Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection

BACKGROUND

The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures.

METHODS

Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function.

RESULTS

Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups.

CONCLUSION

Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.

[Reducing the hospital stay after colorectal resection]

INTRODUCTION

The postoperative hospital stay after colorectal resection is about 15 days in France, when some authors have published a postoperative stay of 2 to 5 days. The aim of this work was to obtain a postoperative hospital stay less than 7 days.

PATIENTS AND METHODS

Sixty-one patients who underwent a colorectal resection performed by laparotomy were included in the study: 16 right hemicolectomies, 9 left hemicolectomies, 15 sigmoidectomies and 21 anterior resections were performed. The operation was performed through a midline incision extended over the umbilicus in 13 cases, limited below the umbilicus in 22 cases and elective in 26 cases (right transverse in 16 and left iliac fossa in 10 cases). The protocol comprised epidural analgesia or wound infusion with ropivacaine, restricted intravenous fluids, early oral feeding and active mobilisation.

RESULTS

The median and mean times of discharge were 6 and 7.3 days respectively; 36 patients (59%) were discharged on postoperative days 3 to 6, 8 patients (13%) on days 7 and 17 (28%) after day 7. A nasogastric tube was necessary in 2 cases (3.3%). Ten (16%) postoperative complications and 3 (5%) readmissions occurred. There were no deaths.

CONCLUSION

Although the postoperative stay cannot be reduced in all the cases, a median hospital stay inferior to which is currently observed can easily be obtained by applying some simple and inexpensive means. This is advantageous for the patient, whose recovery is faster, and contributes to reduce the cost, which is of crucial importance today.

[Laparoscopic colorectal resection for endometriosis: preliminary results]

OBJECTIVE

Colorectal endometriosis is source of chronic pelvic pain greatly affecting quality-of-life. Colorectal resection is indicated after failure of medical treatment. Few data are available on complications and functional results after laparoscopic colorectal resection for endometriosis. Therefore, the aims of this prospective study were to evaluate the feasibility, peri-operative complications and functional results of laparoscopic colorectal resection for endometriosis.

MATERIALS AND METHODS

From March 2001 to March 2003, 32 consecutive women with clinically-suspected colorectal endometriosis confirmed by MR imaging and rectal endoscopic sonography were included in this prospective study.

RESULTS

Conversion to open surgery was required for four of the 32 women (12.5%). Mean operating time was 6 hours (range 4 to 13). Associated surgical procedures were: adhesiolysis (n=24), ureteral lysis (n=19), ovarian cystectomy (n=11), and hysterectomy (n=4). Mean blood loss was 2.4 g/dl (range: 0 to 8.6). Blood transfusion was required in 6 women including two who underwent laparoconversion. Two rectovaginal fistulae (6.3%) occurred requiring a colostomy. Urinary retention was noted in 6 women (15.6%).

CONCLUSION

Laparoscopic colorectal resection for endometriosis is feasible and is associated with a significant improvement of symptoms. However, the benefit of this procedure has to be weighed against the high morbidity.

Risk factors for anastomotic failure after total mesorectal excision of rectal cancer

BACKGROUND

Anastomotic leakage is a major complication of rectal cancer surgery. The aim of this study was to investigate risk factors associated with symptomatic anastomotic leakage after total mesorectal excision (TME).

METHODS

Between 1996 and 1999, patients with operable rectal cancer were randomized to receive short-term radiotherapy followed by TME or to undergo TME alone. Eligible Dutch patients who underwent an anterior resection (924 patients) were studied retrospectively.

RESULTS

Symptomatic anastomotic leakage occurred in 107 patients (11.6 per cent). Pelvic drainage and the use of a defunctioning stoma were significantly associated with a lower anastomotic failure rate. A significant correlation between the absence of a stoma and anastomotic dehiscence was observed in both men and women, for both distal and proximal rectal tumours. In patients with anastomotic failure, the presence of pelvic drains and a covering stoma were both related to a lower requirement for surgical reintervention.

CONCLUSION

Placement of one or more pelvic drains after TME may limit the consequences of anastomotic failure. The clinical decision to construct a defunctioning stoma is supported by this study.

Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients

OBJECTIVE

The objective of this study was to investigate prophylactic pelvic drainage and other factors that might be associated with anastomotic leakage after elective anterior resection of primary rectal cancer.

