Risk factors and predictive factors for anastomotic leakage after resection for colorectal cancer: reappraisal of the literature

A retrospective study examining the association between polypharmacy and complications after laparoscopic surgery for colorectal cancer

BACKGROUND

Polypharmacy is an escalating public health concern across various healthcare settings worldwide. We aimed to comprehensively investigate postoperative complications after laparoscopic surgery for colorectal cancer and explore their association with polypharmacy. As laparoscopic surgery is widespread, clarifying the association between polypharmacy and postoperative complications is clinically important.

METHODS

We retrospectively surveyed the medical charts of adult inpatients who underwent laparoscopic surgery for colorectal cancer at Tohoku Medical and Pharmaceutical University Hospital between April 2019 and March 2023. Postoperative complications were determined using the Clavien-Dindo classification. We explored the factors related to postoperative complications and calculated the cut-off values for the number of medication ingredients.

RESULTS

Among the 236 patients, 32 (13.6%) developed postoperative complications. On multivariable logistic regression analysis, the number of regularly used medication ingredients (odds ratio = 1.160, 95% confidence interval 1.050-1.270, p = 0.002) was identified as a factor related to postoperative complications. The identified cut-off value for complications was 10 ingredients. Patients using 10 or more ingredients had approximately 3.5 times higher occurrence of postoperative complications than those using fewer than 10 ingredients (33.3% vs. 9.3%, p < 0.001, Fisher's exact test).

CONCLUSIONS

Our study comprehensively investigated postoperative complications and examined their association with polypharmacy. We found that the number of regularly used medication ingredients may be linked to complications following laparoscopic surgery for colorectal cancer. These findings have important implications for perioperative management and patient care, providing valuable insights that may influence clinical practices and enhance patient outcomes.

Visualization of Surgical Needle Tips Hidden Inside Organs Using Generative Adversarial Networks

Postoperative complications in surgery are particularly prevalent in laparoscopic procedures, which are difficult for physicians to perform. One complication that is related to the surgical procedure itself is anastomotic leakage, in which the sutures do not fully attach and the contents leak out. A factor that contributes to anastomotic leakage is uneven needle suture spacing. Once the needle is inserted, the physician relies on intuition and experience to carry it through to the needle exit, which makes it difficult to maintain uniform suture spacing. For this reason, to reduce the risk of anastomotic leakage, it is effective to visualize the position of the needle tip in the organ. Therefore, in this study, we constructed a model to visualize the tip of a suture needle hidden inside an organ to improve surgical accuracy. Using the model, we tested the inference of images and achieved a real¬time speed of 33.4 fps, and the average estimated misalignment of the needle tip was 1.03 mm, which is less than 1.8 mm (10% of the total needle length). Thus, we showed that the proposed model effectively estimated needle tips hidden in organs. Therefore, we expect that this model will lead to improved surgical accuracy.

A preoperative prediction model based on Lymphocyte-C-reactive protein ratio predicts postoperative anastomotic leakage in patients with colorectal carcinoma: a retrospective study

Background & Aims

Lymphocyte-C-reactive Protein Ratio (LCR) has been demonstrated as a promising new marker for predicting surgical and oncological outcomes in colorectal carcinoma (CRC). However, anastomotic leakage (AL) is also likely related to this inflammatory marker. Herein, we aimed to identify preoperative predictors of AL and build and develop a novel model able to identify patients at risk of developing AL.

Methods

We collected 858 patients with CRC undergoing elective radical operation between 2007 and 2018 at a single center were retrospectively reviewed. We performed univariable and multivariable analyses and built a multivariable model that predicts AL based on preoperative factors. Propensity adjustment was used to correct the bias introduced by non-random matching of the LCR. The model's performance was evaluated by using the area under the receiver operator characteristic curves (AUROCs), decision curve analysis (DCA), Brier scores, D statistics, and R2 values.

