally invasive surgery, even ambulatory, is studied for better results^5). Postsurgical complications can be evaluated according to the Clavien-Dindo classification⁶.

In the present article, morbidity and colorectal surgeries with primary anastomosis’ characteristics were compared in patients older than 65 years old, according to the handling way, in the Institute of Social Prevision’s Central Hospital (December 2019 - August 2020).

MATERIALS Y METHODS

An observational, descriptive, and retrospective study was performed. The data was collected through the selection of clinical files and procurement of a database. The inclusion criteria were colorectal cancer patients of 65 or more years of age, submitted to colorectal surgery with programmed primary anastomosis, admitted to General Surgery Services of the Institute of Social Prevision’s Central Hospital, during the December 2019 to August 2020 period. Among the exclusion criteria are patients whose initial surgery was performed in a different facility and patients with an incomplete clinical history or medical file.

The surgical handling method was determined and compared to the anastomosis’ configuration, technique, drainage utilization, morbimortality according to the Clavien-Dindo classification, anastomosis leak and inpatient stay. Once the information was compiled, a database processed through an Excel® sheet was designed.

RESULTS

26 patients of 65 years old or older submitted to colorectal surgeries with primary anastomosis were evaluated, of which 30.7% were performed by laparoscopic way, and 69.2% by conventional way.

Base pathologies were found present on all patients operated through laparoscopic way (8/8), and in 72.2% (13/18) of those operated by conventional way.

Within the group submitted to laparoscopic-way surgery, 62.5% were right colectomies, 25% left colectomies, and 12.5% sigmoidectomies. As for the group submitted to conventional-way surgery, 61.1% were right colectomies, 16.6% sigmoidectomies, 11.1% lower anterior resections, 5.5% left colectomies, and 5.5% transversectomies.

Anastomotic configuration in the group submitted to laparoscopic-way surgery was 37.5% term-terminal, 37.5% lateral-lateral, and 25% term-lateral. Through conventional way 38.8% were lateral-lateral, 33.3% were term-lateral, and 27.7% were term-terminal. Manual suturing was used in 12.5% of laparoscopic approaches and in 44.4% of conventional-way approaches. Mechanical suturing was used in 87.5% of laparoscopic approaches and in 55.5% of conventional approaches. (see Table 1)

Regarding anastomosis’ complications, 12.5% presented anastomosis leak through laparoscopic way and 27.7% through conventional way. 87.5% of patients operated through laparoscopic way had a tubular drainage placement, and 88.8% through conventional way did so as well. (see Table 1)

According to the Clavien-Dindo classification, the most frequent complication amongst both groups was type 1. (see Table 1, Graphic 1)

Graphic 1.  Complications’ classification according to the Clavien-Dindo classification 

The average inpatient stay of patients operated through laparoscopic way was 6.75 days, and 9.2 days through conventional way.

DISCUSSION

A revision of 26 colorectal cancer patients who were submitted to colorectal surgeries with primary anastomosis was performed. The most common surgical approach was conventional-way and although it was the most frequent, laparoscopic-way has been the protagonist in our hospital center. In our current day, the laparoscopic way has become the standard method for colon surgeries^7), the use of laparoscopic surgery on geriatric patients with colorectal cancer should increase due to the better long-term results⁸.

No significative difference between the different anastomosis configurations was observed, noting a similar frequency among term-terminal, lateral-lateral, and term-lateral anastomosis for both approach ways. This is also subjected to the patient’s localization and anatomy, the ileocolic anastomosis configuration’s impact that might have in the intestinal transit’s restitution after a right hemicolectomy. It’s necessary to perform a randomized essay comparing isoperistaltic and antiperistaltic modalities^9), ileocolic, isoperistaltic, and antiperistaltic presented similar results in terms of performance, security, and functionality¹⁰.

Regarding the anastomosis technique, the use of mechanical stapler for anastomosis was predominant in both groups. It’s worth mentioning that the use of stapler with manual suture backup after the rectum cancer’s laparoscopic radical resection is convenient and effective¹¹, making the standardized use of laparoscopic way and stapler for rectum cancer evident. A group of collaborators from the European Coloproctology Society informed increased use of the stapler technique rather than the manual one, alike our study, however, the most used surgical approach was laparoscopic way, which does not match the data of our study¹².

Anastomosis leak was mostly present with conventional way and in an increased rate. Luglio and Corcione informed lesser anastomosis leak with the stapler’s use, however, they did not report the surgical approach way and specifically studied ileocolonic anastomosis¹³. Nordholom et al however reports a times two risk of anastomosis leak with the stapler’s use for ileocolic anastomosis, although it does not specify the surgical approach¹⁴. The collaborators’ group from the European Coloproctology Society studied the predictive factors of anastomosis leak in right colon cancer, where the surgery’s duration, conventional approach and stapler’s use was associated with a higher risk of anastomosis leakage¹². There are studies that report that anastomosis leak us related to the deteriorated general survival and high local recurrency^15,16.

In our study, abdominal drainage was left in almost every case, regardless of surgical approach. Some authors are not in favor of the rutinary use of drainages after colon and rectal anastomosis, voicing that it’s associated with an increase in injury’s infection rate which can be up to a 25%¹⁷.

For the morbimortality assessment the Clavien-Dindo classification was used. We observed that the most frequent complication was type 1, for laparoscopic approach as much as for conventional, although no type 5 complications were observed for the conventional-way submitted group, which were present in 25% of the laparoscopic-way submitted patients. The fact that most patients presented type 1 complications is encouraging given that studies report that the complications’ gravity is related to the general survivability^18,19.

The shorter inpatient stay was for laparoscopic way, which matches with other studies with similar results²⁰.

This article may be biased due to the low quantity of studied patients and the fact that the study was performed in a specialized hospital.

CONCLUSION

Of the patient total (26), most (69.2%) was submitted to conventional surgery. The most common resection type was right colectomy. Anastomosis configuration and the use of stapler did not show variations amongst the conventional and laparoscopic surgery groups. Anastomosis leaks were registered in both groups, with a higher rate in the conventional surgery group (27.7%). Complications are categorized according to the Clavien-Dindo classification, without significant discrepancies.