Colorectal anastomotic leak rates are measures of technical skill in surgery

Prospective analysis of 246 fires of da Vinci SureForm SmartFire stapler in colorectal cancer: First Indian study

INTRODUCTION

One of the critical steps involved is the distal transection of the rectum in rectal cancer surgeries. Multiple staple firings have been proven to increase the rate of anastomotic leakage. In this study, we intended to learn the effectiveness of the robotic SureForm SmartFire (SS) stapling system and its application in robotic sigmoid colon and rectal procedures performed at our institution.

PATIENTS AND METHODS

Prospective study of patients who underwent surgeries for sigmoid/rectal cancer at our centre was considered. During the surgery, SS staplers were used, and its internal data log with regard to reload selection by the colour, reloads, clamp attempts and staple fires was considered along with intra- and post-operative outcomes.

RESULTS

246 firings were done in 147 cases with mean body mass index of 26.3 ± 4.3 kg/m2; mean blood loss was 53.6 ± 21.8 ml. None of our patients had stapler-related complications, and the mean length of stay was 7.18 ± 1.5 days. Average reloads used in robotic-low anterior resection (LAR) were 1.73 with the fire attempts beyond lap angle occurring only in robotic-assisted LAR (RA-LAR)/abdominoperineal resection in 87 fires (41%) with 120 instances of controlled and sequential pauses occurred in 246 fires once fire pedal was activated.

CONCLUSION

Apart from oncological nodal and margin clearance in the carcinoma rectum surgery, obtaining adequate distal margin, sphincter preserving approach and distal transection of the rectum forms one of the key steps in the low anterior resection. Robotic SS staplers have 120° angulation in both axes with EndoWrist technology that has better manoeuvrability within the confines of the pelvis.

Prospective analysis of 164 fires of da Vinci SureForm SmartFire stapler in oncological cases: Indian cohort of 76 consecutive cases

Background

The application of robotic staplers in surgeries has increased in recent years. Robotic platform enhances ability of the surgeon to directly control and manoeuvre staplers to achieve required angulation and sealing within the confines of the thorax and pelvis. Hence, in this study, we intended to learn the effectiveness of the SureForm™ SmartFire™ technology stapling system in various oncological procedures.

Patients and Methods

Prospective study of 76 patients who underwent robotic-assisted total oesophagectomy, gastrectomies, hemicolectomies, low anterior resection/abdominoperineal resection and lobectomies/metastasectomy for respective malignancies for 16 months. Internal data log of the da Vinci surgical system for reload colour, reloads used, clamp attempts and staple fires used during each procedure along with patient's post-operative outcomes were recorded.

Results

One hundred and sixty-four firings have been made in 76 cases, with the majority being green reloads (76.8%) and average reloads for radical cystectomy 3.5, lobectomies/metastasectomy 3.44 and oesophagectomy 2.55. None of the cases had incomplete firings and required force-fire activation. In forty per cent of cases, the robotic stapler had to pause for sequential compression and seal. Seventy per cent of anterior resection procedures had at least one firing >45° beyond the laparoscopy limit. Collectively 52% SureForm stapler fires in anterior resection with >45° angle of fire. None of the cases had bleed or leak.

Conclusion

SureForm™ SmartFire™ robotic staplers can be used for various oncological surgeries with minimal peri-operative leak and bleeding and has better articulation in closed spaces. Further case-matched comparative studies with laparoscopic or handheld powered staplers would be required for useful operative decision-making and analyse the clinical outcomes.

Compression automation of circular stapler for preventing compression injury on gastrointestinal anastomosis

Background

Conventional manual compression relies on the surgeon's subjective sensations, so excessive compression can cause tissue injury to the stapling line of the intestinal anastomosis.

Methods

Automatic compression monitoring and compression control system was developed for circular stapler. The tissue injury related compression variables were evaluated and accommodated by compression control device. The compression injury‐reducing performance was verified on collagen sheets of in vitro experiments.

Results

Excessive pressure and tissue deformation were associated with compression‐induced tissue damages. The safe pressure range was very narrow in weaker tissue than normal collagen. The automatic system performed proper compression within a safe pressure range without tissue injury.