Results

Age, nutrition risk screening 2002 (NRS2002) score, tumor location and LCR, together with hemoglobin < 90 g/l, were independent predictors of AL. The models built on these variables showed good performance (internal validation: c-statistic = 0.851 (95%CI 0.803–0.965), Brier score = 0.049; temporal validation: c-statistic = 0.777 (95%CI 0.823–0.979), Brier score = 0.096). A regression equation to predict the AL was also established by multiple linear regression analysis: [Age(≥ 60 year) × 1.281] + [NRS2002(≥ 3) × 1.341] + [Tumor location(pt.) × 1.348]-[LCR(≤ 6000) × 1.593]-[Hemoglobin(< 90 g/L) × 1.589]-6.12.

Conclusion

Preoperative LCR is an independent predictive factor for AL. A novel model combining LCR values, age, tumor location, and NRS2002 provided an excellent preoperative prediction of AL in patients with CRC. The nomogram can help clinical decision-making and support future research.

In-hospital economic burden of anastomotic leakage after colorectal anastomosis surgery: a real-world cost analysis in Italy

BACKGROUND

Anastomotic leakage (AL) is a severe complication of colorectal surgery. We aimed to quantify inpatient costs and key cost contributors associated with AL in a single Italian center.

RESEARCH DESIGN AND METHODS

Electronic records for adults who had undergone colorectal surgery with anastomosis (January 2015 - December 2016), were retrospectively reviewed. Patients with AL were identified using clinical signs and/or imaging findings and/or intraoperative findings. Available data included patient, clinical, and procedural characteristics, healthcare resource utilization, and inpatient costs. Multivariate models were used to adjust for potential confounders.

RESULTS

AL occurred in 12.3% of patients (N = 317). Mean adjusted inpatient cost was 108% higher (p < 0.001) for patients with AL versus no AL (€14,711; 95% CI: 12,113; 17,866 versus €7,089; 95% CI: 6,623; 7,587). Key cost contributors were ward stay, disposables, operating room, and hospital consultations. Mean losses (reimbursement minus costs) were €2,041/patient with AL. AL extended mean length of stay by 9 days and increased odds of reoperation and ICU stay (all p < 0.001).

CONCLUSIONS

Patients with AL place considerable economic and resource burden on healthcare systems and hospital reimbursement rates do not cover treatment costs. This study highlights an unmet need for novel techniques to reduce the burden of AL.

Perioperative intrapelvic hyaluronate application as prophylaxis against complications following rectal anastomotic dehiscence: An experimental study

PURPOSE

The aim of this experimental study was to test the method of prevention of postoperative complications, especially infectious, in partial dehiscence following stapler anastomosis in rectal surgeries.

METHODS

The method includes the application of a hyaluronic acid-based gel in combination with triclosan, which has antibacterial properties. The gel was applied to the space around the rectum with an artificial, precisely defined dehiscence so that the dehiscence was separated from the rest of pelvis and the peritoneal cavity to avoid the spread of infection. The study included 30 female pigs. The rectosigmoid colon was mobilized and transected completely. Anastomosis was constructed with circular staplers. A perforator was then used to create precisely defined artificial dehiscence. Subsequently the lesser pelvis was filled with hyaluronic gel such that the site of artificial dehiscence was covered completely.

RESULTS

All animals survived for 14 days until the second-look revision with no signs of failure in the anastomosis healing, local inflammation, and sepsis or postoperative complications, such as chills, refusal of liquid or feed, abdominal distension, and bowel obstruction.

CONCLUSION

Hyaluronic acid applied as a precursor solution around the rectal anastomosis fills the lesser pelvis perfectly. It prevents the leakage of intestinal contents in the lesser pelvis. Triclosan as an antibacterial substance prevents the spread of inflammation in the pelvis or even in the abdominal cavity.

Short-Term Outcome of Laparoscopic Surgery in Elderly Colorectal Cancer Patients

We aimed to evaluate the short-term outcome of colorectal resection in very elderly patients, aged 85 years or older. As the population ages, the number of elderly patients with colorectal cancer (CRC) is increasing in Japan. At this time, it is unclear whether or not laparoscopic colorectal resection is safe for this very elderly patient population. From January 2005 to November 2014, a total of 20 patients aged 85 years or older underwent laparoscopic colorectal resection at Osaka University Hospital. Pre- and postoperative clinical data and outcomes were collected retrospectively. There were no intraoperative or postoperative deaths. In 2 cases, the laparoscopic procedure was converted to open surgery. Postoperative complications occurred in 6 patients. Two patients developed an infection at the surgical site. Among the 4 patients who underwent low anterior resection (LAR), 2 experienced postoperative anastomotic leakage. Two other patients developed a lung infection and urinary tract infection, respectively. Laparoscopic colectomy for very elderly patients with CRC appears to involve tolerable risk. However, special caution is advisable for patients who may undergo LAR.