SUMMARY BACKGROUND DATA

Anastomotic leak after anterior resection for primary rectal cancer leads to significant postoperative morbidity and mortality. The role of pelvic drainage in the prevention of anastomotic leakage is controversial.

METHODS

We investigated 978 consecutive patients undergoing elective anterior resection for primary rectal cancer between February 1995 and December 1998 in a single institution. Use of a drain and type of drainage were at the surgeon's preference. Data were prospectively collected during hospitalization. Twenty-five independent tumor-, patient-, and treatment-related variables were analyzed. The dependent variable was clinical anastomotic leakage. A binary logistic regression analysis was used to assess the independent association of variables with the dependent variable.

RESULTS

The clinical anastomotic leakage rate was 2.8%. Independent risk factors for anastomotic leakage were use of an irrigation-suction drain (odds ratio [OR], 9.13; 95% confidence interval [CI], 1.16-71.76), blood transfusion, poor colon preparation (OR, 2.58; 95% CI, 1.10-5.88), and anastomotic level 5 cm or less from the anal verge (OR, 2.38; 95% CI, 1.03-5.46).

CONCLUSIONS

Routine use of pelvic drainage is not justified and should be discouraged. In cases in which pelvic drainage is required such as in difficult operations or to prevent pelvic hematoma, pelvic drainage other than irrigation-suction should be considered.

Safety of donor right hepatectomy without abdominal drainage: a prospective evaluation in 100 consecutive liver donors

Although the role of routine abdominal drainage after liver resection for tumors has been questioned, abdominal drainage after donor right hepatectomy for live donor liver transplantation (LDLT) has been a routine practice in most transplant centers. The present study aimed to evaluate the safety of the procedure without abdominal drainage. A prospective study was performed on 100 consecutive liver donors who underwent right hepatectomy for LDLT from July 2000 to September 2003. Biliary anatomy was carefully studied with intraoperative cholangiography using fluoroscopy. The middle hepatic vein was included in the graft in all except 1 patient. Parenchymal transection was performed using an ultrasonic dissector. The right hepatic duct was transected at the hilum and the stump was closed with 6-O polydioxanone continuous suture. Absence of bile leakage was confirmed with methylene blue solution instilled through the cystic duct stump. The abdomen was closed after careful hemostasis without drainage in all donors. The median age of the donors was 36 years (range 18-56 years). Median operative blood loss and operating time were 350 mL (range 42-1,400 mL) and 7.5 hours (range 5.2-10.7 hours), respectively. None of the donors required any blood or blood product transfusion. There was no operative mortality. The median postoperative hospital stay was 8 days (range 5-30 days). Postoperative morbidity occurred in 19 patients (19%), most of which were minor complications. No donor experienced bile leakage, intraabdominal bleeding, or collection. None required surgical, radiologic, or endoscopic intervention for postoperative complications, except for 1 donor who developed late biliary stricture that required endoscopic dilatation. All donors were well with a median follow-up of 32 months (range 11-50 months). In conclusion, with detailed study of the biliary anatomy and meticulous surgical technique, donor right hepatectomy can be safely performed without abdominal drainage. Abdominal drainage is not a mandatory procedure after donor hepatectomy in LDLT.

[Leakages after surgery of the lower gastrointestinal tract]

The incidence of anastomotic leakage in colorectal surgery is 1% to 12%. Every deviation from the normal postoperative course must raise suspicion of a leak. Diagnosis is made radiologically by rectal enema or CT. Limited leakages without clinical signs can be treated conservatively by wait-and-see. Larger anastomotic failure with intra-abdominal abscesses or peritonitis requires reanastomosis in combination with a diverting loop ileostomy or colostomy. A Hartmann procedure with open abdominal management may be indicated in severely ill patients with feculent peritonitis. In the pelvis, even large leaks may heal spontaneously when stool passage is diminished by a proximal diverting enterostomy. There is no benefit of primary loop enterostomies concerning the incidence of anastomotic leaks; however, they reduce the number of operative revisions due to anastomotic failure. Therefore they are proposed in risk patients and intraoperatively difficult anastomoses.

Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis

OBJECTIVE

This study was undertaken to evaluate the feasibility and complications of laparoscopic segmental colorectal resection for endometriosis and its efficacy on gynecologic and digestive symptoms.

