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Bhatia M, Singhal T. Comment on "Implementing a no‑drain policy for extraperitoneal colorectal anastomosis in a real‑life setting: analysis of outcomes and surgeons' adherence". Int J Colorectal Dis 2024; 39:141. [PMID: 39276232 PMCID: PMC11401777 DOI: 10.1007/s00384-024-04716-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2024] [Indexed: 09/16/2024]
Affiliation(s)
- Mohit Bhatia
- Department of Colorectal Surgery, Princess Royal University Hospital, Orpington, King's College, London, UK.
| | - Tarun Singhal
- Department of Colorectal Surgery, Princess Royal University Hospital, Orpington, King's College, London, UK
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Ito R, Matsubara H, Shimizu R, Maehata T, Miura Y, Uji M, Mokuno Y. Anastomotic tension "Bridging": a risk factor for anastomotic leakage following low anterior resection. Surg Endosc 2024; 38:4916-4925. [PMID: 38977498 DOI: 10.1007/s00464-024-11008-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/22/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Excessive tension at the anastomosis contributes to anastomotic leakage (AL) in low anterior resection (LAR). However, the specific tension has not been measured. We assessed whether "Bridging," characterized by the proximal colon resembling a suspension bridge above the pelvic floor, is a significant risk factor for AL following LAR for rectal cancer. METHODS This retrospective study reviewed the medical records and laparoscopic videos of 102 patients who underwent laparoscopic LAR using the double stapling technique at Yachiyo Hospital between January 2014 and December 2023. Patients were classified based on whether they had Bridging (tight or sagging) or were in a Resting state of the proximal colon, and the association between Bridging and AL was examined. RESULTS AL occurred in 31.3% of the Tight Bridging group, 20% of the Sagging Bridging group, and 2.2% of the Resting group (P = 0.002). The incidence of AL was significantly higher in patients with Bridging than in those without (23.2% vs. 2.2%, P = 0.003). Multivariate analysis revealed that Bridging is an independent risk factor for AL (odds ratio = 6.97; 95% confidence interval: 1.45-33.6; P = 0.016). CONCLUSIONS The presence of Bridging is a significant risk factor for AL following LAR for rectal cancer, suggesting the need for implementing preventive measures in patients with this condition.
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Affiliation(s)
- Ryogo Ito
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan.
| | - Hideo Matsubara
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
| | - Ryoichi Shimizu
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
| | - Takahiro Maehata
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
| | - Yasutomo Miura
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
| | - Masahito Uji
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
| | - Yasuji Mokuno
- Department of Surgery, Yachiyo Hospital, 2-2-7 Sumiyoshi, Anjo, Aichi, 446-8510, Japan
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Simpson FH, Kulendran K, Yerkovich S, Beatty A, Flynn D, Mao D, Brooks T, Wood P, Chandrasegaram MD. Perioperative Blood Transfusions and Anastomotic Leak After Colorectal Surgery for Cancer in an Australian Hospital. J Gastrointest Cancer 2024; 55:219-226. [PMID: 37335436 PMCID: PMC11096243 DOI: 10.1007/s12029-023-00947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Peri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery. METHODS This retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not. RESULTS A total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001). CONCLUSION Perioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer.
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Affiliation(s)
- Fraser Hugh Simpson
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia.
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Krish Kulendran
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Stephanie Yerkovich
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Andrew Beatty
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - David Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Derek Mao
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Taylor Brooks
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Phoebe Wood
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Ramadan B, Dahboul H, Mouawad C, Aoun R, Kassar S, Kassouf E, Chakhtoura G, Noun R, Osseis M. Obesity: A risk factor for postoperative complications in laparoscopic surgery for colorectal cancer. J Minim Access Surg 2024; 20:12-18. [PMID: 36124473 PMCID: PMC10898645 DOI: 10.4103/jmas.jmas_165_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/21/2022] [Accepted: 08/04/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The prevalence of obesity in the Eastern Mediterranean is increasing significantly up to 20.8% in 2016. Therefore, a higher percentage of colorectal cancer (CRC) patients are expected to be obese. Laparoscopic colorectal cancer surgery (LCRCS) is regarded as a safe and feasible procedure as laparoscopic approach is becoming the gold standard in CRC surgery, especially in the early stages of disease. However, LCRCS is correlated with a higher risk of short-term post-operative complications in obese patients (body mass index [BMI] ≥30 Kg/m 2 ) than in patients with BMI <30 Kg/m 2 . This study aims to evaluate the impact of obesity on short-term post-operative complications in patients undergoing LCRCS. MATERIALS AND METHODS A retrospective study was conducted. Clinical data of case and control patients were extracted from medical records. These patients underwent LCRCS between January 2018 and June 2021 at Hôtel-Dieu de France Hospital, Beirut-Lebanon. Patients were divided into two groups: obese and non-obese. BMI ≥30 Kg/m 2 was used to define obese patients. Post-operative complications in the 30 days following surgery were the primary outcome. The severity of post-operative complications was evaluated using the Clavien-Dindo score. Chi-square test was used to evaluate the statistical correlation between collected variables. RESULTS We identified 107 patients who underwent LCRCS during this study period at our institution. Among the patients, 23 were obese (21.49%). At 30 days post-operative, 26 patients were reported to having at least one complication. Non-significant differences were found between the two groups regarding the early post-operative complications rate (obese 26.1% and non-obese 23.8% with P = 0.821). Obesity was not demonstrated as a stratification risk by severity of the early post-operative complications ( P = 0.92). CONCLUSION Obesity, which was defined as BMI ≥30 Kg/m 2 , was not a risk factor for early post-operative complications as well as a stratification risk by severity of post-operative complications in LCRCS.
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Affiliation(s)
- Bilal Ramadan
- Department of Digestive Surgery, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Houssam Dahboul
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Christian Mouawad
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Rany Aoun
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Serge Kassar
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Elia Kassouf
- Department of Digestive Surgery, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Ghassan Chakhtoura
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Roger Noun
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Michael Osseis
- Department of Digestive Surgery, Hotel Dieu De France Hospital, Saint Joseph University, Beirut, Lebanon
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Boatman S, Kaiser T, Nalluri-Butz H, Khan MH, Dietz M, Kohn J, Johnson AJ, Gaertner WB, Staley C, Jahansouz C. Diet-induced shifts in the gut microbiota influence anastomotic healing in a murine model of colonic surgery. Gut Microbes 2023; 15:2283147. [PMID: 37990909 PMCID: PMC10730186 DOI: 10.1080/19490976.2023.2283147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
Host diet and gut microbiota interact to contribute to perioperative complications, including anastomotic leak (AL). Using a murine surgical model of colonic anastomosis, we investigated how diet and fecal microbial transplantation (FMT) impacted the intestinal microbiota and if a predictive signature for AL could be determined. We hypothesized that a Western diet (WD) would impact gut microbial composition and that the resulting dysbiosis would correlate with increased rates of AL, while FMT from healthy, lean diet (LD) donors would reduce the risk of AL. Furthermore, we predicted that surgical outcomes would allow for the development of a microbial preclinical translational tool to identify AL. Here, we show that AL is associated with a dysbiotic microbial community characterized by increased levels of Bacteroides and Akkermansia. We identified several key taxa that were associated with leak formation, and developed an index based on the ratio of bacteria associated with the absence and presence of leak. We also highlight a modifiable connection between diet, microbiota, and anastomotic healing, potentially paving the way for perioperative modulation by microbiota-targeted therapeutics to reduce AL.