Colorectal anastomosis during cytoreductive radical surgery in patients with peritoneal surface malignancies. Validation of a new technique (without stoma) to prevent anastomosis leakage in more than 1000 procedures

OBJECTIVE

To describe a novel end-to-end "true" reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer.

METHODS

Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were: (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) "cleaning" the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed.

RESULTS

According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis. Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%.

CONCLUSIONS

A technical modification to create a "true" end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.

How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review

Anastomosis leakage (AL) after colorectal surgery is an embarrassing problem. It is associated with poor consequence. This review aims to summarize published evidence on prevention of AL after colorectal surgery and provide recommendations according to the Oxford Centre for Evidence-Based Medicine. We conducted bibliographic research on January 15, 2020, of PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. We retained meta-analysis, reviews, and randomized clinical trials. We concluded that mechanical bowel preparation did not reduce AL. It seems that oral antibiotic or oral antibiotic with mechanical bowel preparation could reduce the risk of AL. The surgical approach did not affect the AL rate. The low ligation of the inferior mesenteric artery could reduce the AL rate. The mechanical anastomosis is superior to handsewn anastomosis only in case of right colectomies, with similar results in rectal surgery between the 2 anastomosis techniques. In the case of right colectomies, this anastomosis could be performed intracorporeally or extracorporeally with similar outcomes. The air leak test did not reduce AL. There is no interest of external drainage in colonic surgery but drains reduced the rate of AL and rate of reoperation after low anterior resection. The transanal tube reduced the rate of AL.

Is abdominal vascular calcification score valuable in predicting the occurrence of colorectal anastomotic leakage? A meta-analysis

OBJECTIVE

Anastomotic leakage (AL) is a catastrophic surgical complication affecting the prognosis of patients after colorectal surgery. We aimed to determine the value of the arterial calcification (AC) score in predicting AL.

METHODS

Medline and Embase were searched through November 2019. The odds ratio (OR) and 95% confidence interval (CI) were used to estimate the association between AC and AL after colorectal surgery. The fixed-effects model or random-effects model was adopted for data pooling. Subgroup analyses were conducted to assess the effect of different aortoiliac trajectories.

RESULTS

Four studies involving 496 patients were included. The calcium volume and calcium score measurements of different trajectories revealed a significant difference with regard to the left and right common iliac arteries, the superior mesenteric artery, and the left common iliac artery. Calcification of the internal iliac artery significantly increased the risk of AL compared with no AL (OR = 1.005; 95% CI 1.002-1.009; P = 0.005), as did calcification of the left internal iliac artery (OR = 1.009; 95% CI 1.002-1.016; P = 0.011), but not of the common iliac artery (OR = 1.001; 95% CI 1.000-1.001; P = 0.317) or common and internal iliac artery (OR = 1.000; 95% CI 1.000-1.000; P = 1.000).

CONCLUSIONS

AC is associated with increased risk of AL following colorectal surgery.

TRIAL REGISTRATION

CRD42019141236.

The problem of colorectal anastomosis safety

INTRODUCTION

Anastomotic leakage (AL) remains one of the most threatening complications in colorectal surgery with the incidence of up to 20%. The aim of the study is to evaluate the safety and feasibility of novel - trimodal intraoperative colorectal anastomosis testing technique.

METHODS AND ANALYSIS

This multi-center prospective cohort pilot study will include patients undergoing colorectal anastomosis formation below 15 cm from the anal verge. Trimodal anastomosis testing will include testing for blood supply by ICG fluorescence trans-abdominally and trans-anally, testing of mechanical integrity of anastomosis by air-leak and methylene blue leak tests and testing for tension. The primary outcome of the study will be AL rate at day 60. The secondary outcomes will include: the frequency of changed location of bowel resection; ileostomy rate; the rate of intraoperative AL; time, taken to perform trimodal anastomosis testing; postoperative morbidity and mortality; quality of life.

