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Imaizumi Y, Takano Y, Okamoto A, Nakano T, Takada N, Sugano H, Takeda Y, Ohkuma M, Kosuge M, Eto K. High-output stoma is a risk factor for stoma outlet obstruction in defunctioning loop ileostomies after rectal cancer surgery. Surg Today 2024; 54:106-112. [PMID: 37222815 DOI: 10.1007/s00595-023-02704-x] [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: 01/18/2023] [Accepted: 05/01/2023] [Indexed: 05/25/2023]
Abstract
PURPOSE Defunctioning loop ileostomy has been reported to reduce symptomatic anastomotic leakage after rectal cancer surgery; however, stoma outlet obstruction (SOO) is a serious postileostomy complication. We, therefore, explored novel risk factors for SOO in defunctioning loop ileostomy after rectal cancer surgery. METHODS This is a retrospective study that included 92 patients who underwent defunctioning loop ileostomy with rectal cancer surgery at our institution. Among them, 77 and 15 ileostomies were created at the right lower abdominal and umbilical sites, respectively. We defined the output volumeMAX as the maximum output volume the day before the onset of SOO or-for those without SOO-that was observed during hospitalization. Univariate and multivariate analyses were performed to evaluate risk factors for SOO. RESULTS SOO was observed in 24 cases, and the median onset was 6 days postoperatively. The stoma output volume in the SOO group was consistently higher than that in the non-SOO group. In the multivariate analysis, the rectus abdominis thickness (p < 0.01) and output volumeMAX (p < 0.01) were independent risk factors for SOO. CONCLUSION A high-output stoma may predict SOO in patients with defunctioning loop ileostomy for rectal cancer. Considering that SOO occurs even at umbilical sites with no rectus abdominis, a high-output stoma may trigger SOO primarily.
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Affiliation(s)
- Yuta Imaizumi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Yasuhiro Takano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Atsuko Okamoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takafumi Nakano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Naoki Takada
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Sugano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yasuhiro Takeda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masahisa Ohkuma
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Makoto Kosuge
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Alzahrani AA, Alturkistani SA, Alturki H, Baeisa RS, Banoun JA, Alghamdi RA, Alghamdi JA. Evaluation of Factors That Contribute to Intraoperative and Postoperative Complications Following Colorectal Cancer Surgeries at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Cureus 2024; 16:e52339. [PMID: 38230385 PMCID: PMC10790061 DOI: 10.7759/cureus.52339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a major contributor to cancer-related mortality and morbidity due to its high prevalence. Surgery remains the curative option. Colorectal cancer patients come to our institute at an advanced stage due to the lack of adequate national screening programs in developing countries. This carries a particularly high risk of morbidity and mortality. In this study, we aim to provide an overview of the complications of colorectal cancer surgery and to describe the preoperative and intraoperative factors associated with it. METHODS This retrospective record review was done at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, Saudi Arabia. It included all patients aged 18 and older who have undergone colorectal cancer surgeries from January 2017 until August 2022. RESULTS In our sample of 195 patients, 52.3% of the patients were males. The mean age of our sample was 59.32 ± 13.21. We found that 19 (9.7%) patients had an intraoperative complication (IOC). The most frequent IOC was bleeding reported in seven patients (3.6%), followed by intestinal injury in three (1.2%), bladder injury in three (1.2%), and ureter injury in three (1.2%). Regarding preoperative lab tests, patients who had low blood albumin levels (P = 0.004) and high preoperative white blood cell count (WBC; P = 0.015) were more likely to experience IOC. There was a statistically significant relationship between the patient's ASA score and IOC (P = 0.011). Postoperative complications (POC) occurred in 58 patients (29.7%). The most frequent POC was surgical site infection (SSI; 16.4%), followed by urinary tract infections (UTI) (6.7%) and prolonged postoperative ileus (5.6%). Patients who initially presented with vomiting (P = 0.015), had free air on a preoperative abdominal computed tomography (CT) scan (P = 0.028), required intraoperative blood transfusions (P = 0.033), were diagnosed with transverse colon tumors (P = 0.045), and required longer hospital stays (P = 0.011) were found to have a higher rate of POC. CONCLUSION The incidence of colorectal cancer is increasing, and surgery is a successful treatment option. However, complications from surgery may result in morbidities and prolonged hospital stays. The risk of IOC is increased by preoperative variables such as high WBC levels, low albumin, and ASA scores. Patients with initial obstruction signs, free air on CT scans, intraoperative blood transfusions, transverse colon tumors, and longer hospital stays have a higher rate of POC. Patient monitoring and the provision of standardized clinical tools enhance general survival and quality of life.
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Affiliation(s)
| | - Suhail A Alturkistani
- Surgery, Gastrointestinal Oncology Unit, King Abdulaziz University Hospital, Jeddah, SAU
| | - Hassan Alturki
- Surgery, Gastrointestinal Oncology Unit, King Abdulaziz University Hospital, Jeddah, SAU
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Muacevic A, Adler JR, Singh A, Aravind Kumar C, Bisen YT, Dighe OR. Techniques for Diagnosing Anastomotic Leaks Intraoperatively in Colorectal Surgeries: A Review. Cureus 2023; 15:e34168. [PMID: 36843691 PMCID: PMC9949993 DOI: 10.7759/cureus.34168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
Colorectal cancer is one of the most common surgically curable malignancies worldwide, having a good prognosis even with liver metastasis. This improved patient outcome is marred by anastomotic leaks (AL) in operated patients of colorectal cancer despite a microscopically margin-negative resection (R0). Various risk factors have been attributed to causing this. Preoperative non-modifiable factors are age, male sex, cancer cachexia, and neoadjuvant chemo-radiotherapy, and modifiable factors are comorbidities, peripheral vascular disease, anemia, and malnutrition. Intraoperative risk factors include intraoperative surgical duration, blood loss and transfusions, fluid management, oxygen saturation, surgical technique (stapled, handsewn, or compression devices), and approach (open, laparoscopic, or robotic). Postoperative factors like anemia, infection, fluid management, and blood transfusions also have an effect. With the advent of enhanced recovery after surgery (ERAS) protocols, many modifiable factors can be optimized to reduce the risk. Prevention is better than cure as the morbidity and mortality of AL are very high. There is still a need for an intraoperative technique to detect the viability of anastomotic ends to predict and prevent AL. Prompt diagnosis of an AL is the key. Many surgeons have proposed using methods like air leak tests, intraoperative endoscopy, Doppler ultrasound, and near-infrared fluorescence imaging to decrease the incidence of AL. All these methods can minimize AL, resulting in significant intraoperative alterations to surgical tactics. This narrative review covers the methods of assessing of integrity of anastomosis during the surgery, which can help prevent anastomotic leakage.
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Affiliation(s)
- Alexander Muacevic
- Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - John R Adler
- Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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5
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Sandilos G, Zhu C, Giugliano DN, Kwiatt M, Wang YR, Hunter K, McClane SJ. Risk Factors Associated with the Development of Colorectal Anastomotic Strictures Prior to Diverting Loop Ileostomy Reversal. Am Surg 2022:31348221075785. [DOI: 10.1177/00031348221075785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Anastomotic strictures represent a major source of morbidity in colorectal surgery with an incidence reported up to 30%. Despite this, the mechanism by which strictures develop remains unclear. This study aims to determine the incidence of colorectal anastomotic strictures and associated risk factors among a series of diverted patients. Materials and Methods A retrospective chart review was conducted of 142 patients over a 7-year period at a single institution after colorectal resection with anastomosis and diverting ileostomy creation re-examined with postoperative endoscopy. One patient was removed due to anastomotic tumor recurrence. Patient and technical factors were examined for significance using chi-square analysis. Logistic regression was used to perform multivariate analysis to estimate odds ratio (OR) and 95% confidence intervals (CI). Results Among 141 patients, 14.1% (20 patients) developed strictures detected on endoscopy. Strictures were observed in a greater percentage of women than men (21.2% vs 8%, P = .025). 30.6% of patients who underwent resections for diverticulitis developed strictures while those with neoplastic lesions and other indications had stricture rates of 6.8% and 17.6%, respectively ( P = .002). Anastomoses performed during a colostomy reversal were associated with a higher stricture rate (OR 4.23, 95% CI 1.37-13.40, P = .012). Anastomoses performed with a 28/29 mm EEA circular stapler demonstrated a significantly higher stricture rate versus a 31/33 mm stapler (OR 7.21, 95% CI 1.23-155.58, P = .045). Discussion Our data reveal that female sex, history of diverticulitis, anastomoses performed in the setting of colostomy reversal, and smaller stapler size are associated with a higher rate of anastomotic stricture.