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Affiliation(s)
- Sonja Boatman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Thomas Kaiser
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | | | - Mohammad Haneef Khan
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Matthew Dietz
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Julia Kohn
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Abigail J Johnson
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang B Gaertner
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Christopher Staley
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Cyrus Jahansouz
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
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Sakai J, Watanabe J, Ohya H, Takei S, Toritani K, Suwa Y, Iguchi K, Atsumi Y, Numata M, Sato T, Takeda K, Kunisaki C. Redo laparoscopic colorectal resection: a retrospective analysis with propensity score matching. Int J Colorectal Dis 2023; 38:145. [PMID: 37243791 DOI: 10.1007/s00384-023-04439-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Reports of redo laparoscopic colorectal resection (Re-LCRR) are scarce. In order to evaluate the safety and short-term outcomes of Re-LCRR, we performed a matched case-control analysis of patients who underwent this procedure for colorectal cancer. METHOD This was a retrospective, monocentric study that included patients who underwent Re-LCRR for colorectal cancer between January 2011 and December 2019 at our institution. The patients were compared to a 2:1 matched sample. Matching was conducted based on age, sex, BMI, surgical procedure, and clinical stage. RESULT Twenty-nine patients underwent Re-LCRR (RCRR group) and were compared to 58 patients selected by matching who underwent LCRR as primary resection (PCRR group). The median of age of the 29 patients of RCRR group was 75 (IQR 56-81) years and the RCRR group included 14 males. The median operative time of the RCRR group was 167 (IQR 126-232) minutes, and the median intraoperative blood loss was 5 (IQR 2-35) ml. In the RCRR group, there were no cases that required conversion to laparotomy. The short-term outcomes of the two groups did not differ to a statistical extent with respect to operative time (p = 0.415), intraoperative blood loss (p = 0.971), rate of conversion to laparotomy (p = 0.477), comorbidity (p = 0.215), and postoperative hospital stay (p = 0.809). No patients in either group experienced postoperative anastomotic leakage or required re-operation due to postoperative complications, and there was no procedure-related death. However, in terms of oncological factors, although there was no difference in the number of cases with a positive radical margin between the two groups (p = 1.000), the number of harvested lymph nodes in the RCRR group was significantly lower than that in the PCRR group (p = 0.015) and the RCRR group included 10 cases with less than 12 harvested lymph nodes. CONCLUSION Re-LCRR is associated with good short-term results and can be safely performed; however, the number of harvested lymph nodes is significantly reduced in comparison to primary resection cases, and further studies are needed to evaluate its long-term prognosis.
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Affiliation(s)
- Jun Sakai
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
| | - Hiroki Ohya
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Shogo Takei
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Kenichiro Toritani
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Yusuke Suwa
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Kenta Iguchi
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Yosuke Atsumi
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Masakatsu Numata
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Tsutomu Sato
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Kazuhisa Takeda
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
| | - Chikara Kunisaki
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
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Tonini V, Zanni M. Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery. World J Gastrointest Surg 2023; 15:745-756. [PMID: 37342854 PMCID: PMC10277951 DOI: 10.4240/wjgs.v15.i5.745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/21/2023] [Accepted: 04/12/2023] [Indexed: 05/26/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.
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Affiliation(s)
- Valeria Tonini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Bologna, Italy
| | - Manuel Zanni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Bologna, Italy
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Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going? Curr Oncol 2023; 30:3111-3137. [PMID: 36975449 PMCID: PMC10047700 DOI: 10.3390/curroncol30030236] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.
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Intraluminal Anastomotic Assessment Using Indocyanine Green Near-Infrared Imaging for Left-Sided Colonic and Rectal Resections: a Systematic Review. J Gastrointest Surg 2023; 27:615-625. [PMID: 36604377 DOI: 10.1007/s11605-022-05564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) has been used in colorectal surgery to assess anastomotic perfusion and reduce the risks of anastomotic leaks. The main objective of this paper is to review the data on the transanal application of ICG-FA for the intraluminal assessment of colorectal anastomosis. METHODS A literature search was conducted for articles published between 2011 and 2021 using PubMed and Cochrane databases, related to the application of ICG for the intraluminal assessment of colorectal anastomosis. Original scientific manuscripts, review articles, meta-analyses, and case reports were considered eligible. RESULTS A total of 305 studies have been identified. After abstract screening for duplicates, 285 articles remained. Of those, 271 were not related to the topic of interest, 4 were written in a language other than English, and 4 had incomplete data. Six articles remained for the final analysis. The intraluminal assessment of colorectal anastomosis with ICG-FA is feasible, safe, and may reduce the incidence of leaks. CONCLUSION The intraluminal assessment of anastomotic perfusion via ICG-FA may be a promising novel application of ICG technology. More data is needed to support this application further to reduce leak rates after colorectal surgery, and future randomized clinical trials are awaited.
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Dias VE, Castro PASVDE, Padilha HT, Pillar LV, Godinho LBR, Tinoco ACDEA, Amil RDAC, Soares AN, Cruz GMGDA, Bezerra JMT, Silva TAMDA. Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis. Rev Col Bras Cir 2022; 49:e20223363. [PMID: 36449942 PMCID: PMC10578842 DOI: 10.1590/0100-6991e-20223363-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy. METHODS the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05. RESULTS cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35). CONCLUSIONS important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.
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Affiliation(s)
- Vinícius Evangelista Dias
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
- - Universidade Iguaçu - Itaperuna - RJ - Brasil
- - Faculdade Metropolitana São Carlos - Bom Jesus do Itabapoana - RJ - Brasil
| | | | | | | | | | | | - Rodrigo DA Costa Amil
- - Hospital São José do Avaí, Departamento de Cirurgia Geral - Itaperuna - RJ - Brasil
| | - Aleida Nazareth Soares
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
| | - Geraldo Magela Gomes DA Cruz
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
| | - Juliana Maria Trindade Bezerra
- - Faculdade de Medicina da Universidade Federal de Minas Gerais - Belo Horizonte - MG - Brasil
- - Universidade Estadual do Maranhão, Centro de Estudos Superiores de Lago da Pedra - Lago da Pedra - MA - Brasil
- - Universidade Estadual do Maranhão, Programa de Pós-Graduação em Ciência Animal - São Luís - MA - Brasil
| | - Thais Almeida Marques DA Silva
- - Faculdade Santa Casa BH, Programa de Pós-graduação Stricto Sensu em Medicina - Biomedicina - Belo Horizonte - MG - Brasil
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Sripathi S, Khan MI, Patel N, Meda RT, Nuguru SP, Rachakonda S. Factors Contributing to Anastomotic Leakage Following Colorectal Surgery: Why, When, and Who Leaks? Cureus 2022; 14:e29964. [DOI: 10.7759/cureus.29964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
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12
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Nie H, Hao Y, Feng X, Ma L, Ma Y, Zhang Z, Han X, Zhang JZ, Zhang P, Zhao Q, Dong H. Postoperative short-term use of the nonsteroidal anti-inflammatory drug flurbiprofen did not increase the anastomotic leakage rate in patients undergoing elective gastrointestinal surgery-a retrospective cohort study. Perioper Med (Lond) 2022; 11:38. [PMID: 35982476 PMCID: PMC9389786 DOI: 10.1186/s13741-022-00275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Flurbiprofen has been one of the most commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) in China and other Asian countries for perioperative multimodal analgesia in recent years, yet its association with anastomotic leakage in gastrointestinal anastomoses is unknown. The current study was designed to investigate whether short-term administration of flurbiprofen would increase the risk of anastomotic leakage in patients undergoing gastrointestinal surgery for cancer resection. Methods A total of 3653 patients (2487 (66.1%) men) undergoing elective operation for gastrointestinal cancer between 18 July 2017 and 30 Oct 2020 were included. The median age was 61 years (interquartile range 53–67 years). The exposure was the short-term postoperative use of flurbiprofen (defined as flurbiprofen treatment within the first week after surgery). The primary outcome was the frequency of clinical anastomotic leakage. Results Of 3653 patients with available data who were included in the final analysis, 2282 received flurbiprofen administration, and 1371 did not. Anastomotic leakage was not significantly increased among the patients receiving flurbiprofen compared with those who did not (1.62% v 1.46%; P=0.70). In-hospital mortality was comparable between the two groups (0.04% v 0.07%; P=0.72). After adjusted analysis, male sex (OR 3.51, 95% CI 1.80–6.85), ASA score of 3–4 (OR 2.69, 95% CI 1.62–4.48), and intraoperative infusion (OR 2.24, 95% CI 1.19–4.21) were identified as risk factors for anastomotic leakage. Conclusions Postoperative short-term use of flurbiprofen did not increase the risk of anastomotic leakage in gastrointestinal anastomoses.
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Affiliation(s)
- Huang Nie
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yiming Hao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xiangying Feng
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Lina Ma
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yumei Ma
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Zhen Zhang
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xi'an Han
- The Unimed Scientific, Inc., Wu Xi, China
| | | | - Ping Zhang
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Qingchuan Zhao
- Department of Gastrointestinal Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China.
| | - Hailong Dong
- Department of Anesthesiology, Xijing Hospital, Air Force Medical University, Xi'an, China.
