Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer

doi:10.21203/rs.3.rs-4438895/v1

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Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer

https://doi.org/10.21203/rs.3.rs-4438895/v1

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Background

Several methods are used for reconstruction in colon cancer surgery, including hand-sewn or stapled anastomosis. However, few reports have compared short-term outcomes among reconstruction methods. This study compared short-term outcomes between delta-shaped anastomosis (Delta) and functional end-to-end anastomosis (FEEA).

Methods

We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA or Delta reconstruction between January 2016 and December 2023. Patients were divided into two groups according to reconstruction by FEEA (F group; n = 1242) or Delta (D group; n = 72). Propensity score matching was applied to minimize the possibility of selection bias and to balance covariates that could affect postoperative complications. Short-term outcomes were compared between groups.

Results

Postoperative complications occurred in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. Before matching, transverse colon cancer was more frequent (p = 0.002), clinical N-positive status was less frequent (44.1% vs 16.7%, p < 0.001), distant metastasis was less frequent (11.7% vs 1.4%, p = 0.003), and laparoscopic approach was more frequent (87.8% vs 100%, p < 0.001) in D group. After matching, no differences in any clinical factor were evident between groups. Blood loss was lower (28 mL vs 10 mL, p = 0.002) in D group. However, operation time and postoperative complication rates were similar between groups.

Conclusions

Delta and FEEA were both considered safe as reconstruction methods. Delta anastomosis may be more useful for patients with transverse colon cancer for whom transfusion should be minimized.

colon cancer

functional end-to-end anastomosis

delta-shaped anastomosis

postoperative complication

Bowel reconstruction in the treatment of colorectal cancer, particularly right-sided colon cancer, used to be performed by hand-sewn anastomosis, but recent improvements in devices and standardization of techniques have led to the use of mechanical anastomosis. Compared to hand-sewn anastomosis, instrumented anastomosis is considered to offer the advantages of a simpler technique, shorter time requirements, and wider caliber [1–3].

Functional end-to-end anastomosis (FEEA) is a type of instrumented anastomosis first reported by Steichen [4]. As one of the most popular reconstruction methods, FEEA is reported to maintain the same intestinal function as manual anastomosis with a lower rate of anastomotic leakage compared to hand-sewn anastomosis [5].

Another method is delta-shaped anastomosis (Delta), reported by Kanaya et al. in 2002 as a reconstruction method following laparoscopic distal gastrectomy for gastric cancer [6]. Various clinical experiences and instrumentation improvements have improved the safety of this anastomosis, mainly in the field of gastric cancer [7, 8].

There is a paucity of publications comparing short-term prognosis between methods of bowel reconstruction in cases of colorectal cancer [9, 10]. Further, most previous reports have been single-center studies that could have had several sources of bias. The present study therefore compared short-term outcomes between FEEA and Delta using a multicenter database.

We retrospectively reviewed 1314 consecutive patients who underwent colorectal surgery with FEEA/Delta in seven participating hospitals (Nagasaki University Hospital, Sasebo City General Hospital, Nagasaki Medical Center, and Isahaya General Hospital, Ureshino Medical Center, Saiseikai Nagasaki Hospital, and Sasebo Chuo Hospital) between January 2016 and December 2023. Patients with hand-sewn anastomosis were excluded. The study protocol was reviewed and approved by the clinical research review boards of the participating hospitals (approval no. 16062715-5).

FEEA is performed by making a small hole with an electrocautery scalpel in the contralateral mesentery, well away from the tumor. A stapler is inserted to create a common hole, which is then closed with a thread. The intestine is resected with another stapler so that the common hole is on the tumor side, completing tumor resection and intestinal reconstruction at the same time.

For Delta, a stapler is first used to remove the intestinal tract on the oral and anal sides of the tumor. The stapler is inserted through a small hole made with an electrocautery scalpel at each mesenteric side of the dissected segment, and a common hole is created. The common hole is then closed with another stapler to complete the reconstruction.

Patients were divided into two groups: patients who underwent reconstruction by FEEA (F group; n = 1242) and by Delta (D group; n = 72). Propensity score matching (PSM) was applied to minimize the possibility of selection bias and balance covariates that could affect postoperative complications. The following covariates were included in score matching: sex, age, body mass index, American Society of Anesthesiologists (ASA) performance status (PS), comorbidity, presence or absence of colonic stent insertion, tumor location, clinical tumor/node/metastasis (T/N/M) status, surgical approach, and presence or absence of multivisceral resection. Nearest neighbor matching was performed in a 1:1 ratio, with the caliper set at 0.2. Finally, 72 patients in each group were matched.