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Affiliation(s)
| | - Clara Zhu
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | | | - Michael Kwiatt
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Yize R. Wang
- Department of Gastroenterology, Cooper University Hospital, Camden, NJ, USA
| | - Krystal Hunter
- Biostatistics Group, Cooper Research Institute, Cooper University Hospital, Camden, NJ, USA
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Sell NM, Francone TD. Anastomotic Troubleshooting. Clin Colon Rectal Surg 2021; 34:385-390. [PMID: 34853559 DOI: 10.1055/s-0041-1735269] [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 leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.
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Affiliation(s)
- Naomi M Sell
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Todd D Francone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
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Bhattarai A, Kowalczyk W, Tran TN. A literature review on large intestinal hyperelastic constitutive modeling. Clin Biomech (Bristol, Avon) 2021; 88:105445. [PMID: 34416632 DOI: 10.1016/j.clinbiomech.2021.105445] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/29/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023]
Abstract
Impacts, traumas and strokes are spontaneously life-threatening, but chronic symptoms strangle patient every day. Colorectal tissue mechanics in such chronic situations not only regulates the physio-psychological well-being of the patient, but also confirms the level of comfort and post-operative clinical outcomes. Numerous uniaxial and multiaxial tensile experiments on healthy and affected samples have evidenced significant differences in tissue mechanical behavior and strong colorectal anisotropy across each layer in thickness direction and along the length. Furthermore, this study reviewed various forms of passive constitutive models for the highly fibrous colorectal tissue ranging from the simplest linearly elastic and the conventional isotropic hyperelastic to the most sophisticated second harmonic generation image based anisotropic mathematical formulation. Under large deformation, the isotropic description of tissue mechanics is unequivocally ineffective which demands a microstructural based tissue definition. Therefore, the information collected in this review paper would present the current state-of-the-art in colorectal biomechanics and profoundly serve as updated computational resources to develop a sophisticated characterization of colorectal tissues.
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Affiliation(s)
- Aroj Bhattarai
- Department of Orthopaedic Surgery, University of Saarland, Germany
| | | | - Thanh Ngoc Tran
- Department of Orthopaedic Surgery, University of Saarland, Germany.
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8
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Chen JN, Liu Z, Wang ZJ, Zhao FQ, Wei FZ, Mei SW, Shen HY, Li J, Pei W, Wang Z, Yu J, Liu Q. Low ligation has a lower anastomotic leakage rate after rectal cancer surgery. World J Gastrointest Oncol 2020; 12:632-641. [PMID: 32699578 PMCID: PMC7340993 DOI: 10.4251/wjgo.v12.i6.632] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For laparoscopic rectal cancer surgery, the inferior mesenteric artery (IMA) can be ligated at its origin from the aorta [high ligation (HL)] or distally to the origin of the left colic artery [low ligation (LL)]. Whether different ligation levels are related to different postoperative complications, operation time, and lymph node yield remains controversial. Therefore, we designed this study to determine the effects of different ligation levels in rectal cancer surgery. AIM To investigate the operative results following HL and LL of the IMA in rectal cancer patients. METHODS From January 2017 to July 2019, this retrospective cohort study collected information from 462 consecutive rectal cancer patients. According to the ligation level, 235 patients were assigned to the HL group while 227 patients were assigned to the LL group. Data regarding the clinical characteristics, surgical characteristics and complications, pathological outcomes and postoperative recovery were obtained and compared between the two groups. A multivariate logistic regression analysis was performed to evaluate the possible risk factors for anastomotic leakage (AL). RESULTS Compared to the HL group, the LL group had a significantly lower AL rate, with 6 (2.8%) cases in the LL group and 24 (11.0%) cases in the HL group (P = 0.001). The HL group also had a higher diverting stoma rate (16.5% vs 7.5%, P = 0.003). A multivariate logistic regression analysis was subsequently performed to adjust for the confounding factors and confirmed that HL (OR = 3.599; 95%CI: 1.374-9.425; P = 0.009), tumor located below the peritoneal reflection (OR = 2.751; 95%CI: 0.772-3.985; P = 0.031) and age (≥ 65 years) (OR = 2.494; 95%CI: 1.080-5.760; P = 0.032) were risk factors for AL. There were no differences in terms of patient demographics, pathological outcomes, lymph nodes harvested, blood loss, hospital stay and urinary function (P > 0.05). CONCLUSION In rectal cancer surgery, LL should be the preferred method, as it has a lower AL and diverting stoma rate.
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Affiliation(s)
- Jia-Nan Chen
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zhi-Jie Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Fu-Qiang Zhao
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Fang-Ze Wei
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Shi-Wen Mei
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Hai-Yu Shen
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Juan Li
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Zheng Wang
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
| | - Jun Yu
- Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - Qian Liu
- Department of Colorectal Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union College, Beijing 100021, China
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Influence of suture technique on anastomotic leakage rate-a retrospective analyses comparing interrupted-versus continuous-sutures. Int J Colorectal Dis 2019; 34:55-61. [PMID: 30250969 DOI: 10.1007/s00384-018-3168-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE While many hospitals consider a continuous sutured colonic anastomosis with monofilamental fiber the current state of the art, others have advocated for interrupted sutures as the gold standard. The aim of the study was to evaluate the influence of suture technique on leakage rate (primary endpoint), wound infections, postoperative stay, and mortality. METHODS Retrospective analyses of 347 patients (273 elective, 74 urgent) over 6 years with a handsewn colonic anastomosis (190 interrupted, 157 continuous), excluding sigma and rectum anastomosis. Demographic and surgical baseline characteristics were used as competing predictors. RESULTS Overall leakage rate was 9% but strongly dependent on suture technique (interrupted: 16%; continuous: 2.5%; p = 0.001) yielding an odds ratio of 5.10 [95% CI: 2.55, 6.71] (relative risk of leakage). No other variable showed a significant influence on leakage rate. Postoperative stay was prolonged in the interrupted suture group (23 ± 15 vs. 16 ± 11 days; p = 0.000, attributable effect 7.5 days [4.7, 10.3]). CONCLUSIONS Our results indicate a highly significant reduction of anastomotic leakage rate and postoperative stay that generalize to the underlying population by continuous sutures in handsewn colonic anastomosis. In the absence of randomized prospective studies, the current results provide the yet strongest evidence for the superiority of continuous sutures.
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Kawai K, Iida Y, Ishihara S, Yamaguchi H, Nozawa H, Hata K, Kiyomatsu T, Tanaka T, Nishikawa T, Yasuda K, Otani K, Murono K, Watanabe T. Intraoperative colonoscopy in patients with colorectal cancer: Review of recent developments. Dig Endosc 2016; 28:633-40. [PMID: 27037622 DOI: 10.1111/den.12663] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/23/2016] [Accepted: 03/28/2016] [Indexed: 02/06/2023]
Abstract
The use of intraoperative colonoscopy has increased alongside progress in the development of colonoscopy-associated devices and techniques, including the colonoscope itself. In the present review, we focus on four circumstances in which intraoperative colonoscopy is beneficial to colorectal surgery: (i) intraoperative determination of a tumor's location; (ii) observation of the proximal colon in cases of obstructive colorectal cancer; (iii) confirmation of the integrity of anastomosis; and (iv) novel surgical techniques that combine laparoscopic and endoscopic surgery. In light of the findings of our review, a combination of colonoscopy and surgery-especially laparoscopic surgery-is expected to facilitate the optimal handling of a variety of colorectal tumors, ranging from benign cases to advanced and obstructive cases.