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Mazaki J, Katsumata K, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Ishizaki T, Nagakawa Y, Tsuchida A. Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study. Medicine (Baltimore) 2022; 101:e29600. [PMID: 35839009 PMCID: PMC11132375 DOI: 10.1097/md.0000000000029600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Anastomotic leak after gastrointestinal anastomosis is a serious complication. Anastomotic failure depends on various parameters. The aim of our study was to evaluate the pressure resistance of a new device, EEA™ circular stapler with Tri-Staple™ technology 28 mm Medium/Thick (Triple-rows circular stapler; TCS) compared with EEA™ circular stapler with DST series™ technology 28 mm, 4.8 mm staples (double-rows circular stapler; DCS). PATIENTS AND METHODS We performed 30 anastomoses (DSC: 15, TCS: 15) of DST with porcine colon model in vitro. We performed following 3 comparative experiences; Experiment 1: observation of staple shape with a colonoscopy, Experiment 2: comparison of the pressure resistance, Experiment 3: comparison of leakage points. RESULTS There was no hypoplasia of staples and the shapes were well-formed by colonoscopy. The leakage pressure of DCS was 19.6 ± 4.4 mm Hg (mean ± standard deviation) and that of TCS was 38.6 ± 10.2 mm Hg (mean ± standard deviation). There was a significantly difference between 2 groups (P < .001). 12 cases of DCS (80%) and 10 cases of TCS (66.7%) had leakages from Circular stapler point. 2 cases of DCS (13.3%) and 5 cases of TCS (33.3%) had leakages from Crossing points. Only 1 case of DCS had leakages from Dog ear point (6.7%). There was no significantly difference in leakage site between 2 groups (P = .195). CONCLUSIONS TSC showed high pressure resistance during DST compared with that of DCS. It was suggested that TCS may contribute to the reduction of anastomotic leakage rate.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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14
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Mazaki J, Katsumata K, Ishizaki T, Fukushima N, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Nagakawa Y, Tsuchida A. Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score-matched study. Medicine (Baltimore) 2022; 101:e29325. [PMID: 35801763 PMCID: PMC9259104 DOI: 10.1097/md.0000000000029325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Anastomotic leakage (AL) after colorectal surgery is a serious complication. This study aimed to evaluate the effectiveness of the EEA™ circular stapler, a new triple-row circular stapler (TCS), relative to a conventional, double-row circular stapler (DCS). A total of 285 patients who underwent anastomosis with the double stapling technique at the Tokyo Medical University Hospital between 2017 and 2021 were included in this nonrandomized clinical trial with historical controls using a propensity score (PS) analysis. The primary endpoint was the risk of AL. We performed a 1:2 PS matching analysis. Before case matching, AL occurred in 15 (7.4%) and 2 (2.4%) patients in the DCS and TCS groups, respectively, with no significant difference (P = .17). After case matching, AL occurred in 13 patients (11.6%) and 1 patient (1.8%) in the DCS and TCS groups, respectively, revealing a significant difference (P = .04). Cox models were created by applying PS to adjust for group differences via regression adjustment. Odds ratios for AL in the DCS group versus the TCS group were 0.31 (95% confidence interval [CI]: 0.07-1.38) in the entire cohort, 0.15 (95% CI: 0.02-0.64) in the regression adjustment cohort, and 0.14 (95% CI: 0.02-1.09) in the 1:2 PS-matched cohort. PS analysis of clinical data suggested that the use of TCS contributes to a reduced risk of AL after colorectal anastomosis CTwith the double stapling technique.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
- *Correspondence: Junichi Mazaki, Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: )
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Noritoshi Fukushima
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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15
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Kang J, Kim H, Park H, Lee B, Lee KY. Risk factors and economic burden of postoperative anastomotic leakage related events in patients who underwent surgeries for colorectal cancer. PLoS One 2022; 17:e0267950. [PMID: 35584082 PMCID: PMC9116683 DOI: 10.1371/journal.pone.0267950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Nationwide research about the clinical and economic burden caused by anastomotic leakage (AL) has not been published yet in Korea. This study assessed the AL rate and quantified the economic burden using the nationwide database. Methods This real world evidence study used health claims data provided by the Korean Health Insurance Review and Assessment Service (HIRA, which showed that 156,545 patients underwent anterior resection (AR), low anterior resection (LAR), or ultra-low anterior resection (uLAR) for colorectal cancer (CRC) between January 1, 2007 and January 31, 2020. The incidence of AL was identified using a composite operational definition, a composite of imaging study, antibacterial drug use, reoperation, or image-guided percutaneous drainage. Total hospital costs and length of stay (LOS) were evaluated in patients with AL versus those without AL during index hospitalization and within 30 days after the surgery. Results Among 120,245 patients who met the eligibility criteria, 7,194 (5.98%) patients had AL within 30 days after surgery. Male gender, comorbidities (diabetes, metastatic disease, ischemic heart disease, ischemic stroke), protective ostomy, and multiple linear stapler use, blood transfusion, and urinary tract injury were associated with the higher odds of AL. Older age, rectosigmoid junction cancer, AR, LAR, and laparoscopic approach were related with the reduced odds of AL. Patients with AL incurred higher costs for index hospitalization compared to those without AL (8,991 vs. 7,153 USD; p<0.0001). Patients with AL also required longer LOS (16.78 vs. 14.22 days; p<0.0001) and readmissions (20.83 vs. 13.93 days; p<0.0001). Conclusion Among patients requiring resection for CRC, the occurrence of AL was associated with significantly increased costs and LOS. Preventing AL could not only produce superior clinical outcomes, but also reduce the economic burden for patients and payers.
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Affiliation(s)
- Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyesung Kim
- HEMA, Johnson & Johnson Medical Korea, Seoul, Republic of Korea
| | - HyeJin Park
- HEMA, Johnson & Johnson Medical Korea, Seoul, Republic of Korea
| | - Bora Lee
- Institute of Health & Environment, Seoul National University, Seoul, Korea
- RexSoft Corporation, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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16
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A Brave New World: Colorectal Anastomosis in Trauma, Diverticulitis, Peritonitis, and Colonic Obstruction. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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17
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Safiejko K, Tarkowski R, Kozlowski TP, Koselak M, Jachimiuk M, Tarasik A, Pruc M, Smereka J, Szarpak L. Safety and Efficacy of Indocyanine Green in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis of 11,047 Patients. Cancers (Basel) 2022; 14:1036. [PMID: 35205784 PMCID: PMC8869881 DOI: 10.3390/cancers14041036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 02/04/2023] Open
Abstract
Despite the technological advances and improved surgical skills, the incidence of anastomotic leakage following colorectal cancer surgery still ranges from 4% to 19%. Therefore, we performed a systematic review and meta-analysis to evaluate the efficacy and safety of indocyanine green (ICG) use in colorectal cancer surgery. An online search of the Embase, MEDLINE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases (from inception to 10 November 2021) was performed, in addition to manual screening. Thirty-two studies involving 11,047 patients were considered eligible for the meta-analysis. The anastomotic leak rate in the ICG and non-ICG groups varied and amounted to 3.7% vs. 7.6%, respectively (RR = 0.46; 95% CI: 0.39-0.56; p < 0.001). The rate in randomized controlled trials (RCTs) was 8.1% in the ICG group compared with 12.1% in the non-ICG group (RR = 0.67; 95% CI: 0.46-0.98; p = 0.04). In non-RCTs, it equaled 3.1% vs. 7.3%, respectively (RR = 0.43; 95% CI: 0.35-0.52; p < 0.001). Although the publications encompassed in our meta-analysis present different patients, with different factors influencing the results, a pooled analysis revealed a lower incidence of anastomotic leak in cases with ICG use. There are several other convincing advantages: safety, simplicity, and short time of the method adjustment. The presented meta-analysis indicates ICG perfusion assessment as a tool worth considering to decrease the rate of complications following colorectal surgery-valuable in the context of other, well-known risk factors.
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Affiliation(s)
- Kamil Safiejko
- Colorectal Cancer Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland; (K.S.); (T.P.K.); (M.J.); (A.T.)
| | - Radoslaw Tarkowski
- Department of Surgical Oncology, Regional Specialist Hospital, 55-220 Legnica, Poland;
| | - Tomasz Piotr Kozlowski
- Colorectal Cancer Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland; (K.S.); (T.P.K.); (M.J.); (A.T.)
| | - Maciej Koselak
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland;
- Oncological Surgery Subdivision, Masovian Oncology Hospital, 05-135 Wieliszew, Poland
| | - Marcin Jachimiuk
- Colorectal Cancer Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland; (K.S.); (T.P.K.); (M.J.); (A.T.)
| | - Aleksander Tarasik
- Colorectal Cancer Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland; (K.S.); (T.P.K.); (M.J.); (A.T.)
| | - Michal Pruc
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.P.); (J.S.)
| | - Jacek Smereka
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.P.); (J.S.)
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
| | - Lukasz Szarpak
- Colorectal Cancer Unit, Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland; (K.S.); (T.P.K.); (M.J.); (A.T.)
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, 03-411 Warsaw, Poland;
- Research Unit, Polish Society of Disaster Medicine, 05-806 Warsaw, Poland; (M.P.); (J.S.)