STUDY DESIGN

After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 40 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires were completed before and after the procedure. Perioperative complications and linear intensity scores for several gynecologic and digestive symptoms were recorded.

RESULTS

Thirty-six women (90%) underwent laparoscopic segmental colorectal resection and 4 required laparoconversion. Major complications occurred in 4 cases (10%), including 3 rectovaginal fistulae and 1 pelvic abscess. Transient urinary dysfunction occurred in 7 women (17.5%). Median follow-up after colorectal resection was 15 months (3-22 months). Median overall preoperative and postoperative pain scores were 8 +/- 1 (range 4-10) and 2 +/- 2 (0-10), respectively ( P < .0001). Nonmenstrual pelvic pain ( P = .0001), dysmenorrhea ( P < .0001), dyspareunia ( P = .0001), and pain on defecation ( P < .0005) were improved by colorectal resection. Lower back pain and asthenia were not improved.

CONCLUSION

Our results suggest that laparoscopic segmental colorectal resection for endometriosis is feasible but carries a risk of major postoperative complications. Colorectal resection improved gynecologic and digestive symptoms, and the overall pain score.

Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses

OBJECTIVE

To determine the evidence-based value of prophylactic drainage in gastrointestinal (GI) surgery.

METHODS

An electronic search of the Medline database from 1966 to 2004 was performed to identify articles comparing prophylactic drainage with no drainage in GI surgery. The studies were reviewed and classified according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. Seventeen randomized controlled trials (RCTs) were found for hepato-pancreatico-biliary surgery, none for upper GI tract, and 13 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random-effects model.

RESULTS

There is evidence of level 1a that drains do not reduce complications after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis. Drains were even harmful after hepatic resection in chronic liver disease and appendectomy. In the absence of RCTs, there is a consensus (evidence level 5) about the necessity of prophylactic drainage after esophageal resection and total gastrectomy due to the potential fatal outcome in case of anastomotic and gastric leakage.

CONCLUSION

Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A), whereas prophylactic drainage remains indicated after esophageal resection and total gastrectomy (recommendation grade D). For many other GI procedures, especially involving the upper GI tract, there is a further demand for well-designed RCTs to clarify the value of prophylactic drainage.

Prophylactic anastomotic drainage for colorectal surgery

BACKGROUND

There is little agreement on prophylactic use of drains in anastomoses in elective colorectal surgery despite many randomized clinical trials. Results of these trials are contradictory, quality and statistical power of these individual studies have been questioned. Once anastomotic leakage has occurred it is generally agreed that drains should be used for therapeutic purposes. However, on prophylactic use no such agreement exists.

OBJECTIVES

Comparison of safety and effectiveness of routine drainage and non-drainage regimes after colorectal surgery. The following hypothesis was tested: The use of prophylactic anastomotic drainage after elective colorectal surgery does not prevent development of complications.

SEARCH STRATEGY

The studies were identified from CINAHL, EMBASE, LILACS, MEDLINE, Controlled Clinical Trials Database, Trials Register of the Cochrane Colorectal Cancer Group, reference lists.

SELECTION CRITERIA

Randomized controlled trials comparing drainage with non-drainage regimes after anastomoses in elective colorectal surgery were reviewed. Outcome measures were: 1. mortality; 2. clinical anastomotic dehiscence; 3. radiological anastomotic dehiscence; 4. wound infection; 5. reoperation; 6. extra-abdominal complications.

DATA COLLECTION AND ANALYSIS

Data were independently extracted and cross-checked by the two reviewers. The methodological quality of each trial was assessed. Details of the randomization (generation and concealment), blinding, and the number of patients lost to follow-up were recorded. The RCTs were stratified based on experimental group, according to clinical homogeneity (external validity).

MAIN RESULTS

Of the 1140 patients enrolled (6 RCTs), 573 were allocated for drainage and 567 for no drainage. The patients assigned to the drainage group compared with the ones assigned to non-drainage group showed: a) Mortality: 3% (18 of 573 patients) compared with 4% (25 of 567 patients); b) Clinical anastomotic dehiscence: 2% (11 of 522 patients) compared with 1% (7 of 519 patients); c) Radiological anastomotic dehiscence: 3% (16 of 522 patients) compared with 4% (19 of 519 patients); d) Wound infection: 5% (29 of 573 patients) compared with 5% (28 of 567 patients); e) Reintervention: 6% (34 of 542 patients) compared with 5% (28 of 539 patients); f) Extra abdominal complications: 7% (34 of 522 patients) compared with 6% (32 of 519 patients).

