Many experts believe rectal washout to be a measure that reduces implantation of intraluminal shed tumor cells and thus results in decreased anastomotic recurrence. Do you think rectal washout is effective and how do you perform it, in particular:
- Timing, whether at beginning of surgery or just before resection.
- Whether performed after clamping distal to tumor or not.
- Washout agent used, betadine, chlorhexidine or water.
Normally a person to be evidence based in my practice, I am not persuaded by any evidence here. I have not performed a rectal washout in well over 10 years and have not had a patient to date with an anastamotic recurrence.
If you are a believer in washout then it makes sense to washout after clamping (or first stapling if you use a double transverse staple technique before division) distal to the tumour. I'm not sure it matters what you use, as long as you think it kills stray cancer cells.
I think washout is an essential procedure since, cancer stem cells can survive after therapeutic induction of apoptosis. See this paper which gives details with in vitro demo.
https://www.researchgate.net/publication/233742776_Blebbishields_the_Emergency_Program_for_Cancer_Stem_Cells_Sphere_Formation_and_Tumorigenesis_after_Apoptosis
A surgery may have similar outcome I suppose.
Article Blebbishields, the Emergency Program for Cancer Stem Cells: ...
Dear Dr Lund,
Thank you for your comment. I agree that the evidence hasn't been really convincing in this regard.
Only worthwhile study that showed 'some' association (which cannot be considered causal) has been the large retrospective review looking at more than 4000 patients from the Swedish Rectal Cancer Registry. The study could not account for many associated factors, e.g. patients with washout more commonly received neoadjuvant and more frequently had R0 resection compared to those who did not have washout, and did not differentiate between general surgeons or specialist colorectal surgeons.
regards, raza
Dear Dr Jinesh,
Thank you very much for insight into this fascinating aspect of tumor cell survival.
This can be a possible aspect of biology of aggressive tumors that implant at anastomotic site, or those that recur following apparent response..
regards, raza
I was going through the literature on this topic and found this recent meta-analysis that has concluded: "From the results of this meta-analysis, it may be justified to recommend intraoperative rectal washout to prevent local recurrence in rectal cancer surgery."
However, 88.8% of the weight of this meta-analysis is provided by the swedish review i have mentioned above. all the other studies have wide confidence intervals on both sides of the 'line of no effect'. Assuming the concerns about the swedish study, i am not sure how we should interpret the results of this meta-analysis.
regards, raza
Article The Effect of Intraoperative Rectal Washout on Local Recurre...
I am the primary author of the article which Dr. Sayyed mentioned above. Exactly, as you wrote, this study has some limitations such as no RCTs, the deviation of study weight. But even after excluding the large Swedish study from the meta-analysis, it is still significant. Furthermore, in the analysis of anastomotic recurrence, implantation of cancer cell is thought to be a major cause, the beneficial effect is clear (without the Swedish study). Considering the cost, time required and beneficial effects, I can not find any reason to discontinue this procedure.
Dear Dr Matsuda,
Thank you very much for this explanation. I understand the inherent problem with meta-analysis that they rely on quality of data which the original studies provide. keeping this in mind, I agree with your valuable comment that results of this meta-analysis are enough for a surgeon who performs rectal washout routinely to continue with this practice.
However, when considering the surgeons who do not routinely perform rectal washout, there is still an element of equipoise regarding its usefulness. Perhaps it will be very difficult to convince this group of surgeons unless results from a high quality randomized controlled trial are available.
regards, raza
Shed cancer cells can implant on a raw surface for about 15 min. For this reason I irrigate the rectum with water (clamped below tumor) before anastomosis to lyse shed cells.
We wash out for the simple reason to remove faeces from the rectum to ease the passage of the staple gun.......although I secretly believe it may affect luminal recurrence although it assumes you perform the Moran Triple Stapling Technique of a second transverse stapler below the first, if not any tumour cells or distal limit of the tumour are potentially already in the anastomosis!
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