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18
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DIAS VINÍCIUSEVANGELISTA, CASTRO PEDROALVESSOARESVAZDE, PADILHA HOMEROTERRA, PILLAR LARAVICENTE, GODINHO LAURABOTELHORAMOS, TINOCO AUGUSTOCLAUDIODEALMEIDA, AMIL RODRIGODACOSTA, SOARES ALEIDANAZARETH, CRUZ GERALDOMAGELAGOMESDA, BEZERRA JULIANAMARIATRINDADE, SILVA THAISALMEIDAMARQUESDA. Fatores de risco pré-operatórios associados à fístula anastomótica após colectomia para câncer colorretal: revisão sistemática e metanálise. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RESUMO Objetivo: fístula anastomótica (FA) após colectomia para câncer colorretal (CCR) é complicação grave. Esta revisão sistemática e meta-análise avaliou os fatores de risco pré-operatórios para FA em pacientes submetidos à colectomia. Métodos: a pesquisa bibliográfica abrangeu 15 anos e 9 meses (1 de janeiro de 2005 - 19 de outubro de 2020), sendo utilizadas as plataformas PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC e Web of Science. O critério de inclusão foram estudos transversais, coorte e caso-controle em fatores de risco pré-operatórios para FA (desfecho). A escala Newcastle-Ottawa foi usada para avaliação de viés dos estudos. A metanálise envolveu o cálculo dos efeitos de tratamento para cada estudo individualmente incluindo odds ratio (OR), risco relativo (RR) e intervalo de confiança de 95% (IC95%) com construção de modelo de efeitos aleatórios, para avaliar o impacto de cada variável (p<0,05). Resultados: foram selecionados 39 estudos transversais, 21 coortes e quatro casos-controle. A metanálise identificou 14 fatores de risco para FA em pacientes com CCR após colectomia, que são sexo masculino (RR=1,56; IC 95%=1,40-1,75), tabagismo (RR=1,48; IC 95%=1,30-1,69), alcoolismo (RR=1,35; IC 95%=1,21-1,52), diabetes mellitus (RR=1,97; IC 95%=1,44-2,70), doenças pulmonares (RR=2,14; IC 95%=1,21-3,78), doença pulmonar obstrutiva crônica (RR=1,10; IC 95%=1,04-1,16), doença coronariana (RR=1,61; IC 95%=1,07-2,41), doença renal crônica (RR=1,34; IC 95%=1,22-1,47), altas notas na escala ASA (RR=1,70; IC 95%=1,37-2,09), cirurgia abdominal prévia (RR=1,30; IC 95%=1,04-1,64), cirurgia de emergência (RR=1,61; IC 95%=1,26-2,07), quimioterapia neoadjuvante (RR=2,16; IC 95%=1,17-4,02), radioterapia (RR=2,36; IC 95%=1,33-4,19) e quimiorradioterapia (RR=1,58; IC 95%=1,06-2,35). Conclusões: importantes fatores de risco pré-operatórios para FA colorretais em pacientes com CCR foram identificados com base nas melhores pesquisas baseadas em evidências e esse conhecimento deve influenciar decisões relacionadas ao tratamento.
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Affiliation(s)
- VINÍCIUS EVANGELISTA DIAS
- Faculdade Santa Casa BH, Brasil; Universidade Iguaçu, Brazil; Faculdade Metropolitana São Carlos, Brazil
| | | | | | | | | | | | | | | | | | - JULIANA MARIA TRINDADE BEZERRA
- Universidade Federal de Minas Gerais, Brazil; Universidade Estadual do Maranhão, Brazil; Universidade Estadual do Maranhão, Brazil
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Zarnescu EC, Zarnescu NO, Costea R. Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery. Diagnostics (Basel) 2021; 11:diagnostics11122382. [PMID: 34943616 PMCID: PMC8700187 DOI: 10.3390/diagnostics11122382] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 12/13/2022] Open
Abstract
Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.
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Affiliation(s)
- Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-592-483
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.C.Z.); (R.C.)
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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Favuzza J. Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains. Clin Colon Rectal Surg 2021; 34:366-370. [PMID: 34853556 DOI: 10.1055/s-0041-1735266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.
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Affiliation(s)
- Joanne Favuzza
- Division of Colon and Rectal Surgery, Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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21
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Bobel MC, Altman A, Gaertner WB. Immunofluorescence in Robotic Colon and Rectal Surgery. Clin Colon Rectal Surg 2021; 34:338-344. [PMID: 34504405 DOI: 10.1055/s-0041-1729866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The indocyanine green fluorescence imaging system is a surgical tool with increasing applications in colon and rectal surgery that has received growing acceptance in various surgical disciplines as a potentially valid method to enhance surgical field visualization, improve lymph node retrieval, and decrease anastomotic leak. Small noncomparative prospective trials have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion and that its use may impact anastomotic leak rates. However, larger prospective and randomized studies are required to validate its role and impact in colorectal surgery. The purpose of this article is to review the current status of the use of immunofluorescence in colon and rectal surgery, as well as new applications in robotic colon and rectal resections.
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Affiliation(s)
- Matthew C Bobel
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ariella Altman
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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22
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Lazzaron AR, Silveira I, Machado PS, Damin DC. The role of Hartmann's procedure in the elective management of rectal cancer: results of a Brazilian cohort study. Rev Col Bras Cir 2021; 48:e20212977. [PMID: 34378751 PMCID: PMC10683413 DOI: 10.1590/0100-6991e-20212977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. MATERIALS AND METHODS this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann's procedure (HP). Postoperative complications and clinical outcomes were assessed. RESULTS four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. CONCLUSION HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.
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Affiliation(s)
- Anderson Rech Lazzaron
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Ingrid Silveira
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Pauline Simas Machado
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
| | - Daniel C Damin
- - Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Serviço de Coloproctologia - Pós-graduação em Cirurgia (UFRGS) - Porto Alegre - RS - Brasil
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Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection. Dis Colon Rectum 2021; 64:995-1002. [PMID: 33872284 DOI: 10.1097/dcr.0000000000002007] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. DESIGN We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. SETTINGS This was a multicenter trial. PATIENTS Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. INTERVENTION Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURES Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). LIMITATIONS The predetermined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSIONS Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560. VALORACIN DE LA IRRIGACIN DE LADO IZQUIERDO/RESECCIN ANTERIOR BAJA PILAR III UN ESTUDIO ALEATORIZADO, CONTROLADO, PARALELO Y MULTICNTRICO QUE EVALA LOS RESULTADOS DE LA IRRIGACIN CON PINPOINT IMGENES DE FLUORESCENCIA CERCANA AL INFRARROJO EN LA RESECCIN ANTERIOR BAJA ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).
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Marland JRK, Gray ME, Argyle DJ, Underwood I, Murray AF, Potter MA. Post-Operative Monitoring of Intestinal Tissue Oxygenation Using an Implantable Microfabricated Oxygen Sensor. MICROMACHINES 2021; 12:810. [PMID: 34357220 PMCID: PMC8303214 DOI: 10.3390/mi12070810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/02/2022]
Abstract
Anastomotic leakage (AL) is a common and dangerous post-operative complication following intestinal resection, causing substantial morbidity and mortality. Ischaemia in the tissue surrounding the anastomosis is a major risk-factor for AL development. Continuous tissue oxygenation monitoring during the post-operative recovery period would provide early and accurate early identification of AL risk. We describe the construction and testing of a miniature implantable electrochemical oxygen sensor that addresses this need. It consisted of an array of platinum microelectrodes, microfabricated on a silicon substrate, with a poly(2-hydroxyethyl methacrylate) hydrogel membrane to protect the sensor surface. The sensor was encapsulated in a biocompatible package with a wired connection to external instrumentation. It gave a sensitive and highly linear response to variations in oxygen partial pressure in vitro, although over time its sensitivity was partially decreased by protein biofouling. Using a pre-clinical in vivo pig model, acute intestinal ischaemia was robustly and accurately detected by the sensor. Graded changes in tissue oxygenation were also measurable, with relative differences detected more accurately than absolute differences. Finally, we demonstrated its suitability for continuous monitoring of tissue oxygenation at a colorectal anastomosis over a period of at least 45 h. This study provides evidence to support the development and use of implantable electrochemical oxygen sensors for post-operative monitoring of anastomosis oxygenation.