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Affiliation(s)
- Kazushige Kawai
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hironori Yamaguchi
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Yasuda
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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11
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Sasanuma H, Yasuda Y, Mortensen FV, Yamashita K, Nihei Y, Houjou N, Chiba H, Shimizu A, Okada M, Nagai H. Simultaneous Colorectal and Liver Resections for Synchronous Colorectal Metastases. Scand J Surg 2016; 95:176-9. [PMID: 17066613 DOI: 10.1177/145749690609500309] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The surgical strategy for the treatment of colorectal cancer and synchronous hepatic metastases remains controversial. Many surgeons fear anastomotic leakage and intraperitoneal abscesses when performing a one-step procedure. They prefer a two-step procedure with a liver resection 2 to 3 months after resection of the colorectal primary lesion. Subjects and Methods: We analysed medical records from April 1994 to April 2002 for a total of 42 patients with colorectal cancer and synchronous liver metastases who underwent simultaneous liver and colorectal resections with a primary anastomosis. Special attention was paid to data on surgical procedures, postoperative morbidity, and mortality. Results: Forty-two patients, 24 men and 18 women, were studied. Median operating time was 6.50 hours (3.75–11.0 hours), and median blood loss was 1522 ml (range 288 to 5650 ml). Postoperative complications included pleural effusion in 4 patients, ileus in 3, anastomotic leakage in 2, intraperitoneal pelvic abscesses in 1, pneumonia in 1, bile leakage in 1, atelectasis in 1, and wound infection in 1. There was no perioperative mortality. Conclusion: Simultaneous colorectal resection with a primary anastomosis and hepatectomy for synchronous liver metastases is considered a safe procedure.
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Affiliation(s)
- H Sasanuma
- Department of Surgery, Jichi Medical School, Tochigi, Japan.
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12
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Concept Design and Simulation Study on a “Phantom” Anvil for Circular Stapler. Surg Laparosc Endosc Percutan Tech 2015; 25:e72-5. [DOI: 10.1097/sle.0000000000000113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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13
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Chekan E, Whelan RL. Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:305-18. [PMID: 25246812 PMCID: PMC4168870 DOI: 10.2147/mder.s67338] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The introduction of both new surgical devices and reengineered existing devices leads to modifications in the way traditional tasks are carried out and allows for the development of new surgical techniques. Each new device has benefits and limitations in regards to tissue interactions that, if known, allow for optimal use. However, most surgeons are unaware of these attributes and, therefore, new device introduction creates a “knowledge gap” that is potentially dangerous. The goal of this review is to present a framework for the study of device– tissue interactions and to initiate the process of “filling in” the knowledge gap via the available literature. Surgical staplers, which are continually being developed, are the focus of this piece. The integrity of the staple line, which depends on adequate tissue compression, is the primary factor in creating a stable anastomosis. This review focuses on published studies that evaluated the creation of stable anastomoses in bariatric, thoracic, and colorectal procedures. Understanding how staplers interact with target tissues is key to improving patient outcomes. It is clear from this review that each tissue type presents unique challenges. The thickness of each tissue varies as do the intrinsic biomechanical properties that determine the ideal compressive force and prefiring compression time for each tissue type. The correct staple height will vary depending on these tissue-specific properties and the tissue pathology. These studies reinforce the universal theme that compression, staple height, tissue thickness, tissue compressibility, and tissue type must all be considered by the surgeon prior to choosing a stapler and cartridge. The surgeon’s experience, therefore, is a critical factor. Educational programs need to be established to inform and update surgeons on the characteristics of each stapler. It is hoped that the framework presented in this review will facilitate this process.
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Kaur P, Karandikar SS, Roy-Choudhury S. Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis. Clin Radiol 2013; 69:59-62. [PMID: 24156793 DOI: 10.1016/j.crad.2013.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 08/05/2013] [Accepted: 08/06/2013] [Indexed: 11/18/2022]
Abstract
AIMS To assess accuracy of multidetector computed tomography (MDCT) and individual radiological signs in the diagnosis of anastomotic leaks. MATERIALS AND METHODS Patients undergoing anterior resection with a stapled anastomosis over a 2 year period were identified. Electronic and clinical records of these patients were reviewed. Unenhanced and/or enhanced MDCT was performed with intravenous and/or per-rectal contrast medium and read by a radiologist blinded to the patients' clinical details to determine the sensitivity and specificity of specific findings at MDCT for identifying leaks. RESULTS Seventeen percent (30/170) of the anterior resections were suspected to have an anastomotic leak. Ninety-three percent (28/30) of patients underwent MDCT. Seven point six percent (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and positive and negative predictive values of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in one patient. CONCLUSIONS Presence of peri-anastomotic air is a reliable marker of anastomotic leaks at MDCT. Leakage of rectal contrast medium is highly accurate and increases confidence of diagnosis. The appearance of the staple line itself is not accurate in assessing anastomotic integrity.
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Affiliation(s)
- P Kaur
- Department of General Surgery, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK.
| | - S S Karandikar
- Department of General Surgery, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK
| | - S Roy-Choudhury
- Department of Radiology, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK
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Pellino G, Sciaudone G, Candilio G, Camerlingo A, Marcellinaro R, Rocco F, De Fatico S, Canonico S, Selvaggi F. “Mess-o-stomosis”: a matter of malpractice rather than awkwardness. BMC Surg 2013. [PMCID: PMC3847452 DOI: 10.1186/1471-2482-13-s1-a37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Tan WP, Talbott VA, Leong QQ, Isenberg GA, Goldstein SD. American Society of Anesthesiologists class and Charlson's comorbidity index as predictors of postoperative colorectal anastomotic leak: a single-institution experience. J Surg Res 2013; 184:115-9. [PMID: 23830360 DOI: 10.1016/j.jss.2013.05.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 05/03/2013] [Accepted: 05/09/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The American Society of Anesthesiologists (ASA) physical status classification and Charlson comorbidity index (CCI) was adopted to assess patients' physical condition before surgery. Studies suggest that ASA score and CCI might be a prognostic criterion (indicator) for patient outcome. The aim of this study is to determine if ASA classification and CCI can determine the risk of anastomotic leaks (AL) in patients who underwent colorectal surgery. METHODS A retrospective analysis of 505 consecutive colorectal resections with primary anastomoses between 2008 and 2012 was performed at a university hospital. ASA score, CCI, surgical procedure, length of stay, age, body mass index (BMI), comorbidities, and postoperative outcomes were analyzed. RESULTS Two hundred sixty-five patients had an ASA score of I and II, 227 patients had an ASA score of III, and 13 patients had an ASA score of IV. A total of 19 patients had an anastomotic leak (ASA I-II: 5 patients, 1.9%; ASA III: 12 patients, 5.58%; ASA IV: 2 patients, 18.18%). A higher ASA score was significantly associated with AL on further analysis (OR: 2.99, 95% CI: 1.345-6.670, P = 0.007). When matched for age, BMI, and CCI on logistic regression analysis, increased ASA level was independently related to an increased likelihood of leak (OR(steroids) = 14.35, P < 0.01; OR(ASA_III v I-II) = 2.02, P = 0.18; OR(ASA_IVvI-II) = 8.45, P = 0.03). There were no statistically significant differences in means between the leak and no-leak patients with respect to age (60.69 versus 65.43, P = 0.17), BMI (28.03 versus 28.96, P = 0.46), and CCI (6.19 versus 7.58, P = 0.09). CONCLUSIONS ASA score, but not CCI, is independently associated with anastomotic leak. Patients with a high ASA class should be closely followed postoperatively for AL after colorectal operations.