DISCUSSION

Trimodal testing of colorectal anastomosis may be a novel and comprehensive way to investigate colorectal anastomosis and to reveal insufficient blood supply and integrity defects intraoperatively. Thus, prevention of these two most common causes of AL may lead to decreased rate of leakage.

STUDY REGISTRATION

Clinicaltrials.gov (https://clinicaltrials.gov/): NCT03958500, May, 2019.

Effect of Alprostadil on Colorectal Anastomoses Under Relative Ischemia

BACKGROUND

Anastomotic leak after colorectal surgery, which remains a serious clinical problem that causes augmented morbidity and mortality, is usually favored by ischemia. The aim of this study was to determine whether alprostadil may improve anastomotic wound healing under ischemic condition.

METHODS

Ninety-three adult Wistar rats were randomized into three groups: control, ischemia (by devascularization along the first 2 cm at each anastomotic end), and ischemia plus alprostadil. Resection of a colonic segment at the colorectal junction and an anastomosis was performed. Animals were euthanized at 8 d. Surgical site infection, anastomotic leak, and grade of intra-abdominal adhesions using a validated scale were determined. Bursting pressure and tension were calculated and histologic examination of the anastomosis was performed.

RESULTS

The ischemic group revealed an increased anastomotic leak rate (14/31 versus 3/31) and a lower bursting pressure and tension when compared to control group, validating therefore the experimental model. After intraperitoneal injection of alprostadil, anastomotic leak rate was significantly lower (5/31) and the bursting pressure and tension were significantly increased. Histologic examination revealed a lower presence of inflammatory cells, and a significantly higher neovascularization and a higher presence of fibroblasts in treated animals when compared with the ischemic group.

CONCLUSIONS

Alprostadil may have a positive effect on colonic anastomotic wound healing under relative ischemic condition. Alprostadil administration increases anastomotic bursting pressure, decreases leak rate, and reverses most of the histological changes caused by blood flow decrease. These protective effects could be caused by vasodilation, stimulation of neovascularization, and immunomodulatory properties.

Laser Speckle Contrast Imaging for Intraoperative Quantitative Assessment of Intestinal Blood Perfusion During Colorectal Surgery: A Prospective Pilot Study

BACKGROUND

The main limitation of perfusion assessment with indocyanine green fluorescence angiography during colorectal surgery is that the surgeon assesses the quality of perfusion subjectively. The ideal intestinal viability test must be minimally invasive, objective, and reproducible. We evaluated the quantitativity and reproducibility of laser speckle contrast imaging for perfusion assessment during colorectal surgery.

METHODS

This was a prospective, nonrandomized, pilot study of 8 consecutive patients who underwent elective left-sided colorectal resection. Laser speckle perfusion images at the site of proximal transection of the bowel were obtained intraoperatively. We tested the hypothesis that laser speckle contrast imaging was able to quantitatively identify areas of diminished intestinal perfusion after devascularization and assessed the reproducibility of this method.

RESULTS

All surgical procedures were uneventful and blood flow measurements were successfully made in all patients. None of the patients developed postoperative complications related to the anastomosis and stoma. Data analyses were successfully optimized to perform quantitative regional perfusion assessments in all cases. The bowel tissue blood flows of the anal side region adjacent to the transection line were significantly lower than those of the oral side region adjacent to the transection line after ligation of marginal vessels ( P = .012). Interrater reliability was high (intraclass correlation coefficients = 0.989), and a Bland-Altman plot showed few differences of mean flux data between 2 investigators.

CONCLUSION

Laser speckle contrast imaging is feasible for real-time assessment of bowel perfusion with quantitativity and excellent reproducibility during colorectal surgery without administration of any contrast agents.

