Impact of anastomotic leak on recurrence and survival after colorectal cancer surgery: a BioGrid Australia analysis

Modulating Gut Microbiota Prevents Anastomotic Leak to Reduce Local Implantation and Dissemination of Colorectal Cancer Cells after Surgery

PURPOSE

Anastomotic leak (AL) is a major complication in colorectal cancer surgery and consists of the leakage of intestinal content through a poorly healed colonic wound. Colorectal cancer recurrence after surgery is a major determinant of survival. We hypothesize that AL may allow cancer cells to escape the gut and lead to cancer recurrence and that improving anastomotic healing may prevent local implantation and metastatic dissemination of cancer cells.

EXPERIMENTAL DESIGN

We investigated the association between AL and postoperative outcomes in patients with colorectal cancer. Using mouse models of poor anastomotic healing, we assessed the processes of local implantation and dissemination of cancer cells. The effect of dietary supplementation with inulin and 5-aminosalicylate (5-ASA), which activate PPAR-γ in the gut, on local anastomotic tumors was assessed in mice undergoing colonic surgery. Inulin and 5-ASA were also assessed in a mouse model of liver metastasis.

RESULTS

Patients experiencing AL displayed lower overall and oncologic survival than non-AL patients. Poor anastomotic healing in mice led to larger anastomotic and peritoneal tumors. The microbiota of patients with AL displays a lower capacity to activate the antineoplastic PPAR-γ in the gut. Modulation of gut microbiota using dietary inulin and 5-ASA reinforced the gut barrier and prevented anastomotic tumors and metastatic spread in mice.

CONCLUSIONS

Our findings reinforce the hypothesis that preventing AL is paramount to improving oncologic outcomes after colorectal cancer surgery. Furthermore, they pave the way toward dietary targeting of PPAR-γ as a novel way to enhance healing and diminish cancer recurrence.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.

In vivo evaluation of a hyperspectral imaging system for minimally invasive surgery (HSI-MIS)

BACKGROUND

Hyperspectral Imaging (HSI) is a reliable and safe imaging method for taking intraoperative perfusion measurements. This is the first study translating intraoperative HSI to an in vivo laparoscopic setting using a CE-certified HSI-system for minimally invasive surgery (HSI-MIS). We aim to compare it to an established HSI-system for open surgery (HSI-Open).

METHODS

Intraoperative HSI was done using the HSI-MIS and HSI-Open at the Region of Interest (ROI). 19 patients undergoing gastrointestinal resections were analyzed in this study. The HSI-MIS-acquired images were aligned with those from the HSI-Open, and spectra and parameter images were compared pixel-wise. We calculated the Mean Absolute Error (MAE) for Tissue Oxygen Saturation (StO₂), Near-Infrared Perfusion Index (NIR-PI), Tissue Water Index (TWI), and Organ Hemoglobin Index (OHI), as well as the Root Mean Squared Error (RMSE) over the whole spectrum. Our analysis of parameters was optimized using partial least squares (PLS) regression. Two experienced surgeons carried out an additional color-change analysis, comparing the ROI images and deciding whether they provided the same (acceptable) or different visual information (rejected).

RESULTS

HSI and subsequent image registration was possible in 19 patients. MAE results for the original calculation were StO_{2 orig.} 17.2% (± 7.7%)_, NIR-PI_orig. 16.0 (± 9.5), TWI_orig. 18.1 (± 7.9), OHI_orig. 14.4 (± 4.5). For the PLS calculation, they were StO_{2 PLS} 12.6% (± 5.2%), NIR-PI_PLS 10.3 (± 6.0), TWI_PLS 10.6 (± 5.1), and OHI_PLS 11.6 (± 3.0). The RMSE between both systems was 0.14 (± 0.06). In the color-change analysis; both surgeons accepted more images generated using the PLS method.

CONCLUSION

Intraoperative HSI-MIS is a new technology and holds great potential for future applications in surgery. Parameter deviations are attributable to technical differences and can be reduced by applying improved calculation methods. This study is an important step toward the clinical implementation of HSI for minimally invasive surgery.

The Value of Federated Data Networks in Oncology: What Research Questions Do They Answer? Outcomes From a Systematic Literature Review

OBJECTIVES

Real-world evidence (RWE) plays an important role in addressing key research questions of interest to healthcare decision makers. Federated data networks (FDNs) apply novel technology to enable the conduct of RWE studies with multiple partners, without the need to share the individual partner's data set. A systematic review of the published literature was performed to determine which types of research questions can best be addressed through FDNs, specifically in the field of oncology.