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Affiliation(s)
- Wei Phin Tan
- Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Davis B, Rivadeneira DE. Complications of colorectal anastomoses: leaks, strictures, and bleeding. Surg Clin North Am 2012. [PMID: 23177066 DOI: 10.1016/j.suc.2012.09.014] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.
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Affiliation(s)
- Bradley Davis
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267, USA.
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Finite element modelling of stapled colorectal end-to-end anastomosis: Advantages of variable height stapler design. J Biomech 2012; 45:2693-7. [DOI: 10.1016/j.jbiomech.2012.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 07/12/2012] [Accepted: 07/14/2012] [Indexed: 01/14/2023]
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Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech 2012; 22:65-7. [PMID: 22318063 DOI: 10.1097/sle.0b013e3182401e20] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Anastomotic bleeding after a circular-stapled anastomosis in laparoscopic colon resections is a rare but extremely aggravating complication. An intraoperative endoscopic assessment of the anastomosis allows immediate evaluation regarding bleeding and possible leakage. The aim of the study was to evaluate the impact of routine intraoperative endoscopy on postoperative complications. METHODS Since May 1999, data of all laparoscopic colon resections were collected in a prospective database. Since July 2007, we assessed every circular-stapled anastomosis with a flexible endoscope for bleeding, integrity of mucosa, and leakage. The patients with (+) and without (-) routine endoscopic assessment were compared regarding postoperative complications. RESULTS Group(-) consisted of 253 patients [133 male, 120 female; mean age, 60 years (25 to 86 y)] and group(+) consisted of 85 patients [44 male, 41 female; mean age, 62 years (22 to 87 y), P=not significant] In group(-), postoperative anastomotic bleeding was diagnosed in 11 patients (4.3%) and 7 (2.8%) of these patients required endoscopic assessment and clipping. In group(+), endoscopy showed anastomotic bleeding in 5 patients (5.9%) at the time of surgery, which required clipping. Anastomotic leak was observed in 2 patients (2.4%): in one patient the circular staple line was oversewn and in the other patient anastomosis was redone. Two (2.4%) patients in group(+) had postoperative anastomotic bleeding requiring reendoscopy and clipping. The postoperative leakage rate was not significantly different in both the groups [(-)1.6%, (+)1.2%, P= not significant]. CONCLUSIONS Intraoperative endoscopic assessment of circular-stapled anastomosis can detect early anastomotic bleeding and leakage. Although the postoperative rate of bleeding and leakage was not significantly reduced in our study, we still recommend endoscopic assessment of the circular-stapled anastomosis as a routine procedure in colorectal surgery, as the benefits outweigh the risks.
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Fukunaga Y. Superiority of laparoscopic rectal surgery: Towards a new era. World J Gastrointest Surg 2011; 3:142-6. [PMID: 22110845 PMCID: PMC3220726 DOI: 10.4240/wjgs.v3.i10.142] [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: 03/13/2011] [Revised: 09/20/2011] [Accepted: 09/26/2011] [Indexed: 02/06/2023] Open
Abstract
While laparoscopic colon surgery has been established to some degree over this decade, laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field, the lack of precise anatomy of the pelvis, immature procedures of rectal transaction and so on. On the other hand, maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness. However, some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes. This review article discusses how to keep a clear operative field, removing normally existing abdominal structures, and how to transact the rectum and restore the discontinuity based on anatomical investigations. According to this review, laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far, actually entering a new era.
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Affiliation(s)
- Yosuke Fukunaga
- Yosuke Fukunaga, Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan
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Leroy J, Costantino F, Cahill RA, D'Agostino J, Wu WHS, Mutter D, Marescaux J. Technical aspects and outcome of a standardized full laparoscopic approach to the reversal of Hartmann's procedure in a teaching centre. Colorectal Dis 2011; 13:1058-65. [PMID: 20718831 DOI: 10.1111/j.1463-1318.2010.02389.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Laparoscopic reversal of Hartmann's procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula. METHOD The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra-abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation. RESULTS Forty-two patients underwent the procedure over an 8-year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra-operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship. CONCLUSION Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.
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Affiliation(s)
- J Leroy
- IRCAD, University Hospital of Strasbourg, Strasbourg, France.
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El Zarrok Elgazwi K, Baca I, Grzybowski L, Jaacks A. Laparoscopic sigmoidectomy for diverticulitis: a prospective study. JSLS 2011; 14:469-75. [PMID: 21605507 PMCID: PMC3083034 DOI: 10.4293/108680810x12924466008088] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Results of this study suggest that laparoscopic surgery for diverticular disease is a safe, feasible, and effective management strategy. Background: Surgical treatment of complicated colonic diverticular disease is still debatable. The aim of this prospective study was to evaluate the outcome of laparoscopic sigmoid colectomy in patients with diverticulitis. Patients offered laparoscopic surgery presented with acute complicated diverticulitis (Hinchey type I, II, III), chronically recurrent diverticulitis, bleeding, or sigmoid stenosis caused by chronic diverticulitis. Method: All patients who underwent laparoscopic colectomy within a 12-year period were prospectively entered into a database registry. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. A 4-trocar approach with suprapubic minilaparotomy was performed. Main data recorded were age, sex, postoperative pain, return of bowel function, operation time, duration of hospital stay, and early and late complications. Results: During the study period, 260 sigmoid colectomies were performed for diverticulitis. The cohort included 104 male and 156 female patients; M to F ratio was 4:6. Postoperative pain was controlled by NSAIDs or weak opioid analgesia. Fifteen patients (5.7%) required conversion from laparoscopic to open colectomy. The most common reasons for conversion were directly related to the inflammatory process, abscess, and peritonitis. Mean operative time was 130±54. Average postoperative hospital stay was 10±3 days. A longer hospital stay was recorded for Hinchey type IIb patients. Complications were recorded in 30 patients (11.5%). The most common complications that required reoperation were hemorrhage in 2 patients (0.76) and anastomotic leak in 5 patients (only 3 of them required reoperation). The mortality among them was 2 patients (0.76%). Conclusions: Laparoscopic surgery for diverticular disease is safe, feasible, and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.
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Buchberg BS, Masoomi H, Bergman H, Mills SD, Stamos MJ. The use of a compression device as an alternative to hand-sewn and stapled colorectal anastomoses: is three a crowd? J Gastrointest Surg 2011; 15:304-10. [PMID: 21063913 PMCID: PMC3035790 DOI: 10.1007/s11605-010-1376-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 10/19/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA. METHODS A non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed. RESULTS Twenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion. CONCLUSION The CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.
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Affiliation(s)
- Brian S. Buchberg
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Hossein Masoomi
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Herlinda Bergman
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Steven D. Mills
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Michael J. Stamos
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
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Portillo G, Franklin ME. Clinical results using bioabsorbable staple-line reinforcement for circular stapler in colorectal surgery: a multicenter study. J Laparoendosc Adv Surg Tech A 2010; 20:323-7. [PMID: 20465429 DOI: 10.1089/lap.2009.0201] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Anastomotic leakage is a serious postoperative complication of open and laparoscopic colorectal surgery, very often associated with higher morbidity and mortality. Despite proper patient selection and surgical technique, anastomotic leakage cannot be avoided. The use of a synthetic, bioabsorbable staple-line reinforcement material for the circular stapler may help reduce its prevalence. METHODS From May to December of 2006, 14 doctors, from 18 hospitals in the United States, performed 117 laparoscopic and open colorectal procedures, in which circular bioabsorbable Seamguard (CBSG; W.L. Gore and Associates, Elkton, MD) was used. RESULTS Eighty-three patients underwent laparoscopic surgery (70.0%) and 34 open surgery (30%). The procedures included low anterior resection in 49 patients (42%), sigmoidectomy in 46 patients (39.5%), left hemicolectomy in 12 patients (10%), and total colectomy in 10 patients (8.5%). Sixty-four patients had benign disease and 36% malignant disease. Intraoperative anastomotic leakage tests identified 4 patients with leakage (3.4%). All 4 patients had a very low anastomosis (1, 3, 4, and 6 cm, respectively, from the anal verge). Two of the leaks resolved without further intervention. A fecal diversion procedure was performed in the other 2 patients, including 1 patient with rectal bleeding, requiring a transfusion. No clinical complications related to use of CBSG were reported. CONCLUSIONS The use of Seamguard in colorectal open and laparoscopic surgery may result in a lower incidence of anastomotic leakage.