Clinical features were compared between groups before and after propensity score matching. The following data were collected: sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, tumor location, clinical T/N/M status, surgical approach, and presence or absence of multivisceral resection. The surgical and pathological data collected included operation time, blood loss, pathological T/N status, postoperative complications, and postoperative hospital stay. Postoperative complications were defined as complications that occurred within 30 days of the primary surgery. Patients with Clavien–Dindo (CD) grade ≥2 were included in the complication group.

Statistical analysis was performed using JMP software (SAS Institute Inc., Cary, NC, USA). Data are presented as median and range. Differences in categorical variables were compared using the chi-squared test or Fisher’s exact test. Differences in continuous variables were analyzed using the Mann–Whitney U-test. All values of p < 0.05 were considered significant.

Table 1 shows the details of postoperative complications. Postoperative complications of CD grade ≥2 were identified in 215 patients (17.3%) in F group and 8 patients (11.1%) in D group. In F group, 114 patients (11.6%) experienced complications of CD grade 2, including ileus (n = 40, 3.2%), surgical site infection (n = 34, 2.7%), and anastomotic leakage (n = 13, 1.0%). In D group, 4 patients (5.6%) experienced CD grade 2 complications, including anastomotic leakage (n = 2, 2.8%), ileus (n = 1, 1.4%), and surgical site infection (n = 1, 1.4%). In F group, 71 patients (5.7%) experienced CD grade ≥3 complications, including anastomotic leakage (n = 26, 2.1%), surgical site infection (n = 12, 1.0%), and ileus (n = 10, 0.8%). In D group, 4 patients (5.6%) experienced CD grade ≥3 complications, including anastomotic leakage (n = 2, 2.8%) and ileus (n = 2, 2.8%).

Table 1

Details of postoperative complications
Site	F group (n = 1242) (%)	D group (n = 72) (%)
All complications (CD ≥2), n	215 (17.3)	8 (11.1)
CD = 2, n	144 (11.6)	4 (5.6)
Ileus	40 (3.2)	1 (1.4)
Surgical site infection	34 (2.7)	1 (1.4)
Anastomotic leakage	13 (1.0)	2 (2.8)
Pneumonia	8 (0.6)	0 (0)
Delirium	8 (0.6)	0 (0)
Abscess	5 (0.4)	0 (0)
Urinary tract infection	5 (0.4)	0 (0)
Clostridium difficile colitis	4 (0.3)	0 (0)
Chylous ascites	4 (0.3)	0 (0)
Thrombosis	4 (0.3)	0 (0)
Bleeding	4 (0.3)	0 (0)
Diarrhea	1 (0.1)	0 (0)
Other	14 (1.1)	0 (0)
CD ≥3	71 (5.7)	4 (5.6)
Anastomotic leakage	26 (2.1)	2 (2.8)
Surgical site infection	12 (1.0)	0 (0)
Ileus	10 (0.8)	2 (2.8)
Bleeding	4 (0.3)	0 (0)
Pneumonia	3 (0.2)	0 (0)
Stenosis	2 (0.2)	0 (0)
Thrombosis	1 (0.1)	0 (0)
Hernia	1 (0.1)	0 (0)
Diarrhea	1 (0.1)	0 (0)
Other	11 (0.9)	0 (0)
CD, Clavien–Dindo classification

Table 2 compares clinical characteristics between F and D groups before and after matching. Before matching, transverse colon cancer was more common (p = 0.002), clinical N-positive status (44.1% vs 16.7%, p < 0.001) and distant metastases were less common (11.7% vs 1.4%, p = 0.003), and laparoscopic approach was more common (87.8% vs 100%, p < 0.001) in D group. Other factors, including sex, age, BMI, ASA-PS, comorbidity, presence or absence of colonic stent insertion, clinical T status, and presence or absence of multivisceral resection were similar between groups. After matching, no difference in any clinical factor was seen between groups.