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Affiliation(s)
- Jamie R. K. Marland
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Mark E. Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian EH25 9RG, UK; (M.E.G.); (D.J.A.)
| | - David J. Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian EH25 9RG, UK; (M.E.G.); (D.J.A.)
| | - Ian Underwood
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Alan F. Murray
- School of Engineering, Institute for Bioengineering, University of Edinburgh, Faraday Building, Edinburgh EH9 3DW, UK;
| | - Mark A. Potter
- Department of Surgery, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;
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25
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Gray M, Marland JRK, Murray AF, Argyle DJ, Potter MA. Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients. J Pers Med 2021; 11:471. [PMID: 34070593 PMCID: PMC8229046 DOI: 10.3390/jpm11060471] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.
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Affiliation(s)
- Mark Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Jamie R. K. Marland
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Alan F. Murray
- School of Engineering, Institute for Bioengineering, University of Edinburgh, Faraday Building, The King’s Buildings, Edinburgh EH9 3DW, UK;
| | - David J. Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Mark A. Potter
- Department of Surgery, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;
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26
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Management and 1-year outcomes of anastomotic leakage after elective colorectal surgery. Int J Colorectal Dis 2021; 36:929-939. [PMID: 33118101 DOI: 10.1007/s00384-020-03777-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To analyze different types of management and one-year outcomes of anastomotic leakage (AL) after elective colorectal resection. METHODS All patients with anastomotic leakage after elective colorectal surgery with anastomosis (76/1,546; 4.9%), with the exclusion of cases with proximal diverting stoma, were followed-up for at least one year. Primary endpoints were as follows: composite outcome of one-year mortality and/or unplanned intensive care unit (ICU) admission and additional morbidity rates. Secondary endpoints were as follows: length of stay (LOS), one-year persistent stoma rate, and rate of return to intended oncologic therapy (RIOT). RESULTS One-year mortality rate was 10.5% and unplanned ICU admission rate was 30.3%. Risk factors of the composite outcome included age (aOR = 1.08 per 1-year increase, p = 0.002) and anastomotic breakdown with end stoma at reoperation (aOR = 2.77, p = 0.007). Additional morbidity rate was 52.6%: risk factors included open versus laparoscopic reoperation (aOR = 4.38, p = 0.03) and ICU admission (aOR = 3.63, p = 0.05). Median (IQR) overall LOS was 20 days (14-26), higher in the subgroup of patients reoperated without stoma. At 1 year, a stoma persisted in 32.0% of patients, higher in the open (41.2%) versus laparoscopic (12.5%) reoperation group (p = 0.04). Only 4 out of 18 patients (22.2%) were able to RIOT. CONCLUSION Mortality and/or unplanned ICU admission rates after AL are influenced by increasing age and by anastomotic breakdown at reoperation; additional morbidity rates are influenced by unplanned ICU admission and by laparoscopic approach to reoperation, the latter also reducing permanent stoma and failure to RIOT rates. TRIAL REGISTRATION ClinicalTrials.gov # NCT03560180.
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27
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Gräfitsch A, Kirchhoff P, Soysal SD, Däster S, Hoffmann H. Dynamic Serosal Perfusion Assessment during Colorectal Resection Using Visible Light Spectroscopy. Eur Surg Res 2021; 62:25-31. [PMID: 33906197 DOI: 10.1159/000514921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) in colorectal surgery occurs with an incidence of up to 20%. Bowel perfusion is deemed to be one of the most important factors for anastomotic healing. However, not much is known about its variability during colorectal surgery and its impact on the outcome. Therefore, this study aims to evaluate serosal oxygen saturation patterns during colorectal resections with visible light spectroscopy (VLS). MATERIALS AND METHODS Bowel perfusion in patients undergoing left-sided colorectal resections was assessed at different timepoints during surgery using VLS on the colonic serosa. The primary outcome parameter was serosal oxygen saturation (StO2) at the anastomosis during different timepoints of surgery. RESULTS We included 50 patients who underwent colorectal resection for bowel cancer (58%) and diverticular disease (34%). StO2 at the proximal site of the anastomosis increased significantly throughout the surgery (mean difference 3.61%; 95% CI -6.22 to -1.00; p = 0.008). However, aberrancy from this identified perfusion pattern had no impact on the postoperative outcome. CONCLUSION During colorectal resections, we could demonstrate an increase of the colonic StO2 throughout surgery. Appearance of AL was not associated with lower StO2, underlining the multifactorial genesis of developing AL.
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Affiliation(s)
- Alexander Gräfitsch
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Visceral Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Kirchhoff
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Center for Hernia Surgery and Proctology, ZweiChirurgen GmbH, Basel, Switzerland
| | - Savas D Soysal
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Silvio Däster
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Henry Hoffmann
- General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Center for Hernia Surgery and Proctology, ZweiChirurgen GmbH, Basel, Switzerland
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28
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Jordan SG, Nolan GJ. Over-the-scope clip: a novel approach to the management of a colorectal anastomotic leak. ANZ J Surg 2021; 91:2534-2536. [PMID: 33710749 DOI: 10.1111/ans.16749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/28/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Stephanie G Jordan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gregory J Nolan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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29
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Pantoja Pachajoa DA, Gielis M, Palacios Huatuco RM, Benitez MN, Avila MN, Doniquian AM, Alvarez FA, Parodi M. Neutrophil-to-lymphocyte ratio vs C-reactive protein as early predictors of anastomotic leakage after colorectal surgery: A retrospective cohort study. Ann Med Surg (Lond) 2021; 64:102201. [PMID: 33763228 PMCID: PMC7973302 DOI: 10.1016/j.amsu.2021.102201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/28/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction Colorectal surgery (CRS) is associated with high morbidity rates, being anastomotic leakage (AL) one of the most serious complications with an incidence as high as 15%, accounting for up to a third of mortality in these procedures. The identification of pre-clinical markers may allow an early diagnosis and a timely intervention. The objective of the present study was to compare the performance of neutrophil-to-lymphocyte ratio (NLR) vs C-reactive protein (CRP) as early predictors of AL in CRS. Methods A retrospectively analyzed consecutive patients who underwent a colorectal surgery with anastomosis from June 2015 to April 2019. Receiver-operating characteristic (ROC) curves were used to find the cutoff points with the best diagnostic performance of AL. Results A total of 116 patients were included. From 43 patients (37%) who developed a total of 63 complications, 9 (7.76%) presented with an AL with a median of 8 days (range: 5–9). No significant differences were found for NLR between patients with vs without AL. In contrast, median CRP was significantly higher in patients who subsequently presented with AL, both on day 4 (164 vs 64, p = 0.04) and 5 (94 vs 44, p < 0.001) after surgery. The best predictive performance through ROC curves was found on postoperative day 5, with a CRP value of >54 mg/dL (AUC: 0.81, Sensitivity: 89%, Specificity: 61%). Conclusions CRP appears superior to NLR as an early predictor of AL following CRS. The best diagnostic performance was obtained on postoperative day 5 with a cutoff value of >54 mg/dL. In the present study, CRP was found to be superior to NLR as an early predictor of clinically significant AL following CRS. The best predictive performance was obtained at postoperative day 5 with a cutoff value > 54 mg/dL. The importance of this finding may contribute during the hospital stay from the third postoperative day to the early diagnosis of LA.
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30
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Colorectal resection in emergency general surgery: An EAST multicenter trial. J Trauma Acute Care Surg 2021; 89:1023-1031. [PMID: 32890337 DOI: 10.1097/ta.0000000000002894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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31
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Grewal S, Oosterling SJ, van Egmond M. Surgery for Colorectal Cancer: A Trigger for Liver Metastases Development? New Insights into the Underlying Mechanisms. Biomedicines 2021; 9:biomedicines9020177. [PMID: 33670204 PMCID: PMC7916916 DOI: 10.3390/biomedicines9020177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 12/24/2022] Open
Abstract
Surgery is a crucial intervention and provides the best chance of cure for patients with colorectal cancer. Experimental and clinical evidence, however, suggests that paradoxically surgery itself may precipitate or accelerate tumor recurrence and/or liver metastasis development. This review addresses the various aspects of surgery-induced metastasis formation and sheds light on the role of inflammation as potential trigger for metastasis development. Understanding these mechanisms may provide potential new perioperative interventions to improve treatment outcomes, and as such could transform the perioperative timeframe from a facilitator of metastatic progression to a window of opportunity to reduce the risk of liver metastasis development. Ultimately, this can potentially improve long-term survival rates and quality of life in patients with colorectal cancer.