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Abstract
Colorectal anastomotic leak remains one of the most feared post-operative complications, particularly after anterior resection of the rectum with, the shift from abdomino-peritoneal resections to total mesorectal excision and primary anastomosis. The literature fails to demonstrate superiority of stapled over hand-sewn techniques in colorectal anastomosis, regardless of the level of anastomosis, although a high stricture rate was noted in the former technique. Thus, improvements in safety aspects of anastomosis and alternatives to hand-sewn and stapled techniques are being sought. Here, we review alternative anastomotic techniques used to fashion bowel anastomosis. Compression anastomosis using compression anastomotic clips, endoluminal compression anastomotic rings, AKA-2, biofragmental anastomotic rings, or Magnamosis all involve the concept of creating a sutureless end-to-end anastomosis by compressing two bowel ends together, leading to a simultaneous necrosis and healing process that joins the two lumens. Staple line reinforcement is a new approach that reduce the drawbacks of staplers used in colorectal practice, i.e. leakage, bleeding, misfiring, and inadequate tissue approximation. Various non-absorbable, semi or fully absorbable materials are now available. Two other techniques can provide alternative anastomotic support to the suture line: a colorectal drain and a polyester stent, which can be utilized in ultra-low rectal excision and can negate the formation of a defunctioning stoma. Doxycycline coated sutures have been used to overcome the post-operative weakness in anastomosis secondary to rapid matrix degradation mediated by matrix metalloproteinase. Another novel technique, the electric welding system, showed promising results in construction of a safe, neat, smooth sutureless bowel anastomosis. Various anastomotic techniques have been shown to be comparable to the standard techniques of suturing and stapling. However, most of these alternatives need to be accepted and optimized for future use.
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Experimental evaluation of a bovine pericardium-derived collagen matrix buttress in ileocolic and colon anastomoses. J Biomed Mater Res B Appl Biomater 2010; 92:48-54. [DOI: 10.1002/jbm.b.31488] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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NITI Endoluminal Compression Anastomosis Ring (NITI CAR 27®): A breakthrough in compression anastomoses? Eur Surg 2009. [DOI: 10.1007/s10353-009-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ulrich A, Weitz J, Slodczyk M, Koch M, Jaeger D, Münter M, Büchler MW. Neoadjuvant treatment does not influence perioperative outcome in rectal cancer surgery. Int J Radiat Oncol Biol Phys 2009; 75:129-36. [PMID: 19304407 DOI: 10.1016/j.ijrobp.2008.10.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 10/26/2008] [Accepted: 10/30/2008] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify the risk factors for perioperative morbidity in patients undergoing resection of primary rectal cancer, with a specific focus on the effect of neoadjuvant therapy. METHODS AND MATERIALS This exploratory analysis of prospectively collected data included all patients who underwent anterior resection/low anterior resection or abdominoperineal resection for primary rectal cancer between October 2001 and October 2006. The study endpoints were perioperative surgical and medical morbidity. Univariate and multivariate analyses of potential risk factors were performed. RESULTS A total of 485 patients were included in this study; 425 patients (88%) underwent a sphincter-saving anterior resection/low anterior resection, 47 (10%) abdominoperineal resection, and 13 (2%) multivisceral resection. Neoadjuvant chemoradiotherapy was performed in 100 patients (21%), and 168 (35%) underwent neoadjuvant short-term radiotherapy (5 x 5 Gy). Patient age and operative time were independently associated with perioperative morbidity, and operative time, body mass index >27 kg/m(2) (overweight), and resection type were associated with surgical morbidity. Age and a history of smoking were confirmed as independent prognostic risk factors for medical complications. Neoadjuvant therapy was not associated with a worse outcome. CONCLUSION The results of this prospective study have identified several risk factors associated with an adverse perioperative outcome after rectal cancer surgery. In addition, neoadjuvant therapy was not associated with increased perioperative complications.
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Affiliation(s)
- Alexis Ulrich
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
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Hyman NH, Osler T, Cataldo P, Burns EH, Shackford SR. Anastomotic leaks after bowel resection: what does peer review teach us about the relationship to postoperative mortality? J Am Coll Surg 2008; 208:48-52. [PMID: 19228502 DOI: 10.1016/j.jamcollsurg.2008.09.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 08/21/2008] [Accepted: 09/17/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anastomotic leak is a dreaded complication of intestinal surgery and has been associated with a high mortality rate. But it is uncertain exactly which patient populations are at risk of death from the leak. We sought to assess the impact of surgeon volume on leak rate and to better understand the relationship of a leak to postoperative mortality. STUDY DESIGN All adult patients having a small or large bowel resection with anastomosis at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained quality database; data were entered by a specially trained nurse practitioner who rounded daily with housestaff. Patients with a postoperative leak based on standardized criteria were identified. Patient characteristics, surgical procedure, and operating surgeon were noted. Overall complication and leak rates by surgeon were compared using Fisher's exact test. Individual case review by a group of peers was performed for all patients with a leak who died, to determine the relationship to mortality. RESULTS Five hundred fifty-six patients underwent resection with anastomosis during the study period. There were 27 patients with leaks (4.9%), 6 of whom died. Leak rate for the highest-volume surgeons ranged from 1.6% to 9.9% (p <0.01), and overall complication rate varied from 30.5% to 44% (p=0.04). In four of six deaths, leaks occurred in very ill patients undergoing emergency procedures and appeared to be premorbid events. In only one patient did the leak appear to be the primary cause of death. CONCLUSIONS The variability in leak rate by surgeons doing similar operations suggests that many leaks may be preventable. But death after a leak is most often a surrogate for a critically ill patient and was infrequently the actual cause of death.
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Affiliation(s)
- Neil H Hyman
- Department of Surgery, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT, USA
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Intraoperative colonoscopy for stapled anastomosis in colorectal surgery. Surg Today 2008; 38:1063-5. [PMID: 18958570 DOI: 10.1007/s00595-007-3740-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 12/07/2007] [Indexed: 12/16/2022]
Abstract
Although stapling colorectal anastomosis is widely accepted as an alternative for hand-sewn anastomosis, we continue to experience postoperative complications such as anastomotic hemorrhage and leakage, which sometimes lead to serious morbidity or even mortality. To secure stapling colorectal anastomosis, we adopted intraoperative colonoscopy (IOCS). We performed IOCS in 73 cases of colorectal resection with stapling anastomosis from November 2004 to October 2005. Intraoperative colonoscopy revealed active bleeding from stapling anastomosis in 7 patients (9.6%). Of these, additional sutures were done in 6 patients, while the anastomosis was exteriorized in the other. The air leak test performed by IOCS was positive in 4 patients (5.5%), with additional sutures being done in 2 patients and reanastomoses performed in the other 2. Incomplete cutting of the mucosa was found in one patient, but it was successfully managed. Following the introduction of IOCS, there were no cases of postoperative anastomotic hemorrhage, and only one case of anastomotic leakage (1.4%).