REVIEWERS' CONCLUSIONS

There is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.

Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases

OBJECTIVE

The aim of this study was to determine whether abdominal drainage is beneficial after elective hepatic resection in patients with underlying chronic liver diseases.

SUMMARY BACKGROUND DATA

Traditionally, in patients with chronic liver diseases, an abdominal drainage catheter is routinely inserted after hepatic resection to drain ascitic fluid and to detect postoperative hemorrhage and bile leakage. However, the benefits of this surgical practice have not been evaluated prospectively.

PATIENTS AND METHODS

Between January 1999 and March 2002, 104 patients who had underlying chronic liver diseases were prospectively randomized to have either closed suction abdominal drainage (drainage group, n = 52) or no drainage (nondrainage group, n = 52) after elective hepatic resection. The operative outcomes of the 2 groups of patients were compared.

RESULTS

Fifty-seven (55%) patients had major hepatic resection with resection of 3 Coiunaud's segments or more. Sixty-nine (66%) patients had liver cirrhosis and 35 (34%) had chronic hepatitis. Demographic, surgical, and pathologic details were similar between both groups. The primary indication for hepatic resection was hepatocellular carcinoma (n = 100, 96%). There was no difference in hospital mortality between the 2 groups of patients (drainage group, 6% vs. nondrainage group, 2%; P = 0.618). However, there was a significantly higher overall operative morbidity in the drainage group (73% vs. 38%, P < 0.001). This was related to a significantly higher incidence of wound complications in the drainage group compared with the nondrainage group (62% vs. 21%, P < 0.001). In addition, a trend toward a higher incidence of septic complications in the drainage group was observed (33% vs. 17%, P = 0.07). The mean (+/- standard error of mean) postoperative hospital stay of the drainage group was 19.0 +/- 2.2 days, which was significantly longer than that of the nondrainage group (12.5 +/- 1.1 days, P = 0.005). With a median follow-up of 15 months, none of the 51 patients with hepatocellular carcinoma in the drainage group developed metastasis at the drain sites. On multivariate analysis, abdominal drainage, underlying liver cirrhosis, major hepatic resection, and intraoperative blood loss of >1.5L were independent and significant factors associated with postoperative morbidity.

CONCLUSION

Routine abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases.

A pelvic drain may be avoided after radical retropubic prostatectomy

PURPOSE

We reassessed the role of routine pelvic cavity drainage to prevent complications after radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

RRP was performed in 116 consecutive patients with clinically localized adenocarcinoma of the prostate. Clinical and pathological information was recorded for each patient. After the prostate was removed and the anastomotic sutures were tied the bladder was filled with saline through the urethral catheter. If there was no significant leakage, a drain was not placed.

RESULTS

We did not place a drain in 85 of the 116 patients (73%). There were 3 immediate postoperative complications. In a patient without a drain, a urinoma developed that required percutaneous placement of a drain on postoperative day 2. None of the 116 patients had clinical evidence of infection, lymphocele or hematoma. Two patients had hematuria 2 weeks after catheter removal and needed bladder irrigation. Neither patient had a drain. Three patients (drain and no drain in 1 each) were in urinary retention after catheter removal, which required catheter reinsertion for an additional week. None had an anastomotic stricture.

CONCLUSIONS

The morbidity of RRP is low when performed by those who regularly perform this procedure. If the bladder neck is preserved or meticulously reconstructed, there may be little or no extravasation and, thus, routine drainage may be unnecessary. In properly selected cases morbidity is not increased by omitting a drain from the pelvic cavity after RRP.

The uses and abuses of drains in abdominal surgery

Controversy surrounds the indications for and effectiveness of the abdominal drain. There are a variety of factors which mitigate against formulating rigid guidelines for the indications of drains, but surgeons should understand the benefits and applications of drainage and the tissue responses to the constituent materials. Drains are not a substitute for meticulous surgical technique.