Table 2

Clinical characteristics in the FEEA and delta reconstruction before and after matching
	Before matching
	FEEA (n = 1242) (%)	Delta (n = 72) (%)	p value	FEEA (n = 72) (%)	Delta (n = 72) (%)	p value
Sex			0.808			0.867
Male	581 (46.8)	35 (48.6)		33 (45.8)	35 (48.6)
Female	661 (53.2)	37 (51.4)		39 (54.2)	37 (51.4)
Age, y	74 (13–98)	73 (49–93)	0.499	74 (34–92)	73 (49–93)	0.964
BMI, kg/m²	22 (13–40)	23 (14–35)	0.748	23 (15–32)	23 (14–35)	0.763
ASA performance status			0.461			0.771
1	285 (16.7)	12 (16.7)		12 (16.7)	12 (16.7)
2	818 (70.8)	51 (70.8)		48 (66.7)	51 (70.8)
3	139 (12.5)	9 (12.5)		12 (16.7)	9 (12.5)
Comorbidity			0.307			1.000
No	421 (33.9)	20 (27.8)		21 (29.2)	20 (27.8)
Yes	821 (66.1)	52 (72.2)		51 (70.8)	52 (72.2)
Colonic stent insertion			0.618			0.619
No	1164 (93.7)	69 (95.8)		71 (98.6)	69 (95.8)
Yes	78 (6.3)	3 (4.2)		1 (1.4)	3 (4.2)
Tumor location			0.002			0.866
Cecum	273 (22.0)	15 (20.8)		11 (15.3)	15 (20.8)
Ascending colon	599 (48.2)	33 (45.8)		36 (50.0)	33 (45.8)
Transverse colon	275 (22.1)	19 (26.4)		18 (25.0)	19 (26.4)
Descending colon	93 (7.5)	3 (4.2)		5 (6.9)	3 (4.2)
Other	2 (0.2)	2 (2.8)		2 (2.8)	2 (2.8)
Clinical T status			0.074			0.810
1–3	973 (78.3)	63 (87.5)		61 (84.7)	63 (87.5)
4	269 (21.7)	9 (12.5)		11 (15.3)	9 (12.5)
Clinical N status			< 0.001			1.000
Negative	694 (55.9)	60 (83.3)		60 (83.3)	60 (83.3)
Positive	548 (44.1)	12 (16.7)		12 (16.7)	12 (16.7)
Distant metastasis			0.003			1.000
No	1097 (88.3)	71 (98.6)		71 (98.6)	71 (98.6)
Yes	145 (11.7)	1 (1.4)		1 (1.4)	1 (1.4)
Surgical approach			< 0.001			1.000
Laparoscopic	1091 (87.8)	72 (100)		72 (100)	72 (100)
Open	151 (12.2)	0 (0)		0 (0)	0 (0)
Multivisceral resection			0.070			1.000
No	1184 (95.3)	72 (100)		72 (100)	72 (100)
Yes	58 (4.7)	0 (0)		0 (0)	0 (0)
Data are presented as the number of patients (percentage) or the median (range).
ASA, American Society of Anesthesiologists; BMI, body mass index. Differences in categorical variables were compared using Fisher’s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed using the Mann–Whitney U-test.

Table 3 compares perioperative characteristics between F and D groups after matching. After matching, volume of blood loss was less (28 mL vs 10 mL, p = 0.002) in D group. No differences in any other clinical factors were evident between groups, including operation time and postoperative complications.

Table 3

Perioperative characteristics in FEEA and delta reconstruction after matching
	FEEA (n = 72) (%)	Delta (n = 72) (%)	p value
Operation time, min (range)	199 (60–646)	197 (138–561)	0.972
Blood loss, mL (range)	28 (0–560)	10 (0–300)	0.002
Pathological T status			1.000
1–3	63 (87.5)	63 (87.5)
4	9 (12.5)	9 (12.5)
Pathological N status			0.649
Negative	59 (81.9)	62 (86.1)
Positive	13 (18.1)	10 (13.9)
Postoperative complications, CD ≥2	13 (18.1)	8 (11.1)	0.345
Anastomotic leakage	3 (4.2)	4 (5.6)
Hospital stay, days (range)	12 (1–155)	11 (7–43)	0.051
Data are presented as the number of patients (percentage) or the median (range).
T, tumor; N; node; CD, Clavien–Dindo classification.
Differences in categorical variables were compared using Fisher’s exact test or the chi-squared test, as appropriate. Differences in continuous variables were analyzed with the Mann–Whitney U-test.

The present multicenter study examined short-term outcomes of FEEA and Delta in colorectal cancer surgery using propensity score matching. Postoperative complication rates were 17.3% in F group and 11.1% in D group. Before matching, transverse colon cancer was more frequent, clinical N-positive status and distant metastases were less common, and use of a laparoscopic approach were more common in D group. After matching, volume of blood loss was less in D group. However, operation time and postoperative complication rates were similar between groups.

Several studies have reported on instrumented anastomosis for colorectal cancer [9, 11–13]. The overall complication rate was 25.7% for FEEA and 35.4% for triangular anastomosis [9]. In the present study, complication rates were 17.3% for FEEA and 11.1% for Delta, comparable to previous reports, and both anastomoses were performed safely.