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Affiliation(s)
- Simran Grewal
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, 1007 MB Amsterdam, The Netherlands;
- Department of Surgery, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-4448080
| | | | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Centers, 1007 MB Amsterdam, The Netherlands;
- Department of Surgery, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
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Kaçmaz E, Slooter MD, Nieveen van Dijkum EJM, Tanis PJ, Engelsman AF. Fluorescence angiography guided resection of small bowel neuroendocrine neoplasms with mesenteric lymph node metastases. Eur J Surg Oncol 2021; 47:1611-1615. [PMID: 33353827 DOI: 10.1016/j.ejso.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/24/2020] [Accepted: 12/13/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Surgery for small bowel neuroendocrine neoplasms (SB-NEN) might result in vascular compromise of the remaining bowel due to resection of lymph node metastases in close proximity to main mesenteric vessels. Fluorescence angiography (FA) has been described as a safe technique to assess perfusion during gastro-intestinal surgery. This study aimed to evaluate the potential value of intraoperative FA during surgery for SB-NEN. METHODS This study included patients undergoing surgery for SB-NEN of any stage. The planned level of transection was marked by the surgeon, after which FA using indocyanine green (ICG) was performed. The primary study outcome was change in management due to FA. RESULTS Ten consecutive patients with SB-NEN were included, all with metastatic lymph nodes close to main mesenteric vessels. FA use led to management changes in eight patients (80%); four patients had less bowel resected with a preserved length of 5-35 cm. The other four patients had more extended bowel resections with an additional length varying from 3 to 25 cm. The median postoperative stay was 4 days (interquartile range 4-6). No anastomotic leakage occurred. CONCLUSION This is the first known series describing preliminary results of FA during SB-NEN surgery. FA led to a management change in 80% of patients with better tailoring the extent of resection of small bowel. Structural implementation of FA to assess small bowel perfusion after dissection for small bowel NET results in change of management, either by preserving small bowel or resecting ill-perfused small bowel.
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Affiliation(s)
- E Kaçmaz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - E J M Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands; ENETS Center of Excellence, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A F Engelsman
- Cancer Center Amsterdam, Amsterdam, the Netherlands; ENETS Center of Excellence, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands.
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Yan D, Yang XF. A commentary on "assessment of a circular powered stapler for creation of anastomosis in left-sided colorectal surgery: A prospective cohort study" (Int J Sury 2020; 84:140-6). Int J Surg 2020; 85:55-56. [PMID: 33359387 DOI: 10.1016/j.ijsu.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Dong Yan
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
| | - Xiong-Fei Yang
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
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Ding R, Zhou J, Yang Y, Zhao L, Luo S, Huang M. A rare complication after radiofrequency ablation in the treatment of colorectal liver metastasis: A case report. J Interv Med 2020; 3:213-215. [PMID: 34805937 PMCID: PMC8562243 DOI: 10.1016/j.jimed.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/08/2020] [Accepted: 08/03/2020] [Indexed: 11/30/2022] Open
Abstract
Radiofrequency ablation (RFA) is one of the safe and effective treatments of colorectal cancer with liver metastasis, which has the advantages of minimally invasive, fewer complications, short hospitalization time and repeatable operation. A special case with advanced transverse colon carcinoma was treated by RFA in our center. All the procedures were performed, which were recommended by the guideline. An intestinal perforation occurred on the second day after the RFA, then surgeon performed emergency surgery, unfortunately, anastomotic leakage occurred on the 21st day after the operation, yet after conservative medical treatment, the patient achieved remission of symptoms and discharged from the hospital. Rare complications occurred after RFA in the treatment of colorectal cancer with liver metastasis are unpredictable, which could affect the efficacy of RFA and performance status of patients. Further investigation of the mechanism of these complications is warranted urgently, which might offer more effective methods against these rare complications.
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Gill SS, Buote NJ, Peterson NW, Bergman PJ. Factors associated with dehiscence and mortality rates following gastrointestinal surgery in dogs. J Am Vet Med Assoc 2020; 255:569-573. [PMID: 31429652 DOI: 10.2460/javma.255.5.569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify factors associated with dehiscence and mortality rates following gastrointestinal surgery in dogs. ANIMALS 170 client-owned dogs that underwent gastrointestinal surgery from 2010 to 2016. PROCEDURES Medical records of all included dogs were reviewed to collect information on preoperative (breed, sex, age, body weight, American Society of Anesthesiologists [ASA] physical status classification, emergency status, and plasma lactate concentration), intraoperative (indication for surgery, type of surgery, and whether bacterial peritonitis was identified), and postoperative (development of dehiscence and survival status at 2 weeks after surgery) factors. Preoperative and intraoperative factors were evaluated for associations among each other and with postoperative factors. RESULTS Univariate analyses revealed that preoperative plasma lactate concentration increased with increasing ASA status, and lactate concentrations were significantly higher for nonsurvivors (mean ± SD, 4.6 ± 3.7 mmol/L) than for survivors (2.4 ± 1.7 mmol/L). Multivariate analysis controlling for age, body weight, and plasma lactate concentration revealed that dogs with an ASA status ≥ 3 were more likely to develop dehiscence after gastrointestinal surgery than were dogs with a lower ASA status (OR, 17.77; 95% confidence interval, 2.17 to 144.06). Multivariate analysis also revealed that dogs with an ASA status ≥ 3 or high lactate concentration were less likely to survive than were other dogs. CONCLUSIONS AND CLINICAL RELEVANCE These findings regarding ASA status and preoperative plasma lactate concentration and their associations with outcome may help clinicians to determine and provide optimal perioperative care to dogs requiring gastrointestinal surgery as well as to inform owners about prognosis.
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Risk factors for adverse events after elective colorectal surgery: beware of blood transfusions. Updates Surg 2020; 72:811-819. [PMID: 32399595 DOI: 10.1007/s13304-020-00753-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/20/2020] [Indexed: 01/19/2023]
Abstract
Purpose of the present study is to analyze risk factors for adverse events after elective colorectal resection. A wide range of adverse events after elective colorectal surgery was reported, anastomotic leakage (AL) and related morbidity and mortality being the most feared ones. Clear definition of risk factors is crucial to limit the related mortality. Prospective, 1-year multicenter enrollment of 1546 elective colorectal resections with anastomosis. Endpoints were anastomotic leakage (AL), overall morbidity, major morbidity and mortality rates (ClinicalTrials.gov; Identifier: NCT03560180). AL rate was 4.92%. Overall morbidity, major morbidity and mortality rates were 30.20%, 9.76% and 1.29%, respectively. Intra- and/or postoperative blood transfusion(s) was the only variable independently influencing all the endpoints: Odds ratios (OR) were 8.15 for AL, 19.33 for overall morbidity, 10.17 for major morbidity and 3.70 for mortality); overall morbidity rates were also independently influenced by American Society of Anesthesiologists class III vs I-II and extra- vs intra-corporeal anastomosis (OR 1.57 and 1.49, respectively); major morbidity rates were also independently influenced by female vs male gender and by the length of the procedure (OR 0.60 and 1.004, respectively); mortality rates were also independently influenced by increasing age (OR 1.16). This study clearly identifies intra- and/or postoperative blood transfusion(s) as an independent risk factor for all adverse events after elective colorectal surgery.
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Anastomotic leakage after elective colorectal surgery: a prospective multicentre observational study on use of the Dutch leakage score, serum procalcitonin and serum C-reactive protein for diagnosis. BJS Open 2020; 4:499-507. [PMID: 32134216 PMCID: PMC7260403 DOI: 10.1002/bjs5.50269] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background The purpose of this study was to test use of the Dutch leakage score (DLS), serum C‐reactive protein (CRP) and serum procalcitonin (PCT) in the diagnosis of anastomotic leakage (AL) after elective colorectal resection in a prospective observational study. Methods Patients undergoing elective colorectal resection with anastomosis in 19 centres were enrolled over a 1‐year period from September 2017. The DLS and CRP and PCT levels were evaluated on postoperative day (POD) 2, POD3 and POD6. Statistical analysis, including determination of the area under the receiver operating characteristic (ROC) curve (AUC), was performed for the primary endpoint of AL; secondary endpoints were morbidity and mortality rates (
http://clinicaltrials.gov identifier: NCT03560180). Results Among 1546 patients enrolled, the AL rate was 4·9 per cent. Morbidity and mortality rates were 30·2 and 1·3 per cent respectively. With respect to AL, DLS performed better than CRP and PTC levels on POD2 and POD3 (AUC 0·75 and 0·84), whereas CRP levels were documented with better AUC values on POD6 (AUC 0·81). Morbidity was poorly predicted, whereas mortality was best predicted by PCT on POD2 (AUC 0·83) and by DLS on POD3 and POD6 (AUC 0·87 and 0·98 respectively). Overall, the combination of positive PCT, CRP and DLS values resulted in a probability of AL of 21·3 per cent on POD2, 33·4 per cent on POD3, and 47·1 per cent on POD6. However, the combination of their negative values excluded AL in 99·0 per cent of cases on POD2, 99·3 per cent on POD3, and 99·2 per cent on
POD6. Conclusion DLS and CRP level are good positive and excellent negative predictors of AL; the addition of PCT improved the predictive value for diagnosis of
AL.