A new surgical concept for rectal replacement after low anterior resection: the transverse coloplasty pouch

OBJECTIVE

To analyze the feasibility, safety, complication and death rates, and early functional results of the transverse coloplasty pouch procedure after low anterior rectal resection and total mesorectal excision.

SUMMARY BACKGROUND DATA

The authors previously developed a novel neorectal reservoir, the transverse coloplasty pouch, in an animal model; they report the first clinical data of a prospective phase 1 study.

METHODS

Forty-one patients underwent low anterior rectal resection with total mesorectal excision for rectal cancer (n = 37) or benign pathology (n = 4). The continuity was restored with a transverse coloplasty pouch anastomosis, and the colon was defunctionalized for 3 months. Patients were followed up at 2-month intervals for functional outcome.

RESULTS

Intraoperative complications occurred in three patients (7%), none related to the transverse coloplasty pouch. There were no hospital deaths and the total complication rate was 27% (11/41); an anastomotic leakage rate of 7% was recorded. The stool frequency was 3.4 per 24 hours at 2 months follow-up and gradually decreased to 2.1 per 24 hours at 8 months. Stool dysfunctions such as stool urgency, fragmentation, and incontinence grade 1 and 2 were regularly observed until 6 months; the incidence significantly decreased thereafter. None of the patients had difficulties in pouch evacuation.

CONCLUSIONS

The transverse coloplasty pouch is a small-volume reservoir that can safely be used for reconstruction after sphincter-preserving rectal resection. The early functional outcome is favorable and can be compared to other colonic reservoirs. The concept of reducing early dysfunction seen after straight coloanal anastomosis and avoiding long-term problems of pouch evacuation is supported by this study. Future trials will compare the transverse coloplasty pouch with other techniques of restorative resections of the rectum.

Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection

OBJECTIVE

To test the hypothesis that routine intraperitoneal drainage is not required after pancreatic resection.

SUMMARY BACKGROUND DATA

The use of surgically placed intraperitoneal drains has been considered routine after pancreatic resection. Recent studies have suggested that for other major upper abdominal resections, routine postoperative drainage is not required and may be associated with an increased complication rate.

METHODS

After informed consent, eligible patients with peripancreatic tumors were randomized during surgery either to have no drains placed or to have closed suction drainage placed in a standardized fashion after pancreatic resection. Clinical, pathologic, and surgical details were recorded.

RESULTS

One hundred seventy-nine patients were enrolled in the study, 90 women and 89 men. Mean age was 65.4 years (range 23-87). The pancreas was the tumor site in 142 (79%) patients, with the ampulla (n = 24), duodenum (n = 10), and distal common bile duct (n = 3) accounting for the remainder. A pancreaticoduodenectomy was performed in 139 patients and a distal pancreatectomy in 40 cases. Eighty-eight patients were randomized to have drains placed. Demographic, surgical, and pathologic details were similar between both groups. The overall 30-day death rate was 2% (n = 4). A postoperative complication occurred during the initial admission in 107 patients (59%). There was no significant difference in the number or type of complications between groups. In the drained group, 11 patients (12.5%) developed a pancreatic fistula. Patients with a drain were more likely to develop a significant intraabdominal abscess, collection, or fistula.

CONCLUSION

This randomized prospective clinical trial failed to show a reduction in the number of deaths or complications with the addition of surgical intraperitoneal closed suction drainage after pancreatic resection. The data suggest that the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis. Based on these results, closed suction drainage should not be considered mandatory or standard after pancreatic resection.

Anastomotic leak in colorectal surgery: a single surgeon's experience

BACKGROUND

Anastomotic leakage following colorectal resection and anastomosis has been proposed as a colorectal surgical indicator. Leak rates after elective surgery vary and tend to be higher as anastomoses become lower. The present study audits leak rates and outcomes of patients undergoing colorectal surgery, under the care of a single surgeon, in two geographically different centres.

METHODS

Patients presenting to the University Colorectal Service in Wellington between 1975 and 1990 and patients presenting to the colorectal service at King Faisal Specialist Hospital (KFSH) between 1990 and 1999 were recorded in computerized databases. These databases were searched for patients who developed anastomotic leakage. The records of patients identified were examined in relation to diagnoses, presentation, primary operation, further surgery performed, and final outcome.