Conclusions

Manual compression of circular stapler could cause tissue injuries by excessive pressure and tissue deformation. Our automatic compression system is designed to control peak pressure to prevent the compressive tissue injury.

Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery

INTRODUCTION

The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice.

METHODS

A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting.

RESULTS

Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds.

CONCLUSIONS

This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer

BACKGROUND

Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT.

PATIENTS AND METHODS

This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared.

RESULTS

Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group.

CONCLUSIONS

With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.

Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes

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.

Bovine pericardium buttress reinforces colorectal anastomoses in a canine model

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.

Single-stapled double-pursestring anastomosis after anterior resection of the rectum

BACKGROUND

Single-stapled double-pursestring technique for colorectal anastomosis to the mid-rectum or upper rectum is the most commonly used technique in the single institution reported here. The investigators evaluate single-stapled double-pursestring anastomosis after anterior resection of the rectum performed at a single institution.

METHODS

Medical records of patients who underwent single-stapled double-pursestring anastomosis between January 2000 and May 2005 were analyzed to identify postoperative anastomotic complications. Patients with previous radiation, diverting stoma, coloanal, and hand-sewn and double-stapled anastomoses were excluded. The primary goal was to identify postoperative anastomotic complications.

RESULTS

Of 160 patients, 153 (96%) no septic complications. One patient (.6%) developed anastomotic leak requiring diversion. Of the 4 patients with pelvic abscesses (2.5%), 2 were treated with antibiotics and 2 with computed axial tomography-guided drainage.

CONCLUSIONS

Single-stapled double-pursestring anastomosis is reliable, with very low rates of leak, subsequent diversion, and pelvic abscess (.6%, .6%, and 2.5% respectively).

The incidence of anastomotic leaks in patients undergoing colorectal surgery

BACKGROUND

There is evolving interest in auditing and credentialling the performance of surgeons. The incidence of anastomotic leakage has been proposed as a measure of performance following colorectal surgery. The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage in patients undergoing resections of the colon and rectum.

METHODS

A prospective database was developed for all patients undergoing colorectal surgery. Anastomotic leakage was defined prior to the commencement of the study. A logistic regression analysis was performed to determine independent predictors of leakage. The variables analysed included age, sex, American Society of Anesthesiology (ASA) score, anatomical location, pathology, emergency surgery, type of anastomosis, a covering stoma and radiotherapy. Significance was defined as the probability of a type 1 error of < 5%. The results are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

There were 1598 patients who underwent 1639 anastomoses. Their mean age was 63 years, 34% of patients were ASA 3 or 4, and 16% of the operations were emergencies. Anastomotic leaks occurred in 2.4% (40/1639) of anastomoses. The leak rate for intraperitoneal anastomoses was 1.5% (19/1283) vs 6.6% for extraperitoneal anastomoses (21/316). Half of these leaks (20/40) were managed with re-operation or percutaneous drainage procedures. Ultra-low anterior resections were associated with the highest leak rate (8%, 18/225). A logistic regression analysis identified a covering stoma (P = 0.0001, OR 5.078, 95% CI 2.527-10.23) and diverticular disease (P = 0.037, OR 2.304, 95% CI 1.053-5.042) as independent predictors of a leak.

CONCLUSIONS

Within this surgical unit, the incidence of leaks from intraabdominal anastomoses was relatively low. However, leaks in patients undergoing extraperitoneal anastomoses continue to be a major cause of morbidity and mortality.

Transrectal and Transvaginal Sonographic Intervention of Infected Pelvic Fluid Collections

Infected pelvic fluid collections are relatively common particularly after abdominal or pelvic surgery or in patients suffering from benign intestinal disease such as diverticulitis, appendicitis, or Crohn's disease. Historically the treatment of pelvic abscess has been either laparotomy with lavage or blind surgical incision and drainage through the rectal or vaginal wall. More recently, computed tomography and ultrasound-guided percutaneous drainage has become the procedure of choice, when feasible, for the treatment of pelvic abscess. However, many deep pelvic collections are not amenable to percutaneous technique. Transrectal or transvaginal ultrasound-guided abscess drainage is a safe and effective method used in the treatment of deep pelvic abscesses. The purpose of this article is to review the techniques, patient selection, pre- and post-procedural care, and monitoring aspects of transrectal or transvaginal ultrasound-guided drainage.