Reconstruction Techniques and Vascular Approach After Laparoscopic Left Hemicolectomy and Rectum Low Anterior Resection (TAHR)

Reconstruction Techniques and Vascular Approach After Laparoscopic Left Hemicolectomy and Rectum Low Anterior Resection

Reconstruction Techniques and Vascular Approach After Laparoscopic Left Hemicolectomy and Laparoscopic Low Anterior Resection for Rectal Cancer: a Randomized Clinical Trial

This is an interventional, controlled and randomized single-center clinical trial with patients diagnosed with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer. All patients included in the study (study 1) are randomized into two groups (group 1A and group 1B): in the group 1A the surgical technique initially dissects the inferior mesenteric vein (IMV) and in the group 1B the surgical technique initially dissects the inferior mesenteric artery. The patients who will undergo a colorectal anastomosis will be included in the study 2 and will be randomized to group 2A and group 2B: in group 2A the patients will have a latero-terminal colorectal anastomosis and in group 2B a termino-terminal colorectal anastomosis. Study hypothesis: Study 1: the surgical technique that initially dissects the IMV presents a greater number of total resected lymph nodes compared to the technique that initially dissects the IMA. Study 2: latero-terminal anorectal anastomosis has a better anorectal functional outcome than termino-terminal anorectal anastomosis. Primary outcome measures: Study 1:To compare the total number of resected lymph nodes and the distance to the surgical margins between the two arms (1A and 1B). Study 2: to compare the anorectal functional outcome at 12 months after surgery or ileostomy closure between the two arms (2A and 2B). The anorectal function will be assessed by the scores of the validated Colorectal Functional Outcome Questionnaire (COREFO) and the validated scale LARS (Syndrome anterior resection of the rectum). Secondary outcome measures: Study 1: to compare the duration of surgery, bleeding and need for surgical conversion between the two arms (1A and 1B). Another objectives are to compare the incidence of postoperative complications (measured by the Clavien-Dindo classification) and survival. Study 2: to compare the quality of life and anorectal functional outcomes at : 6, 12, 18 and 24 months after intervention (or ileostomy closure) between the two arms (2A and 2B). The anorectal function will be assessed by the validated COREFO questionnaire and the LARS scale. The quality of life will be assessed by the validated questionnaire of quality of life: SF-36. Another objective is to compare the incidence of postoperative complications assessed by the Clavien-Dindo classification and the incidence of anastomotic leakage.

This is an interventional, controlled and randomized single-center clinical trial with patients diagnosed with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer. Methods: All patients included in the study (study 1) are randomized into two groups (group 1A and group 1B): in the group 1A the surgical technique initially dissects the inferior mesenteric vein (IMV) and in the group 1B the surgical technique initially dissects the inferior mesenteric artery. The patients who will undergo a colorectal anastomosis will be included in the study 2 and will be randomized to group 2A and group 2B: in group 2A the patients will have a latero-terminal colorectal anastomosis and in group 2B a termino-terminal colorectal anastomosis. Study hypothesis: Study 1: the surgical technique that initially dissects the IMV presents a greater number of total resected lymph nodes compared to the technique that initially dissects the IMA. Study 2: latero-terminal anorectal anastomosis has a better anorectal functional outcome than termino-terminal anorectal anastomosis. Primary outcome measures: Study 1:To compare the total number of resected lymph nodes and the distance to the surgical margins between the two arms (1A and 1B). Study 2: to compare the anorectal functional outcome at 12 months after surgery or ileostomy closure between the two arms (2A and 2B). The anorectal function will be assessed by the scores of the validated Colorectal Functional Outcome Questionnaire (COREFO) and the validated scale LARS (Syndrome anterior resection of the rectum). Secondary outcome measures: Study 1: to compare the duration of surgery, bleeding and need for surgical conversion between the two arms (1A and 1B). Another objectives are to compare the incidence of postoperative complications (measured by the Clavien-Dindo classification) and survival. Study 2: to compare the quality of life and anorectal functional outcomes at : 6, 12, 18 and 24 months after intervention (or ileostomy closure) between the two arms (2A and 2B). The anorectal function will be assessed by the validated COREFO questionnaire and the LARS scale. The quality of life will be assessed by the validated questionnaire of quality of life: SF-36. Another objective is to compare the incidence of postoperative complications assessed by the Clavien-Dindo classification and the incidence of anastomotic leakage. Duration and follow up Study 1: the expected study duration is 6'5 years. Study 2: the expected duration of the study is 3'5 years. The planned duration of follow up in the study 1 is 5 years, in the study 2 is 2 years. Selection criteria Inclusion Criteria: Study 1: Patients with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer. Age ≥ 18 years Histology proven adenocarcinoma or adenoma with or without chemotherapy or neoadjuvant radiochemotherapy Any T, any N, M or any adenoma Attempt to R0 resection Signed informed consent by the patient and by the researcher Quality of Life Questionnaire completed Study 2: Patients with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer with colorectal anastomosis. Age ≥ 18 years Histology proven adenocarcinoma or adenoma with or without chemotherapy or neoadjuvant radiochemotherapy Any T, any N, M or any adenoma Attempt to R0 resection Signed informed consent by the patient and by the researcher Quality of Life Questionnaire completed Exclusion Criteria: Study 1: Colorectal tumor with different histology to adenocarcinoma or adenoma History of colorectal cancer surgery different to the local excision Inflammatory bowel disease with pathologic confirmation Patients with psychiatric illness, addiction or disorder with inability to understand informed consent Inability to read or understand any of the languages of the informed consent and questionnaires (Catalan, spanish) Another synchronous malignancy Emergency Surgery Any patient that medical characteristics present an individual risk raised to be included and complete the study Study 2: Patients who won't undergo colorectal anastomosis Colorectal tumor with different histology to adenocarcinoma or adenoma History of colorectal cancer surgery different to the local excision Inflammatory bowel disease with pathologic confirmation Patients with psychiatric illness, addiction or disorder with inability to understand informed consent Inability to read or understand any of the languages of the informed consent and questionnaires (Catalan, spanish) Another synchronous malignancy Emergency Surgery