Progress in prevention and treatment of anastomotic leakage after surgery for rectal cancer

Colorectal cancer (CRC) is one of the most common malignant tumors in the world, and its morbidity and mortality both rank third among all malignant tumors in China. Rectal cancer accounts for 60%-70% of cases of CRC. With the in-depth study of the pathogenesis of CRC and the mechanism of tumor metastasis, and the improvement of surgical techniques and methods, anal sphincter surgery for middle and low rectal cancer is increasing gradually. Although the quality of life of the patients improves significantly after anal sphincter preservation for rectal cancer, anastomotic leakage is still one of the most common and serious complications. Studies show that the incidence of anastomotic leakage after surgery for low rectal cancer is 3%-21%, and the death rate is up to 3%. Therefore, a comprehensive assessment of patients and analysis of risk factors before operation is of great significant for reducing the potential risk of anastomotic leakage and choosing surgical approach and appropriate preventive measures to prevent and reduce the occurrence of anastomotic leakage. In this paper, we summarize the recent research on anastomotic leakage after rectal cancer surgery in order to help other clinicians reduce the incidence of anastomotic leakage in clinical practice.

Effects of Ghrelin on the Oxidative Stress and Healing of the Colonic Anastomosis in Rats

BACKGROUND

Anastomotic leakage is the deadliest complication of colonic procedures. Ghrelin is an orexigenic hormone with potent actions on growth hormone release and functions in the processes of growth, tissue inflammation, repair, and oxidative stress. We evaluated the hypothesis that the exogenous administration of ghrelin causes beneficial effects on the healing of colonic anastomosis.

MATERIALS AND METHODS

Sixty-four male Wistar rats were randomly assigned to eight subgroups receiving postoperative intraperitoneal administration of ghrelin (23 μg/kg/d) or saline after a colonic anastomosis. The anastomotic tissue was evaluated on the third, seventh, and 14th postoperative days. Anastomotic bursting pressure, histological parameters, hydroxyproline content, and tissue oxidative stress markers were compared.

RESULTS

There was a significant increase in the mean anastomotic bursting pressure in the ghrelin subgroup on the seventh postoperative day (P = 0.035). Histological evaluation demonstrated a significant difference in the neutrophilic infiltrate (P = 0.035) on the third and 14th d and in apoptosis (P = 0.004), granulation tissue (P = 0.011) and peritoneal inflammation (P = 0.014) on the 14th postoperative day. There was a statistically significant increase in the hydroxyproline content in the ghrelin subgroup on the 14th postoperative day (P = 0.043). There were significant differences in the nitrite tissue levels (P = 0.021) on day 3 and in reactive oxygen species (P = 0.012) on day 14.

CONCLUSIONS

The administration of ghrelin had beneficial anti-inflammatory and antioxidant effects, increasing the resistance of the anastomosis and the hydroxyproline tissue content in the postoperative period.

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

PURPOSE

"Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.

METHODS

We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed.

RESULTS

Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days.

CONCLUSIONS

Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Safety and Feasibility of Umbilical Diverting Loop Ileostomy for Patients with Rectal Tumor

BACKGROUND

Fashioning an ileostomy in the umbilicus and combining the trauma from extraction of colorectum with that from ileostomy should be less invasive and lead to improved cosmetic outcomes. However, there are only a few reports regarding umbilical ileostomy.

METHODS

We retrospectively collected data for 121 consecutive patients with rectal tumor who underwent elective laparoscopic rectal resection with diverting loop ileostomy between 2010 and 2015 at Osaka University Hospital, Japan. The safety and feasibility of umbilical diverting loop ileostomy and its influence on stoma care were investigated.

RESULTS

A total of 83 patients were included in this study; of these, 30 underwent umbilical diverting loop ileostomy and 53 underwent conventional diverting loop ileostomy, which was created in the right lower quadrant of the abdomen. The umbilical and conventional groups showed similar rates of postoperative and stoma-related complications (26.7 vs. 32.1%, p = 0.804 and 3.3 vs. 3.8%, p = 1.000, respectively). Level of parastomal dermatitis was evaluated by DET score at three time points (stoma self-management establishment, first outpatient review post-discharge, and just before stoma closure). DET scores at any time points did not differ significantly between the two groups.

CONCLUSIONS

Umbilical diverting loop ileostomy is comparable to conventional ileostomy with regard to safety and feasibility. Our methods for umbilical ileostomy using the umbilical skin flap were less invasive and did not have a negative impact on stoma care and parastomal dermatitis. Umbilical ileostomy may be a promising alternative to conventional ileostomy in selected cases.