RESULTS

Two thousand and 11 patients were entered into the Wellington database and 1,348 were entered into the Riyadh database. Twenty-nine patients with a leaking anastomosis (3.6%) were identified. There were 19 male patients. The postoperative mortality rate in patients who did not leak was 1.7% but in patients who developed a leak after the same operation this rate was 24.1%. Most patients who sustained a leak had an original diagnosis of colorectal cancer. More non-leaking anastomoses were sutured. Sixteen patients with leaks (55.2%) received perioperative total parenteral nutrition (TPN) (9.2% in the no-leak group). Leaking anastomoses were associated with more postoperative respiratory problems (55.2% vs 24.0%) and wound infections (65.5% vs 14.8%). Of the 22 living patients, seven had no surgical intervention, 14 had stomata (two stomata were retained) and one patient with a localized leak was drained percutaneously. Five other patients in addition to having a stoma constructed were drained percutaneously. No patient developed an enteric fistula following leakage.

CONCLUSION

Anastomotic leakage may be minimized by ensuring that patients are as fit as possible prior to surgery, stomata are used liberally, particularly in emergency patients, and a good anastomotic technique is utilized at all times. Despite these precautions some patients will still develop a leak and if timely and appropriate action is taken the majority will survive and have their stomata closed.

Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery

BACKGROUND

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.

METHODS

A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.

RESULTS

Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.

CONCLUSION

There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.

Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients

OBJECTIVE

To identify the risk factors for surgical site infection (SSI) in patients undergoing elective resection of the colon and rectum.

SUMMARY BACKGROUND DATA

SSI causes a substantial number of deaths and complications. Determining risk factors for SSI may provide information on reducing complications and improving outcome.

METHODS

The authors performed a prospective study of 2,809 consecutive patients undergoing elective colorectal resection via laparotomy between February 1995 and December 1998 at a single institution. The outcome of interest was SSI, which was classified as being incisional or organ/space with or without clinical leakage. A likelihood ratio forward regression model was used to assess the independent association of variables with SSIs.

RESULTS

The overall SSI, incisional SSI, and organ/space SSI with and without clinical anastomotic leakage rates were 4.7%, 3%, 2%, and 0.8%, respectively. Risk factors for overall SSI were American Society of Anesthesiology (ASA) score 2 or 3 (odd ratio [OR] = 1.7), male gender (OR = 1.5), surgeons (OR = 1.3-3.3), types of operation (OR = 0.3-2.1), creation of ostomy (OR = 2.1), contaminated wound (OR = 2.9), use of drainage (OR = 1.6), and intra- or postoperative blood transfusion (1-3 units, OR = 5.3; >/=4 units, OR = 6.2). However, SSIs at specific sites differed from each other with respect to the risk factors. Among a variety of risk factors, only blood transfusion was consistently associated with a risk of SSI at any specific site.

CONCLUSIONS

In addition to ASA score and surgical wound class, blood transfusion, creation of ostomy, types of operation, use of drainage, sex, and surgeons were important in predicting SSIs after elective colorectal resection.

Anastomotic leakage after colorectal anastomosis

Leakage is a problem largely confined to anastomoses within 6 cm of the anal verge when optimal surgical technique is exercised. At such low levels, most surgeons now use a combination of linear and circular staplers. The Moran Triple Stapling Technique is our chosen method. Most recently, the simultaneous use of two linear staplers to seal the specimen and wash the distal stump is a rapid technique for anastomosis onto the dentate line within the external sphincter. Proximal defunctioning and the short colon pouch with side-to-end colo-anal anastomosis are currently considered optimal. A trial is under way to assess a silastic transanal stent as an alternative. Ultra-low anastomosis, however, remains potentially hazardous and still should be undertaken only by specialists.

Surgical Management of Diverticulitis

Diverticular disease, and particularly diverticulitis, has an increasing incidence in Westernized countries because of low-fiber diet. Diverticular disease may be classified as asymptomatic, atypical, acute or uncomplicated, and complicated. Conservative or medical management is usually indicated for acute or uncomplicated diverticulitis, with elective surgical resection generally being recommended after two documented episodes. Complicated diverticulitis, because of the high rate of recurrent problems, is generally managed promptly with sigmoid resection. Sigmoid resection for diverticulitis, under appropriate circumstances, has one of the highest success rates of any of the common gastrointestinal procedures.