In colorectal cancer surgery, suture failure is a serious complication that not only increases the risk of reoperation due to peritonitis and mortality, but also affects long-term outcomes such as risk of recurrence [14–16]. In a meta-analysis comparing hand-sewn and instrumented anastomoses for colorectal cancer surgery, stapled anastomosis was reported to be significantly safer with fewer suture failures compared to hand-sewn anastomosis (failure rate: 1.4% vs 5.8%, respectively; p = 0.02) [5]. In recent reports, the anastomotic leakage rate for FEEA has been reported as 1.6–4.8% [9, 10], with limited data available for Delta anastomosis. Su et al. reported no anastomotic complications, including suture failure, in a study of 86 cases treated using Delta methods, the number of cases remains small and accumulation of more data is needed [12]. In the present study, FEEA and Delta anastomosis were used in 3.1% and 5.5% of cases, respectively, with no significant differences observed between either method.

Ileus was one of the most frequent complications in this study. The diameter of the anastomotic hole at the time of anastomosis is often a problem, and long-term anastomotic stenosis is said to occur in 6.8–8.4% of cases [17]. In the present case of ileus, no direct evidence of anastomotic stenosis was observed. Some patients who developed ileus may have had relatively temporary stenosis due to postoperative edema. Further, no cases showed long-term complete stenosis requiring surgery or other treatment, and long-term function in patients who showed ileus was excellent.

In a comparison of clinical and periodic backgrounds of F and D groups, a tendency was seen toward more frequent transverse colon cancer in D group. The transverse colon varies greatly in length from person to person, and obese patients may show a shortened mesentery, making adequate mesenteric transfer difficult. If the tension during anastomosis is too high, FEEA may cause anastomotic stricture and postoperative bleeding due to mesenteric engorgement [9]. In fact, a report examining the choice of instrumented anastomosis limited to the transverse colon found that FEEA was mainly selected for ileocolic anastomosis after extensive dissection and hemicolectomy rather than for colocolic anastomosis, which is less mobile and prone to tension in the intestinal tract. Delta anastomosis is less problematic than FEEA in terms of bowel tension during anastomosis and can be performed with relatively little bowel movement. This may be why transverse colon cancer was more common in the Delta group.

In addition, significantly fewer Lap cases were seen in the FEEA group among pre-PSM cases in this study. This may be due to the fact that cancers were more advanced in the FEEA group. In this study, we were able to adjust for these covariates using PSM

To the best of our knowledge, no previous studies have compared FEEA and delta anastomoses. In the present study, we compared the short-term outcomes of the two anastomosis methods under conditions of comparable patient backgrounds using PSM, and found no significant differences in operative time or postoperative complications (including anastomotic leakage) between groups. Based on this, we considered Delta anastomosis to be as safe as FEEA. In addition, Delta anastomosis tended to result in less blood loss than FEEA. This may be due to the fact that Delta anastomosis requires a smaller area for dissection than FEEA, resulting in relatively less bleeding.

Several limitations to this study should be kept in mind. First, this was a retrospective study and the number of delta-shaped anastomosis was relatively small. Second, this was a rural multicenter study and the background characteristics of patients may have been biased. Third, the present multicenter database lacked information on intra- or extracorporeal anastomosis. A prospective study of a larger cohort is therefore needed.

Despite these limitations, Delta and FEEA were considered to both represent safe reconstruction methods, including in terms of complication rates and operation time. Delta anastomosis was considered useful for reconstruction in patients with transverse colon cancer and other cases in which the extent of transfusion should be minimized

Disclosures

Drs. Rika Ono, Tetsuro Tominaga, Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, Kazuhide Ishimaru, Terumitsu Sawai, Keitaro Matsumoto have no conflicts of interest or financial ties to disclose.

Funding:

None

Author Contribution

Rika Ono and Tetsuro Tominaga mainly designed this study. Mitsutoshi Ishii, Makoto Hisanaga, Masato Araki, Yorihisa Sumida, Takashi Nonaka, Shintaro Hashimoto, Toshio Shiraishi, Keisuke Noda, Hiroaki Takeshita, Hidetoshi Fukuoka, Shosaburo Oyama, and Kazuhide Ishimaru performed surgery. Terumitsu Sawai and Keitaro Matsumoto supervised this study.

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No competing interests reported.

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You are reading this latest preprint version

Short-term outcomes of delta-shaped anastomosis versus functional end-to-end anastomosis using linear staplers for colon cancer

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