Autologous adipose-derived stem cell sheets enhance the strength of intestinal anastomosis

Objective

Adipose-derived stem cells (ASCs) are capable of multiple differentiation pathways, imparting immunomodulatory effects, and secreting factors that are important for wound healing. These characteristics can be exploited to decrease the incidence of anastomotic leakage.

Methods

In order to delay local wound healing at the anastomotic site, we induced ischemia in a portion of porcine small intestine by ligating vessels. Then, we injected mitomycin C into the serosa of the small intestine above the ligated vessels. Anastomotic sites were created by 2 cm incisions made in the opposite mesenteric area. ASCs were isolated from the porcine subcutaneous fat tissues and expanded under culture conditions. ASCs were trypsinized and seeded on temperature-responsive dishes and cultured to form confluent sheets. Three ASC sheets were transplanted onto the serous membrane after suturing. The extent of anastomotic wound healing was evaluated by bursting pressure, hydroxyproline content, and mRNA expression of collagen-1 alpha1 and collagen-3 alpha1.

Results

We found that transplantation of ASC sheets increased anastomotic site bursting pressure. Additionally, transplantation of ASC sheets increased the hydroxyproline content of the anastomoses. Furthermore, transplantation of ASC sheets increased mRNA expression of collagen-1 alpha1 and collagen-3 alpha1.

Conclusions

Our findings showed that transplantation of autologous ASC sheets enhanced collagen synthesis and anastomotic strength. Further studies are necessary to identify substances that, in combination with ASC sheets, might enhance collagen synthesis and healing in sites of anastomosis.

•

Transplantation of adipose-derived stem cell (ASC) sheets after intestinal anastomosis stimulated collagen synthesis and improved anastomotic strength.

•

Paracrine effects of the growth factors released by the ASC sheets might contribute to healing at the anastomotic site and stimulate the fibroblast and the collagen synthesis.

•

This new approach might be a feasible and promising strategy to prevent anastomotic leakage.

Risk factors of small bowel obstruction following total proctocolectomy and ileal pouch anal anastomosis with diverting loop-ileostomy for ulcerative colitis

Small bowel obstruction (SBO) often occurs after total proctocolectomy and ileal pouch anal anastomosis with diverting loop‐ileostomy for ulcerative colitis. Little is known about the association between SBO and surgical procedures for diverting loop‐ileostomy. We conducted a multicenter, retrospective questionnaire survey. Unlinkable anonymized data on ileostomy procedures and ileostomy‐related complications including SBO were collected from institutions specializing in surgery for inflammatory bowel disease. In total, 515 patients undergoing total proctocolectomy and ileal pouch anal anastomosis with loop‐ileostomy among 1022 patients with ulcerative colitis undergoing surgery during a 3‐year period between 2012 and 2014 were analyzed. Twenty‐nine patients without information on complications were excluded. Incidence of ileostomy‐related complications and factors associated with the development of small bowel obstruction were determined in 486 patients. The most common complications were parastomal dermatitis (n=169, 34.8%), SBO (n=111, 22.8%), mucocutaneous dehiscence (n=59, 12.1%), stoma prolapse (n=21, 4.3%), parastomal hernia (n=12, 2.5%), and stoma retraction (n=11, 2.3%). Incidence of small bowel obstruction was significantly higher in patients with distance from the ileal pouch to the ileostomy of less than 30 cm and in patients undergoing laparoscopic surgery. Procedures for diverting loop‐ileostomy after surgery for ulcerative colitis varied among institutions. Incidence of small bowel obstruction was high after total proctocolectomy and ileal pouch anal anastomosis with diverting loop‐ileostomy. Shorter distance between the pouch and the stoma and the laparoscopic surgery were risk factors for SBO in univariate analysis.

Neoadjuvant CapeOx therapy followed by sphincter-preserving surgery for lower rectal cancer

PURPOSE

This retrospective study investigates the safety of neoadjuvant chemotherapy with oxaliplatin capecitabine (CapeOx), followed by laparoscopic surgery, for lower rectal cancer, and its efficacy in preserving the sphincter.

METHODS

Ten patients with diagnosed lower rectal cancer received three or four cycles of neoadjuvant CapeOx chemotherapy, prior to undergoing low anterior resection or intersphincteric resection, with total mesorectal excision. The primary outcomes were R0 resection and the rate of sphincter preservation.