METHODS

Systematic searches of MEDLINE and Embase were undertaken to identify the types of research questions that had been addressed in studies using FDNs. Additional information was retrieved about study characteristics, statistical methods, and the FDN itself.

RESULTS

In total, 40 publications were included where research questions on the following had been addressed (multiple categories possible): disease natural history (58%), safety surveillance (18%), treatment pathways (15%), comparative effectiveness (10%), and cost/resource use studies (3%)-13% of studies had to be left uncategorized. A total of 50% of the studies were run with data partners in networks of ≤5. The size of the networks ranged from 227 patients to >5 million patients. Statistical methods used included distributed learning and distributed regression methods.

CONCLUSIONS

Further work is needed to raise awareness of the important role that FDNs can play in leveraging readily available RWE to address key research questions of interest in cancer and the benefits to the research community in engaging in federated data initiatives with a long-term perspective.

The impact of cervical anastomotic leak after esophagectomy on long-term survival of patients with esophageal cancer

BACKGROUND

Anastomotic leak is a major complication after esophagectomy. There is a paucity of data on long-term oncological outcomes of cervical anastomotic leak after esophagectomy for cancer. We evaluated the impact of such a leak on postoperative outcomes as well as on long-term oncological outcomes.

METHODS

A retrospective analysis of a prospectively maintained database of patients with esophageal cancer who underwent esophagectomy with a cervical esophagogastric anastomosis between 2010 and 2017. Patients were divided into 3 groups: patients with no anastomotic leak; patients with nonsevere (type 1 & 2) leak, and patients with severe (type 3) leak. A comparison of postoperative and long-term oncological outcomes was made between the groups.

RESULTS

Two hundred and eight patients were included in this study. Thirty-two (15%) patients had cervical anastomotic leak, of which 20 (63%) had type 1 and 2 (nonsevere) leak, and 12 (37%) had type 3 (severe) leak. Overall, 30-day mortality rate was 7%. Mortality rate was 4% in patients without leak, 15% in patients with nonsevere leak, and 25% in patients with severe anastomotic leak (P = .007). Overall median survival was 42 months. Patients with severe leak had poorer overall survival compared to patients with nonsevere and no anastomotic leak (6, 38, and 39 months, respectively, P = .011). There was no difference in disease-free survival of patients with or without anastomotic leak.

CONCLUSION

Leakage from cervical anastomosis after esophagectomy had no impact on disease-free survival of patients with esophageal cancer. Severe anastomotic leak was associated with lower overall survival, probably due to a high rate of postoperative mortality.

Does rectal tube/transanal stent placement after an anterior resection for rectal cancer reduce anastomotic leak? A systematic review and meta-analysis

BACKGROUND

There is increasing evidence that either a transanal stent (TAS) or rectal tube (RT) can decrease the risk of anastomotic leakage (AL) after anterior resection for rectal cancer, in which a diverting stoma may not be required.

OBJECTIVES

The aim of this review was to investigate the efficacy and safety of RT/TAS in preventing AL after anterior resections.

DATA SOURCES

An up-to-date systematic review was performed on the available literature between 2000 and 2020 on PubMed, EMBASE, Medline and Cochrane Library databases.

STUDY SELECTION

All studies reporting on anterior resections in adults, comparing transanal tube/stent versus non-tube/stent, were analysed.

MAIN OUTCOME MEASURE

The primary outcome was rates of AL, whereas secondary outcomes compared associated unplanned re-operation for AL and hospital length of stay (LOS).

RESULTS

Two randomized controlled trials and 13 observational studies were included, with 1714 patients receiving RT/TAS and 1741 patients without. There were 119 (7%) patients with AL in the RT/TAS group compared to 216 (12.3%) patients in the non-RT/TAS group (OR: 0.48, 95% CI: 0.38-0.62, p < 0.001). There were 47 (2.9%) patients with AL complications requiring surgery in the RT/TAS group compared to 132 (8%) patients in the non-RT/TAS group (OR: 0.29, 95% CI: 0.20-0.42, p < 0.001) and no significant difference identified with the standardized mean difference (SMD) favouring the RT/TAS group for hospital LOS (SMD: -0.23, 95% CI: -0.51 to 0.06, p = 0.115).

CONCLUSION

The use of RT/TAS post restorative anterior resection for rectal cancer should be considered, given the benefits shown from this meta-analysis.