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Kaidar-Person O, Rosenthal RJ, Wexner SD, Szomstein S, Person B. Compression anastomosis: history and clinical considerations. Am J Surg 2008; 195:818-26. [PMID: 18367149 DOI: 10.1016/j.amjsurg.2007.10.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 09/23/2007] [Accepted: 10/10/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite the fact that the concept of compression anastomosis has been investigated for nearly 2 centuries, it has not yet achieved widespread acceptance. The aim of the current report is to review the literature regarding compression anastomoses. DATA SOURCES A multi-database search was conducted using PubMed, Ovid, and the Cochrane Databases (all until June 2007), in addition to electronic links to related articles and references of selected articles. The following terms were used for the search in various combinations: anastomosis, anastomoses, sutureless, compression, nickel-titanium; Nitinol; CAC; CAR; AKA-2, Valtrac biofragmentable anastomotic ring, BAR. Language restrictions were not applied. CONCLUSIONS The various methods of compression anastomosis have been shown to be at least comparable to the standard techniques of suturing and stapling. The measurement of outcomes, including cost, safety, and efficacy of treatment, indicated that compression anastomosis can save time, is cost-effective, and offers an acceptable cost/benefit ratio compared to both stapled and sutured anastomoses. However, compression anastomosis did not gain worldwide popularity.
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Affiliation(s)
- Orit Kaidar-Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Vermeulen J, Vrijland W, Mannaerts GHH. Reversal of Hartmann's procedure through the stomal side: a new even more minimal invasive technique. Surg Endosc 2008; 22:2319-22. [PMID: 18622545 DOI: 10.1007/s00464-008-0049-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2007] [Revised: 05/16/2008] [Accepted: 05/26/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann's procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications. METHODS HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intra-abdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created. RESULTS Mean duration of operation was 81 min (range 58-109 min); mean hospital stay was 4.2 days (range 2-7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site. CONCLUSIONS In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary.
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Affiliation(s)
- Jefrey Vermeulen
- Department of Surgery, Erasmus University Medical Center, Dr. Molenwaterplein 40, 3015 GD Rotterdam, The Netherlands.
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Balaa FK, Gamblin TC, Tsung A, Marsh JW, Geller DA. Right hepatic lobectomy using the staple technique in 101 patients. J Gastrointest Surg 2008; 12:338-43. [PMID: 17701266 DOI: 10.1007/s11605-007-0236-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 06/30/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Application of linear stapling devices for extrahepatic vascular control in liver surgery has been well-established. However, the technique for use of stapling devices in hepatic parenchymal transection is not well defined. PURPOSE To describe the safety and efficacy of our technique for use of vascular stapling devices in hepatic parenchymal transection during open right hepatic lobectomy is the purpose of this study. METHODOLOGY We reviewed our experience with 101 consecutive open right hepatic lobectomies performed by a single surgeon between January 2003 and July 2006, in which vascular staplers were utilized for the parenchymal transection phase. RESULTS Of the 101 patients who underwent resection, 53 (52%) were female. The mean age was 58 years. Malignant disease was the indication for resection in the majority of patients (88%). Of those with cancer, 78% (69 of 89) had metastatic colorectal cancer, 6% (5 of 89) had metastatic neuroendocrine tumor, 4% (4 of 89) had hepatocellular carcinoma, 4% (4 of 89) had cholangiocarcinoma, and the remaining 8% were other metastatic cancers. Twelve patients (12%) underwent resection for hepatic adenoma or symptomatic benign disease (FNH or hemangioma). Forty-eight patients (48%) underwent a major ancillary procedure at the time of hepatic resection. Thirty-nine patients (39%) had a nonanatomic wedge resection of a left lobe lesion, 27 patients (27%) had one or more lesions treated with radiofrequency ablation (RFA), and 6 patients (6%) were treated with a synchronous bowel resection. The median total operative time was 336 min (range 155-620 min). A Pringle maneuver for temporary vascular inflow occlusion was utilized in all cases, with a median time of 9 min (range 4-17 min). Ten patients (10%) required blood transfusion during surgery or in the postoperative period. The maximum transfusion was 2 U of packed red blood cells (PRBC) in seven patients and 1 U of PRBC in three patients. The mean nadir postoperative hematocrit was 28.2. All patients with malignant disease had tumor-free margins at the completion of the procedure. The average hospital length of stay was 6.0 days. One patient (1%) developed a clinically significant bile leak requiring a postoperative endoscopic retrograde cholangiography (ERCP). No patient required reoperation. The 30 and 60-day postoperative survival was 100%. CONCLUSION These findings indicate that application of vascular stapling devices for parenchymal transection in major hepatic resection is a safe technique, with low transfusion requirements and minimal postoperative bile leak. The technique allows for rapid transection of the entire right hepatic lobe in under 10 min. Short video clips of the technique will be demonstrated.
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Affiliation(s)
- Fady K Balaa
- UPMC Liver Cancer Center, Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Hagerman GF, Gaertner WB, Ruth GR, Potter ML, Karulf RE. Bovine pericardium buttress reinforces colorectal anastomoses in a canine model. Dis Colon Rectum 2007; 50:1053-60. [PMID: 17473940 DOI: 10.1007/s10350-007-0212-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The consequences of an anastomotic leak or disruption can be devastating, particularly in the colorectal surgery population. The purpose of this study was to evaluate and compare colon anastomoses with or without a collagen matrix buttress derived from bovine pericardium. METHODS A circular stapler was used to create colon-colon anastomoses in a canine model. Twenty animals underwent two anastomoses each: one buttressed with bovine pericardium, and one without any reinforcement. Staple lines were evaluated at Days 0, 3, 7, 14, 42, and 84. Three animals were killed at each time interval, and evaluation included bursting pressure, bursting location, and histology. RESULTS Colon segments with nonbuttressed anastomoses were more likely to burst at the staple line (63 percent), whereas buttressed anastomoses were more likely to burst at the adjacent intestine (74 percent; P=0.048). The burst pressure of nonbuttressed staple lines tended to be consistently, although not significantly, higher than the burst pressure of buttressed staple lines (P=0.651). At histologic analysis, the bovine pericardium buttress demonstrated an ability to allow cellular ingrowth at Day 3 and neovascularization at Day 7. There was no evidence of stenosis or infection. CONCLUSIONS The use of a collagen matrix buttress in colorectal anastomoses was safe in a canine model. Our study indicates that true burst strength of the majority of buttressed anastomoses was greater than the adjacent intestine.
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Affiliation(s)
- Gonzalo F Hagerman
- Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
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Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 2007; 245:254-8. [PMID: 17245179 PMCID: PMC1876987 DOI: 10.1097/01.sla.0000225083.27182.85] [Citation(s) in RCA: 421] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Anastomotic leaks are among the most dreaded complications after colorectal surgery. However, problems with definitions and the retrospective nature of previous analyses have been major limitations. We sought to use a prospective database to define the true incidence and presentation of anastomotic leakage after intestinal anastomosis. METHODS A prospective database of two colorectal surgeons was reviewed over a 10-year period (1995-2004). The incidence of leak by surgical site, timing of diagnosis, method of detection, and treatment was noted. Complications were entered prospectively by a nurse practitioner directly involved in patient care. Standardized criteria for diagnosis were used. A logistic regression model was used to discriminate statistical variation. RESULTS A total of 1223 patients underwent resection and anastomosis during the study period. Mean age was 59.1 years. Leaks occurred in 33 patients (2.7%). Diagnosis was made a mean of 12.7 days postoperatively, including four beyond 30 days (12.1%). There was no difference in leak rate by surgeon (3.6% vs. 2.2%; P = 0.08). The leak rate was similar by surgical site except for a markedly increased leak rate with ileorectal anastomosis (P = 0.001). Twelve leaks were diagnosed clinically versus 21 radiographically. Contrast enema correctly identified only 4 of 10 leaks, whereas CT correctly identified 17 of 19. A total of 14 of 33 (42%) patients had their leak diagnosed only after readmission. Fifteen patients required fecal diversion, whereas 18 could be managed nonoperatively. CONCLUSIONS Anastomotic leaks are frequently diagnosed late in the postoperative period and often after initial hospital discharge, highlighting the importance of prospective data entry and adequate follow-up. CT scan is the preferred diagnostic modality when imaging is required. More than half of leaks can be managed without fecal diversion.
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Affiliation(s)
- Neil Hyman
- Dept. of Surgery, Fletcher 464, University of Vermont College of Medicine, 89 Beaumont Ave., Burlington, VT 05405, USA.