Laparoscopic left hemicolectomy for left colon cancer or laparoscopic low anterior resection for rectal cancer. In the group 1A the surgical technique initially dissects the inferior mesenteric vein (IMV)

Laparoscopic left hemicolectomy for left colon cancer or laparoscopic low anterior resection for rectal cancer. In the group 1B the surgical technique initially dissects the inferior mesenteric artery.

The patients who will undergo a colorectal anastomosis will be included in the study 2 and will be randomized to group 2A and group 2B: in group 2A the patients will have a latero-terminal colorectal anastomosis and in group 2B a termino-terminal colorectal anastomosis.

The patients who will undergo a colorectal anastomosis will be included in the study 2 and will be randomized to group 2A and group 2B: in group 2A the patients will have a latero-terminal colorectal anastomosis and in group 2B a termino-terminal colorectal anastomosis.

Study 2: to compare the anorectal functional outcome at 12 months after surgery or ileostomy closure between the two arms (2A and 2B). Assessed by the validated Colorectal Functional Outcome Questionnaire (COREFO)

Study 2: to compare the anorectal functional outcome at 12 months after surgery or ileostomy closure between the two arms (2A and 2B). Assessed by the validated scale LARS (Syndrome anterior resection of the rectum).

Study 1: to compare the incidence of surgical conversion to laparotomy between the two arms (1A and 1B).

Study 1 and 2: Postoperative complications within 90 days after surgery (Clavien-Dindo classification).

Study 2: to compare the quality of life : 6, 12, 18 and 24 months after intervention (or ileostomy closure) between the two arms (2A and 2B). Assessed by the validated the validated questionnaire of quality of life: SF-36.

Study 2: to compare the anorectal functional outcomes at : 6, 18 and 24 months after intervention (or ileostomy closure) between the two arms (2A and 2B). Assessed by the validated Colorectal Functional Outcome Questionnaire (COREFO).

Study 2: to compare the incidence of postoperative complications assessed by the Clavien-Dindo classification and the incidence of anastomotic leakage according to the classification of the International Group for Rectal Cancer Study.

to compare the anorectal functional outcomes at : 6, 18 and 24 months after intervention (or ileostomy closure) between the two arms (2A and 2B). Assessed by the validated scale LARS (Syndrome anterior resection of the rectum).

Inclusion Criteria: Study 1: Patients with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer. Age ≥ 18 years Histology proven adenocarcinoma or adenoma with or without chemotherapy or neoadjuvant radiochemotherapy Any T, any N, M or any adenoma Attempt to R0 resection Signed informed consent by the patient and by the researcher Quality of Life Questionnaire completed Study 2: Patients with colorectal cancer that will undergo laparoscopic left hemicolectomy or laparoscopic low anterior resection for rectal cancer with colorectal anastomosis. Age ≥ 18 years Histology proven adenocarcinoma or adenoma with or without chemotherapy or neoadjuvant radiochemotherapy Any T, any N, M or any adenoma Attempt to R0 resection Signed informed consent by the patient and by the researcher Quality of Life Questionnaire completed Exclusion Criteria: Study 1: Colorectal tumor with different histology to adenocarcinoma or adenoma History of colorectal cancer surgery different to the local excision Inflammatory bowel disease with pathologic confirmation Patients with psychiatric illness, addiction or disorder with inability to understand informed consent Inability to read or understand any of the languages of the informed consent and questionnaires (Catalan, spanish) Another synchronous malignancy Emergency Surgery Any patient that medical characteristics present an individual risk raised to be included and complete the study Study 2: Patients who won't undergo colorectal anastomosis Colorectal tumor with different histology to adenocarcinoma or adenoma History of colorectal cancer surgery different to the local excision Inflammatory bowel disease with pathologic confirmation Patients with psychiatric illness, addiction or disorder with inability to understand informed consent Inability to read or understand any of the languages of the informed consent and questionnaires (Catalan, spanish) Another synchronous malignancy Emergency Surgery

Colorectal Surgery Unit. Department of General and Digestive Surgery. University Hospital Dr. Josep Trueta of Girona

Planellas P, Farres R, Cornejo L, Rodriguez-Hermosa JI, Pigem A, Timoteo A, Ortega N, Codina-Cazador A. Randomized clinical trial comparing side to end vs end to end techniques for colorectal anastomosis. Int J Surg. 2020 Nov;83:220-229. doi: 10.1016/j.ijsu.2020.09.039. Epub 2020 Oct 7.