RESULTS

Nine patients completed CapeOx as scheduled and a partial response was achieved in four; thus, the overall response rate was 40% (n = 4/10). After surgical intervention, 80% of tumors displayed downstaging. Postoperative anastomosis leakage developed in one patient. The distance from the anal verge to the tumor increased by 60% (median 1.5 cm) after CapeOx treatment. The anal sphincter was preserved in all patients and all pathological distal and radial margins were negative (R0 resections). A pathological complete response was achieved in one patient.

CONCLUSIONS

Neoadjuvant CapeOx chemotherapy is a promising approach, because it extended the distance from the anus to the tumor. Subsequent laparoscopic intervention for advanced lower rectal cancer could allow for safe preservation of the sphincter.

Safety and efficacy of an "enhanced recovery after surgery" protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study

PURPOSE

The aim of this multi-institutional study was to prospectively evaluate the safety and efficacy of an enhanced recovery after surgery (ERAS) protocol for colonic surgery.

METHODS

The subjects of this study were 320 patients with an American Society of Anesthesiologists (ASA) grade I or II physical status. Patients underwent elective open or laparoscopic colonic resection or high anterior resection between April 2011 and January 2014 at one of six institutions. Three hospitals implemented an ERAS protocol (n = 159), and three administered conventional care (n = 161). The primary outcome measure was the surgical complication rate.

RESULTS

Most operations, irrespective of group, were performed laparoscopically. The incidence of a surgical complication was 17.0 % in the ERAS group vs. 16.1 % in the conventional group (P = 0.842), in which several non-surgical complications also arose. Oral food intake was implemented earlier for the ERAS group vs. the conventional group, after a median (range) of 1 (1-31) vs. 3 (1-9) days for the ERAS vs. conventional care groups, respectively (P < 0.001). The median length of postoperative hospital stay was reduced by 5.5 days for the ERAS group, being 8.5 (5-41) vs. 14 (7-56) days for the ERAS vs. conventional care groups, respectively (P < 0.001).

CONCLUSION

This multi-institutional controlled study clearly demonstrated that an ERAS protocol was efficient, without increasing the complication risk.

Prevention of Perioperative Anastomotic Healing Complications: Anastomotic Stricture and Anastomotic Leak

The anastomotic healing complications of postoperative leak and stricture continue to plague surgeons despite many broadly targeted interventions. Evaluation of preventive measure efficacy is difficult due to inconsistent definitions and reporting of these complications. Few interventions have been shown to impact rates of leakage or stricture. However, new evidence is emerging that the intestinal microbiota can play an important role in the development of anastomotic complications. A more holistic approach to understanding the mechanisms of anastomotic complications is needed in order to develop tailored interventions to reduce their frequency. Such an approach may require a more complete definition of the role of the microbiota in anastomotic healing.

Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4-34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC.

METHOD

From April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis.

RESULTS

We report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016).

CONCLUSION

CRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.

Right Versus Left-Sided Colectomies: A Comparison of Outcomes

Surgeons often consider that a right colectomy (RC) carries less risk than a left or sigmoid colectomy (L/SC). Our aim was to compare outcomes between RC and L/SC. Review of the Carolinas Medical Center National Surgical Quality Improvement Program data from 2013 to February 2015 was performed. Procedures were categorized as RC versus L/SC based on current procedural terminology codes for both open and laparoscopic colectomies. Demographics and minor and major complications were evaluated using standard statistical methods. A total of 164 RC and 211 L/SC were studied. RC patients were older (63.9 ± 14.2 vs 59.4 ± 13.0, P < 0.001). Patients undergoing RC had more comorbidities, and 64.6 per cent had an American Society of Anesthesiologist (ASA) Class III or above versus 51.7 per cent of those undergoing L/SC ( P = 0.02). RC had significantly higher rates of postop urinary tract infection (7.3% vs 2.8%, P = 0.04) and postop transfusions ( P = 0.01). Average length of stay was longer for RC (10.1 ± 8.6 days vs 8.3 ± 7.0 days, P < 0.01). After controlling for ASA class, preoperative hematocrit and surgical technique (lap versus open), multivariate analysis indicated that there were no longer any significant differences in outcomes between RC and L/SC. There were no differences between the group complications including superficial or deep surgical site infections, anastomotic leak, myocardial infarction (MI), pneumonia, or 30-day mortality. RC patients tended to be sicker and had more medical complications postop with initial evaluation of the data. However, when controlling for ASA, hematocrit, and techniques, there were no differences in complications when RC was compared to L/SC. The belief that L/SC has a higher rate of complications compared to RC is not supported.