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Klein A, Scotti S, Hidalgo A, Viateau V, Fayolle P, Moissonnier P. Rectovaginal fistula following colectomy with an end-to-end anastomosis stapler for a colorectal adenocarcinoma. J Small Anim Pract 2007; 47:751-3. [PMID: 17201830 DOI: 10.1111/j.1748-5827.2006.00148.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
An 11-year-old, female neutered Labrador retriever was presented with a micro-invasive differentiated papillar adenocarcinoma at the colorectal junction. A colorectal end-to-end anastomosis stapler device was used to perform resection and anastomosis using a transanal technique. A rectovaginal fistula was diagnosed two days later. An exploratory laparotomy was conducted and the fistula was identified and closed. Early dehiscence of the colon was also suspected and another colorectal anastomosis was performed using a manual technique. Comparison to a conventional manual technique of intestinal surgery showed that the use of an automatic staple device was quicker and easier. To the authors' knowledge, this is the first report of a rectovaginal fistula occurring after end-to-end anastomosis stapler colorectal resection-anastomosis in the dog. To minimise the risk of this potential complication associated with the limited surgical visibility, adequate tissue retraction and inspection of the anastomosis site are essential.
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Affiliation(s)
- A Klein
- Department of Surgery, Ecole Nationale Vétérinaire d'Alfort, 94700 Maisons Alfort, France
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Papp Z, Szalai L, Molnár G, Czakó T, Assefa A, Petri I. Evaluation of colonic anastomoses performed in the last twenty-five years. Orv Hetil 2007; 148:117-20. [PMID: 17289615 DOI: 10.1556/oh.2007.27836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Célkitűzés:
A szerzők célul tűzték ki, hogy közleményükben megvizsgálják az elektív vastagbél-anastomosisok gyógyulását, illetve összehasonlítják a kézzel és géppel varrt bélösszeköttetések szövődményeit és a mortalitást. Rövid történeti áttekintést is adnak a vastagbélsebészet történetéből.
Módszer:
1979. január 1. és 2004. december 31. között, tehát 25 év alatt készített 710 elektív vastagbél-anastomosisok hasonlítanak össze.
Eredmények:
Gyakorlatilag standard személyi és tárgyi feltételek mellett az elmúlt 25 évben 710 elektív vastagbél-anastomosisok készítettek, 2/3-ukat kézzel, l/3-ukat géppel. Saját eredményeik alapján a két technika egyenértékű, szignifikáns eltérés sem a szövődmények, sem a mortalitás tekintetében nem volt a két csoport között.
Következtetés:
A gépi technika drágább, de rectosigmodealis resectióknál, különösen mély rectumresectióknál ma már nem nélkülözhető.
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Affiliation(s)
- Zoltán Papp
- Bugyi István Kórház, Sebészeti Osztály, Szentes.
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Abstract
Anastomotic disruption is a feared and serious complication of colon surgery. Decades of research have identified factors favoring successful healing of anastomoses as well as risk factors for anastomotic disruption. However, some factors, such as the role of mechanical bowel preparation, remain controversial. Despite proper caution and excellent surgical technique, some anastomotic leaks are inevitable. The rapid identification of anastomotic leaks and the timely treatment in these cases are paramount.
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Abstract
INTRODUCTION Anastomotic leakage is a major complication of colorectal surgery causing a significant increase in 30-day mortality. The long-term prognosis of anastomotic leakage is poorly documented. This study was designed to assess whether anastomotic leakage affects five-year survival and local recurrence. METHODS A total of 5,173 patients were recruited to the Wessex Colorectal Cancer Audit during the period September 1991 to August 1995 (prospective data, 5-year follow-up). The effect of anastomotic leakage on five-year survival and local recurrence was analyzed using Kaplan-Meier curves and the log-rank test. RESULTS A total of 1,834 patients underwent a curative resection with an anastomosis (anastomotic leak = 71; 3.9 percent): 30-day mortality: 18.3 percent in the leak group, and 3.5 percent in the nonleak group (P < 0.001); local recurrence: 19 percent in the leak group, and 9.8 percent in the nonleak group (P = 0.018). A total of 1,201 patients underwent colonic anastomosis (anastomotic leak = 31; 2.6 percent). There was no significant difference in local recurrence or five-year survival between the leak and nonleak groups. A total of 633 patients underwent rectal anastomosis (anastomotic leakage = 40; 6.3 percent): 30-day mortality: 10 percent in the leak group, and 2 percent in the nonleak group (P = 0.014); cumulative five-year estimate of local recurrence: 25.1 (95 percent confidence interval, 9.6-40.5) percent in the leak group, and 10.4 (95 percent confidence interval, 7.7-13) percent in the nonleak group (P = 0.007). Cumulative five-year estimate of overall survival: 52.8 (95 percent confidence interval, 36.1-69.4) percent in the leak group, and 63.9 (95 percent confidence interval, 59.9-67.9) percent in the nonleak group (P = 0.19). CONCLUSIONS After rectal anastomosis, an anastomotic leak is associated with a significant increase in local recurrence.
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Affiliation(s)
- Graham Branagan
- Department of Surgery, Salisbury District Hospital, Salisbury, Wilts, UK.
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Lechaux D, Redon Y, Trebuchet G, Lecalve JL, Campion JP, Meunier B. Résection rectale pour cancer par laparoscopie avec exérèse totale du mésorectum (ETM). Résultats à long terme d'une série de 179 patients. ACTA ACUST UNITED AC 2005; 130:224-34. [PMID: 15847857 DOI: 10.1016/j.anchir.2004.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2004] [Accepted: 12/28/2004] [Indexed: 01/14/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcomes and the five-year survival of 179 consecutive patients with rectal carcinoma operated with a laparoscopic procedure between April 1992 and April 2003. METHODS Patients with obstructing, bulky cancers were excluded from this study. Tumor stage was defined according to the TNM classification. Preoperative radiation therapy was offered to T(3) N(0) or N(+) patients (45 Gy). The laparoscopic-assisted technique included total mesorectal excision (TME), primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. All the N+ patients received adjuvant chemotherapy. The outcomes were defined as five-years recurrence (local recurrence and distant metastasis) and the diseases-free survival. The survival rates were calculated with the Kaplan-Meier test. RESULTS There were 108 males and 71 females, median age was 67 (range 39-88). There were 61 upper rectum localizations (34%), 68 middle rectum (38%) and 50 low rectum (28%). Twenty-nine patients required open conversion (16%). Surgical operative morbidity was 24% and medical morbidity was 4%. There were 60 stage I (40%), 25 stage II (16%), 49 stage III (32%), and 16 stage IV (10%). Ninety patients (71%) are alive and disease free, ten (5%) are alive with disease recurrence, and 37 patients (20%) are deceased. Only one case of trocar site implantation occurred after curative resection during an average follow up of 76 months. Five-year observed survival rate were 85% for stage I, 70% for stage II, and 63% for stage III. CONCLUSION In our experience laparoscopic rectal resection could be done safely. The oncologic outcome was similar to that of open surgery. Further randomized trials will be necessary to confirm the value of this technique.
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Affiliation(s)
- D Lechaux
- Service de chirurgie viscérale, centre hôpitalier Yves-Lefoll, 10 rue Marcel-Proust, 22023 Saint-Brieuc, France.