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38
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Panda S, Connolly MP, Ramirez MG, Beltrán de Heredia J. Costs Analysis of Fibrin Sealant for Prevention of Anastomotic Leakage in Lower Colorectal Surgery. Risk Manag Healthc Policy 2020; 13:5-11. [PMID: 32021515 PMCID: PMC6968803 DOI: 10.2147/rmhp.s221008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Postoperative anastomotic leaks remain a common and serious complication of colorectal surgeries and are a major cause of mortality and morbidity of these procedures. Anastomotic leaks (AL) have been extensively studied; however, there has been no significant reduction in their prevalence over time. In addition, there is a significant economic burden from AL attributed to the need for repeat surgery, radiologic intervention and lengthened hospital stay. We conducted a comparative cost analysis of patients undergoing colorectal surgery with anastomosis, with the application of fibrin sealant (FS) to the sutured anastomosis versus not treating the sutured anastomosis with FS. Methods The deterministic decision-tree model was populated with clinical data including operating room time, hospitalization days, occurrence of AL, need for revision surgery, blood products and radiologic interventions to treat the AL in lower colorectal surgery. A systematic literature review was conducted to identify appropriate studies with these variables. Results The average cost per case treated lower colorectal surgery with fibrin sealant glue 10 mL Tisseel® and those not treated with a fibrin sealant after suturing the anastomoses was €3233 and €4130, respectively, for resource expenses paid by the healthcare system. This would suggest potential savings of €897 per surgery, achieved through the application of FS to the sutured anastomosis for preventing AL following colorectal surgery. Conclusion Application of FS to the sutured anastomosis in lower colorectal surgery resulted in a decrease in post-operative AL, and cost savings based on a reduction in hospitalization days, a reduction needing: revision surgery, radiologic intervention and blood products to treat AL.
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Affiliation(s)
- Saswat Panda
- Global Market Access Solutions LLC, Charlotte, NC, USA
| | - Mark P Connolly
- Global Market Access Solutions LLC, Charlotte, NC, USA.,University of Groningen, Department of Pharmacy, Unit of Pharmacoeconomics, Groningen, Netherlands
| | - Manuel G Ramirez
- Global HEOR Advanced Surgery, Baxter Health Care Corporation, Deerfield, MA, USA
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Luo W, Qian C, Lu T, Zhang L, Sun M, Li F, Xu Z, Jia Y. A Modified Side-to-Side Anastomosis Using a Circular Stapler Reduces Anastomotic Leakage in Colonic Surgery. Surg Innov 2020; 27:143-149. [PMID: 31893973 DOI: 10.1177/1553350619895629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background. Anastomotic leakage (AL) remains one of the serious complications after colonic surgery. Method. A prospective interventional study to assess a modified technique of creating the ileocolic, colic-colic, and colorectal side-to-side anastomoses using a circular stapler. The primary endpoint was to evaluate the safety and efficacy of this technique in the reduction of AL. Computed tomography scan was performed when AL was clinically suspected. Result. One hundred and forty-five patients who underwent colonic resection between January 2015 and August 2018 were included. One patient underwent surgery for severe inflammatory bowel disease, and the others underwent surgery for colonic cancer. The procedures were open surgeries, including right hemicolectomy (n = 79 [54.5%]), left hemicolectomy (n = 29 [20%]), sigmoidectomy (n = 30 [20.7%]), and transverse colectomy (n = 7 [4.8%]). In 23 patients with ascending colonic obstruction, emergency right colectomy with primary anastomosis was performed. Two surgeons performed the operations (52.4% and 47.6%, respectively), and intraoperative blood loss was 50 to 100 mL. The operative time was 160 to 240 minutes. There was no mortality postoperatively, and 26 (17.9%) patients developed complications. One patient who underwent transverse colonic cancer resection developed a clinical AL (0.7%). After ileostomy, the patient was discharged with no other serious complication. The median of postoperative hospital stay was 8 days (range = 5-18 days). Conclusion. This modified technique is a safe and efficient method for anastomotic configuration in colonic surgery.
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Affiliation(s)
- Wenjun Luo
- Suining Central Hospital, Suining, Sichuan, China
| | - Chuan Qian
- Suining Central Hospital, Suining, Sichuan, China
| | - Tingting Lu
- Suining Central Hospital, Suining, Sichuan, China
| | | | - Meng Sun
- Suining Central Hospital, Suining, Sichuan, China
| | - Fugen Li
- Suining Central Hospital, Suining, Sichuan, China
| | - Zhengwen Xu
- Suining Central Hospital, Suining, Sichuan, China
| | - Yingdong Jia
- Suining Central Hospital, Suining, Sichuan, China
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Wallace B, Schuepbach F, Gaukel S, Marwan AI, Staerkle RF, Vuille-dit-Bille RN. Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Gastroenterol Res Pract 2020; 2020:9057963. [PMID: 32411206 PMCID: PMC7199605 DOI: 10.1155/2020/9057963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 02/08/2023] Open
Abstract
Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.
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Affiliation(s)
- Bradley Wallace
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | | | - Stefan Gaukel
- Department of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Switzerland
| | - Ahmed I. Marwan
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | - Ralph F. Staerkle
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Switzerland
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41
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Risk factors for ileocolic anastomosis dehiscence; a cohort study. Am J Surg 2019; 220:170-177. [PMID: 31759455 DOI: 10.1016/j.amjsurg.2019.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/25/2019] [Accepted: 11/10/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anastomotic leak (AL) after ileocolic anastomosis influences morbidity, mortality, length of hospitalization and costs. This study analyzes risk and protective factors for AL on ileocolic anastomoses. METHODS We retrospectively analyzed our single institution patients' series undergoing elective ileocolic anastomosis for AL between 1/2008-12/2017. AL grade A/B (antibiotic treatment and/or radiological drainage) were summarized as mild, grade C (surgical re-intervention) corresponds to severe AL. RESULTS We included 470 patients (mean age 70.8 years, 43.2% females). Overall AL rate was 9.4% (44 patients) with 6.0% severe and 3.4% mild AL. There was no difference in AL between hand sewn and stapled anastomoses. Multivariate analysis revealed preoperative serum albumin (p = 0.004), smoking habits (p = 0.005) and perioperative blood transfusion (p = 0.038) as risk factors for AL. Suture oversewing as anastomotic reinforcement resulted as independent protective factor (p < 0.001). CONCLUSION Poor nutritional status, smoking habits and perioperative blood transfusion are negative factors influencing on AL. Suture oversewing as anastomotic reinforcement associates with significantly less AL.
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42
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Chang YK, Foo CC, Yip J, Wei R, Ng KK, Lo O, Choi HK, Law WL. The impact of indocyanine-green fluorescence angiogram on colorectal resection. Surgeon 2019; 17:270-276. [DOI: 10.1016/j.surge.2018.08.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/08/2018] [Accepted: 08/16/2018] [Indexed: 02/07/2023]
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Baastrup NN, Hartwig MFS, Krarup PM, Jorgensen LN, Jensen KK. Anastomotic Leakage After Stoma Reversal Combined with Incisional Hernia Repair. World J Surg 2019; 43:988-997. [PMID: 30483884 DOI: 10.1007/s00268-018-4866-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Stoma reversal in patients with an incisional hernia represents a clinical dilemma, as it remains unknown whether hernia repair should be concomitantly employed. We aimed at examining postoperative complications and mortality in patients undergoing stoma reversal with or without concomitant hernia repair. METHODS This study included all patients subjected to stoma reversal between 2010 and 2016 at our institution. Patients were grouped according to conductance of concomitant incisional hernia repair or not. The primary outcome was anastomotic leak (AL). Secondary outcomes were surgical site occurrences (SSO), overall surgical complications, 90-day mortality and overall survival. RESULTS In total, 142 patients were included of whom 18 (13%) underwent concomitant hernia repair. The incidence of AL was significantly higher in patients subjected to concomitant hernia repair (four out of 18 [22.2%]) compared with patients undergoing stoma reversal alone (three out of 124 [2.4%], P = 0.002). Additional variables associated with AL were duration of surgery (P < 0.001) and ischemic heart disease (P = 0.039). Twenty-two patients (15.5%) developed a SSO: eight (44.4%) in the hernia repair group and 14 (11.3%) in the non-hernia repair group (P < 0.001). In the multivariable analysis, concomitant hernia repair remained significantly associated with development of postoperative complications (OR = 5.92, 95% CI = 1.54-25.96, P = 0.012). CONCLUSIONS Compared with stoma reversal alone, incisional hernia repair concomitant with stoma reversal was associated with a higher incidence of AL and other complications.