A clinical trial of autologous adipose-derived regenerative cell transplantation for a postoperative enterocutaneous fistula

PURPOSE

Adipose-derived stem cell (ADSC) transplantation is expected to be a minimally invasive, but effective, treatment for postoperative enterocutaneous fistulas associated with poor blood flow and chronic inflammation. The aim of this study was to assess the safety and efficacy of a novel ADSC therapy for this condition.

METHODS

We conducted an open-label, single-arm exploratory phase I study to assess the safety and efficacy of a novel ADSC therapy. Using the Celution system, we isolated adipose-derived regenerative cells (ADRCs) containing abundant ADSCs from liposuction-obtained gluteal adipose tissue. A mixture of ADRCs and fibrin glue was subsequently transplanted into the fistula, and ADRCs were percutaneously and endoscopically injected around the fistula. We evaluated the safety and feasibility of ADRC transplantation and fistula closure in six patients (UMIN000007316).

RESULTS

ADRC transplantation was completed in all patients. The fistula closure rates were 83.3 % at 4 and 12 weeks and 100 % at 24 weeks. All patients had grade 1 pain and subcutaneous hemorrhage at the liposuction sites, but no serious adverse events related to this procedure were observed.

CONCLUSIONS

Transplantation of autologous ADRCs is safe, feasible and advantageous, as it can secure a sufficient cell count without culture or multiple passages, and will likely be effective for a postoperative enterocutaneous fistula.

Procalcitonin ratio and on-demand relaparotomy for septic peritonitis: validation of the focus index (FI)

PURPOSE

Secondary peritonitis remains challenging to manage and some recent evidence suggests that on-demand relaparotomy is more appropriate than planned relaparotomy. This study was designed to validate the predictive power of postoperative procalcitonin (PCT) changes in relation to elimination of the septic abdominal focus.

METHODS

In this prospective trial, postoperative PCT serum levels were monitored in 234 surgical patients with secondary peritonitis. The PCT ratio on postoperative days (PODs) 1 and 2 (focus index; FI) was calculated and correlated with the success of the operation.

RESULTS

A cutoff value of 1.1 was calculated for the FI. Values below 1.1 indicated insufficient elimination of the focus and values above 1.1 correlated with effective treatment. The optimal time for first PCT sampling was found to be 12-24 h after the index operation. After the respective data cleanup, successful elimination of the intraabdominal focus could be confirmed, with a sensitivity of 93 % and a specificity of 71 %.

CONCLUSIONS

The FI is a single parameter-based reliable predictor of successful surgical eradication and strengthens the on-demand relaparotomy concept as the method of choice to treat secondary peritonitis.

Tricks to decrease the suture line dehiscence rate during endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM)

BACKGROUND

ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long-term oncological results and better Quality of Life. The authors' policy is to close the residual defect, with possibly a higher risk of dehiscence from tension on the suture line. Aim is to evaluate if a modified technique may reduce the risk of dehiscence.

METHODS

The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients underwent ELRR by TEM with the authors' standard technique. In Group B, a subsequent series of 25 patients also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent prior to rectal wall closure. After suture completion, the rectal ampulla was stuffed with gauzes to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla. A transanal Foley catheter was positioned for gas evacuation.

RESULTS

There were no significant differences in mean tumor distance from the anal verge, mean lesion diameter, mean operative time, and pathological staging between the two groups. Neoadjuvant radio-chemotherapy (n-RCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 patients (12%) and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6-7). None of these patients had undergone n-RCT.

CONCLUSION

After ELRR by TEM, suture line dehiscence is presumably related to the wider size of the residual cavity. Obliteration of the residual perirectal space with hemostatic agent and by gauzes' introduction in the rectal ampulla may reduce the risk of postoperative perirectal abscess and thus reduce the suture line dehiscence rate.