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Yeh CY, Changchien CR, Wang JY, Chen JS, Chen HH, Chiang JM, Tang R. Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective study of 978 patients. Ann Surg 2005; 241:9-13. [PMID: 15621985 PMCID: PMC1356840 DOI: 10.1097/01.sla.0000150067.99651.6a] [Citation(s) in RCA: 223] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective of this study was to investigate prophylactic pelvic drainage and other factors that might be associated with anastomotic leakage after elective anterior resection of primary rectal cancer. SUMMARY BACKGROUND DATA Anastomotic leak after anterior resection for primary rectal cancer leads to significant postoperative morbidity and mortality. The role of pelvic drainage in the prevention of anastomotic leakage is controversial. METHODS We investigated 978 consecutive patients undergoing elective anterior resection for primary rectal cancer between February 1995 and December 1998 in a single institution. Use of a drain and type of drainage were at the surgeon's preference. Data were prospectively collected during hospitalization. Twenty-five independent tumor-, patient-, and treatment-related variables were analyzed. The dependent variable was clinical anastomotic leakage. A binary logistic regression analysis was used to assess the independent association of variables with the dependent variable. RESULTS The clinical anastomotic leakage rate was 2.8%. Independent risk factors for anastomotic leakage were use of an irrigation-suction drain (odds ratio [OR], 9.13; 95% confidence interval [CI], 1.16-71.76), blood transfusion, poor colon preparation (OR, 2.58; 95% CI, 1.10-5.88), and anastomotic level 5 cm or less from the anal verge (OR, 2.38; 95% CI, 1.03-5.46). CONCLUSIONS Routine use of pelvic drainage is not justified and should be discouraged. In cases in which pelvic drainage is required such as in difficult operations or to prevent pelvic hematoma, pelvic drainage other than irrigation-suction should be considered.
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Affiliation(s)
- Chien Yuh Yeh
- Department of Surgery, Colorectal Section of Chang Gung Memorial Hospital, at Linko, Taiwan
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Abstract
PURPOSE An extended Hartmann's procedure is occasionally useful in rectal resections, because anastomotic, perineal, and functional problems are eliminated. This study was designed to examine the occurrence of pelvic sepsis after this procedure and identify possible risk factors. METHODS Medical records were available for 163 patients (89 females) undergoing rectal resection with colostomy and closure of the rectal remnant. Information about pelvic sepsis and possible risk factors was obtained by review of the medical records. RESULTS Pelvis sepsis developed in 31 of 163 patients (18.6 percent). When the rectum had been transected <2 cm above the pelvic floor, 24 of 73 patients (32.9 percent) developed an abscess in contrast to 7 of 90 (7.8 percent) after higher transsection (P = 0.0001). Other risk factors were male gender and missing foot pulses. Only 61 percent of pelvic abscesses healed after a median of 59 days, leaving 39 percent unhealed after an observation period of 277 (range, 20-1,643) days. CONCLUSIONS Surgical alternatives should be considered to an extended Hartmann's procedure when the level of transsection is <2 cm above the pelvic floor, particularly in males.
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Affiliation(s)
- Anders Tøttrup
- Department of Surgery L, University Hospital of Aarhus, Tage Hansensgade 2, 8000 Aarhus C, Denmark.
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Singer MA, Cintron JR, Benedetti E, Lamba A, Abcarian H. Hand-Sewn versus Stapled Intestinal Anastomoses in a Chronically Steroid-Treated Porcine Model. Am Surg 2004. [DOI: 10.1177/000313480407000211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Chronic steroid treatment is known to delay wound healing; however, there are no trials examining stapled intestinal anastomoses in subjects chronically treated with steroids. The current study compares mechanically stapled to manually sutured intestinal anastomoses in a steroid-treated porcine model. Twenty adult male pigs were treated with daily prednisolone (0.5 mg/kg IM) for 14 days. The pigs were divided between hand-sewn and stapled groups. All pigs underwent a laparotomy with construction of a jejunojejunostomy, an ileocecostomy, and a colocolostomy. Pigs were sacrificed on postoperative day 4. Bursting pressure, collagen content, and inflammatory scores were used to evaluate each anastomosis. Bursting pressure was greater for the hand-sewn group at the jejunojejunostomies only (1.52 vs 0.79 psi; P < 0.001). The collagen content and microscopic inflammatory scores were not significantly different at any location. The mean gross inflammatory score was greater for the hand-sewn colocolostomies only (5.20 vs 4.00; P < 0.01). Stapled ileocecostomies and colocolostomies appear to heal as well as hand-sewn anastomoses. This may not be true of the jejunojejunostomies as evidenced by the decreased bursting pressures. These data may provide evidence in support of the use of stapled anastomoses in steroid-treated patients.
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Affiliation(s)
| | | | | | - Amit Lamba
- University of Illinois, Chicago, Illinois
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Fritscher-Ravens A, Mosse CA, Mukherjee D, Mills T, Park PO, Swain CP. Transluminal endosurgery: single lumen access anastomotic device for flexible endoscopy. Gastrointest Endosc 2003. [PMID: 14520300 DOI: 10.1067/s0016-5107(03)02006-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Forming anastomoses between two hollow organs at flexible endoscopy might reduce the need for surgery for obstructing malignancy. Current methods require access to both lumens. The aim of this work was to develop methods of forming an anastomosis at flexible endoscopy, such as a gastrojejunostomy or cholecystoduodenostomy, when access to only one lumen is feasible. METHODS A modified needle was passed through a large-channel echoendoscope from the accessible lumen into the target hollow organ. An anastomotic device was formed by using two 7F catheter segments, which were pushed over a guidewire into the target, the less accessible lumen. When released, by withdrawing the guidewire, the catheters formed a cross shape and created an anastomosis when compressed against a plate from the accessible side. OBSERVATIONS These devices were tested in live animal experiments. With an echoendoscope in the stomach, it was repeatedly possible to place needles, threaded tags, and guidewires into the small intestine and gallbladder. In 4 to 7 days, anastomoses were formed in 16 pigs between the small intestine and the stomach, and between the gallbladder and the stomach. The initial diameter of the anastomoses ranged from 3 to 9 mm. No complication occurred. CONCLUSIONS It is feasible to form anastomoses at flexible endoscopy when access is limited to a single side.
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Sasson AR, Sigurdson ER. Surgery of Rectal Cancer. COLORECTAL CANCER 2002. [DOI: 10.1007/978-1-59259-160-2_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, Chiang JM, Wang JY. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients. Ann Surg 2001; 234:181-9. [PMID: 11505063 PMCID: PMC1422004 DOI: 10.1097/00000658-200108000-00007] [Citation(s) in RCA: 375] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify the risk factors for surgical site infection (SSI) in patients undergoing elective resection of the colon and rectum. SUMMARY BACKGROUND DATA SSI causes a substantial number of deaths and complications. Determining risk factors for SSI may provide information on reducing complications and improving outcome. METHODS The authors performed a prospective study of 2,809 consecutive patients undergoing elective colorectal resection via laparotomy between February 1995 and December 1998 at a single institution. The outcome of interest was SSI, which was classified as being incisional or organ/space with or without clinical leakage. A likelihood ratio forward regression model was used to assess the independent association of variables with SSIs. RESULTS The overall SSI, incisional SSI, and organ/space SSI with and without clinical anastomotic leakage rates were 4.7%, 3%, 2%, and 0.8%, respectively. Risk factors for overall SSI were American Society of Anesthesiology (ASA) score 2 or 3 (odd ratio [OR] = 1.7), male gender (OR = 1.5), surgeons (OR = 1.3-3.3), types of operation (OR = 0.3-2.1), creation of ostomy (OR = 2.1), contaminated wound (OR = 2.9), use of drainage (OR = 1.6), and intra- or postoperative blood transfusion (1-3 units, OR = 5.3; >/=4 units, OR = 6.2). However, SSIs at specific sites differed from each other with respect to the risk factors. Among a variety of risk factors, only blood transfusion was consistently associated with a risk of SSI at any specific site. CONCLUSIONS In addition to ASA score and surgical wound class, blood transfusion, creation of ostomy, types of operation, use of drainage, sex, and surgeons were important in predicting SSIs after elective colorectal resection.
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Affiliation(s)
- R Tang
- Colorectal Section, Chang Gung Memorial Hospital, Linkou, Taiwan
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Abstract
The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.
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Affiliation(s)
- A R Sasson
- Department of Surgical Oncology, Fox Chase Cancer Center, 7701 Burholme Avenue, Philadelphia, PA 19111, USA
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