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Affiliation(s)
- Niklas N Baastrup
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark.
| | - Morten F S Hartwig
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Peter-Martin Krarup
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Kristian K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
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El-Said MM, Emile SH. Cellular therapy: A promising tool in the future of colorectal surgery. World J Gastroenterol 2019; 25:1560-1565. [PMID: 30983816 PMCID: PMC6452228 DOI: 10.3748/wjg.v25.i13.1560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 02/06/2023] Open
Abstract
Cellular therapy may be the solution of challenging problems in colorectal surgery such as impaired healing leading to anastomotic leakage and metastatic colorectal cancer (CRC). This review aimed to illustrate the role of cellular therapy in promotion of wound healing and management of metastatic CRC. An organized literature search for the role of cellular therapy in promotion of wound healing and management of metastatic CRC was conducted. Electronic databases including PubMed/Medline, Scopus, and Embase were queried for the search process. Two types of cellular therapy have been recognized, the mesenchymal stem cells (MSCs) and bone marrow-mononuclear cells (BM-MNCs) therapy. These cells have been shown to accelerate and promote healing of various tissue injuries in animal and human studies. In addition, experimental studies have reported that MSCs may help suppress the progression of colon cancer in rat models. This article reviews the possible mechanisms of action and clinical utility of MSCs and BM-MNCs in promotion of healing and suppression of tumor growth in light of the published literature. Cellular therapy has a potentially important role in colorectal surgery, particularly in the promotion of wound healing and management of metastatic CRC. Future directions of cellular therapy in colorectal surgery were explored which may help stimulate futures studies on the role of cellular therapy in colorectal surgery.
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Affiliation(s)
- Mohammed Mohammed El-Said
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura 35516, Egypt
| | - Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura 35516, Egypt
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45
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Saur NM, Paulson EC. Operative Management of Anastomotic Leaks after Colorectal Surgery. Clin Colon Rectal Surg 2019; 32:190-195. [PMID: 31061649 DOI: 10.1055/s-0038-1677025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anastomotic leak is associated with increased morbidity and mortality after colorectal surgery. Although surgical techniques have improved over time, anastomotic leak is still a reality in colorectal surgery with rates ranging from as low as 1% for low-risk anastomoses, such as enteroenteric or ileocolic, to 19% for high-risk coloanal anastomoses. There are many varied risk factors for anastomotic leak. However, many of the risk factors have not been definitively proven in high-quality studies. Presumably, risk factors are cumulative and every effort should be made to optimize modifiable risk factors in the perioperative period. Treatment of anastomotic leak should start with the determination of patient stability followed by resuscitation and diagnostic imaging or operative exploration. Operative findings will dictate surgical approach with the goal of controlling sepsis and stabilizing the patient. If nonoperative treatment is undertaken, close patient monitoring is necessary to ensure control of sepsis and that intervention is undertaken if the clinical picture changes. Early intervention at each stage is key to decreasing the morbidity of anastomotic leak.
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Affiliation(s)
- Nicole M Saur
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - E Carter Paulson
- Division of Colon and Rectal Surgery, Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania.,Department of General Surgery, Corporal Michael J. Crescenze VA Medical Center, Philadelphia, Pennsylvania
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46
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Yi X, Huang Y, He Y, Chen C. Risk Factors Associated with Anastomotic Leakage in Colorectal Cancer. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1757-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Venara A, Jaouen R, Lermite E, Le Naoures P, Casa C, Mirallié E, Duchalais E, Hamy A. The Predictive Value of Pulse Wave Velocity for Anastomotic Leakage After Colorectal Surgery. World J Surg 2019; 43:252-259. [PMID: 30109387 DOI: 10.1007/s00268-018-4757-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Arterial perfusion defects are a risk factor for anastomotic leakage (AL) following colorectal surgery. Measuring arterial stiffness using pulse wave velocity (PWV) is known to reflect the performance of the arterial network. The objective of this study was to assess the predictive value of PWV for AL after colorectal surgery. METHODS A prospective monocentric study was conducted on all consecutive patients who underwent colorectal surgery scheduled between March 1, 2016 and May 1, 2017. Patients were divided into two groups according to the PWV which was measured preoperatively using the pOpmètre® device: PWV+ (PWV > 10 m/s) and PWV- (PWV ≤ 10 m/s). We then compared the PWV+ and PWV- groups. The primary endpoint was the AL rate. RESULTS A total of 96 patients were studied, including 60 in the PWV- group and 36 in the PWV+ group. Patients in the PWV+ group were more at risk of presenting with AL than those in the PWV- group (6.25 vs 0%) (p = 0.002). There was no difference in immediate postoperative complications between the two groups apart from the length of hospital stay. PWV predicted the appearance of AL with a sensitivity of and a negative predictive value of 100%. CONCLUSION Measuring PWV could be a used as a predictive examination in the early detection of AL after colorectal surgery.
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Affiliation(s)
- A Venara
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France.
- Angers Medical University, Angers, France.
- INSERM U1235- TENS, The Enteric Nervous System in Gut and Brain Disorders, Institute of Digestive Tract Disorders, (Institut des maladies de l'appareil digestif), 1 Rue Gaston Veil 44035, Nantes, France.
| | - R Jaouen
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France
- Angers Medical University, Angers, France
| | - E Lermite
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France
- Angers Medical University, Angers, France
| | - P Le Naoures
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - C Casa
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - E Mirallié
- Department of Visceral and Endocrine Surgery, Nantes University Hospital, 1 Place Alexis Ricordeau, 44000, Nantes, France
| | - E Duchalais
- INSERM U1235- TENS, The Enteric Nervous System in Gut and Brain Disorders, Institute of Digestive Tract Disorders, (Institut des maladies de l'appareil digestif), 1 Rue Gaston Veil 44035, Nantes, France
- Department of Visceral and Endocrine Surgery, Nantes University Hospital, 1 Place Alexis Ricordeau, 44000, Nantes, France
| | - A Hamy
- Department of Visceral and Endocrine Surgery, CHU Angers, Angers University Hospital, 4 Rue Larrey, 49933, Angers Cedex 9, France
- Angers Medical University, Angers, France
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Colorectal surgery in Italy: a snapshot from the iCral study group. Updates Surg 2019; 71:339-347. [PMID: 30747374 DOI: 10.1007/s13304-018-00612-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 11/28/2018] [Indexed: 12/24/2022]
Abstract
During a recent prospective trial on early diagnosis of anastomotic leakage (AL) after colorectal surgery, we gathered a large database on more than 1500 procedures performed in 19 surgical centers in Italy over a 12-month period. Main purpose of the present paper is to show the epidemiological data about colorectal procedures and anastomotic leakage. Prospective enrollment for all elective colorectal resections with anastomosis (September 2017-September 2018). Primary endpoint was AL; secondary endpoints were morbidity and mortality rates, readmission and reoperation rates, and length of post-operative hospital stay (ClinicalTrials.gov; Identifier: NCT03560180). There were 1546 enrolled cases (56.9% of 2717 total resected cases). The rate of minimally invasive resections was 83.5%. Overall AL rate was 4.92% (76 cases; range per center 0-12.12%). Mean ± SD time to AL diagnosis was 5.95 ± 4.78 days (median 5, range 1-31). Overall morbidity rate was 30.20%, mortality 1.29% (20 cases; range per center 0-3.27), readmission 0.90%, and reoperation 6.92%. Mean ± SD post-operative LOS was 7.89 ± 5.97 days (median 6; range 1-120). AL significantly influenced all other secondary endpoints. This study offers a good snapshot of colorectal resections in Italy. There was a high rate of laparoscopic resections, reflecting the special interest in this kind of surgery by the participating centers. AL, morbidity, mortality, readmission and reoperation rates are compared to those reported in previous population-based studies. Compared to series dealing with open colorectal resections, the time to diagnosis of AL was shortened by several days.
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50
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Cortina CS, Alex GC, Vercillo KN, Fleetwood VA, Smolevitz JB, Poirier J, Myers JA, Orkin BA, Singer MA. Longer Operative Time and Intraoperative Blood Transfusion are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery. Am Surg 2019. [DOI: 10.1177/000313481908500218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce A. Orkin
- Division of Colorectal Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Marc A. Singer
- Division of Colorectal Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
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