Anastomotic leak risk in complete responders to neoadjuvant therapy for rectal cancer: a systematic review

PURPOSE

The oncological benefits of achieving a complete pathological response following neoadjuvant chemoradiotherapy for rectal cancer are well defined. How a pathological response affects anastomotic healing or leak rates is not clear. The aim of this systematic review was to compare anastomotic leak rates among patients who did and did not achieve a complete pathological response.

METHODS

Three major databases (PubMed, Embase, and Scopus) were searched. Predetermined inclusion criteria included prospective and retrospective articles published in English reporting complete pathological response and anastomotic leak rates following total mesorectal excision in ≥ 30 patients with rectal cancer who underwent neoadjuvant chemoradiotherapy and total mesorectal excision. The primary outcomes measured included complete pathological response and 30-day postoperative morbidity.

RESULTS

From a total of 8919 patients with rectal cancer in 7 studies, 4165 fulfilled the criteria for inclusion. The majority (> 80%) of patients had clinical stage II or III disease. A defunctioning loop ileostomy was formed in 76.5%. A total of 589 (14.1%) patients achieved a pCR of whom 63 (10.7%) developed an anastomotic leak compared to 272/3576 (7.6%) patients without a pCR (p = 0.02).

CONCLUSION

Patients with complete pathological response following neoadjuvant chemoradiotherapy and total mesorectal excision may be at higher risk of anastomotic leak than incomplete responders. This may need to be taken into account when counseling patients about the relative risks of organ preservation versus anterior resection.

The impact of anastomotic leakage on oncology after curative anterior resection for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Anastomotic leakage (AL) is a serious clinical complication after anterior resection for rectal cancer and will lead to an increase in postoperative mortality. However, the effect on long-term oncology outcomes remains controversial.

METHODS

We searched the PubMed, Embase, and Cochrane library databases for related articles. The included studies assessed local recurrence, distant recurrence, overall survival, cancer-specific survival and disease-free survival. The systematic reviews and meta-analyses was conducted in accordance with the PRISMA guidelines. The combined RRs with 95% CI were then calculated using a fixed effects model or a randomized effect model.

RESULTS

A total of 18 cohort studies included 34,487 patients who met the inclusion criteria. The meta-analysis demonstrated that AL was associated with increased local recurrence (RR 1.47, 95% CI 1.14-1.90, I = 57.8%). Anastomotic leakage decreased overall survival (RR 0.92, 95% CI 0.88-0.96, I = 58.1%), cancer-specific survival (RR 0.96, 95% CI 0.92-1.00, I = 30.4%), and disease-free survival (RR 0.85, 95% CI 0.77-0.94, I = 80.4%). Distant recurrence may had no significant effects of AL (RR 1.16, 95% CI 0.91-1.46, I = 58.4%).

CONCLUSION

AL has a negative effect on local recurrence and long-term survival (including overall survival, cancer-specific survival, and disease-free survival) after anterior resection for rectal cancer, but not related to distant recurrence.

Impact of hospital geographic remoteness on overall survival after colorectal cancer resection using state-wide administrative data

BACKGROUND

This study aimed to use administrative data (AD) linked to the Victorian death index (VDI) to report on overall long-term survival following colorectal cancer (CRC) surgery, comparing regional to metropolitan hospitals.

METHODS

A retrospective cohort study using prospectively gathered AD linked to VDI. The primary outcome was overall survival (OS). Outcomes were adjusted for potential confounders via multivariable Cox proportional hazard regression analysis.

RESULTS

Total of 17 533 patients: 12 879 metropolitan patients, 3835 inner regional patients and 719 outer regional patients. Multivariable Cox regression, adjusted for the effects of age, ASA score, Charlson score, position of tumour, mode of access, admission type, lymph node metastases, distant metastases, return to theatre, length of stay, HDU admission and discharge destination showed no difference in OS comparing CRC resection patients from inner or outer regional hospitals to metropolitan ((HR 1.02, 95% CI 0.95-1.09, P = 0.59) and (HR 0.97, 95% CI 0.85-1.11, P = 0.68) respectively).

CONCLUSION

This is the largest and most detailed study concerning OS after CRC resection involving Victorian public hospitals. There was no difference in OS following CRC resection when inner or outer regional hospitals were compared to metropolitan hospitals in Victoria. The study demonstrated the utility of AD with validated algorithms, linked to death data for reporting CRC survival outcomes.

Impact of hospital geographic remoteness on short-term outcomes after colorectal cancer resection using state-wide administrative data

BACKGROUND

This study aimed to use validated coding algorithms, applied to a central repository of administrative data (AD), to report on short-term outcomes following resection for colorectal cancer (CRC) comparing regional to metropolitan Victorian hospitals.

METHODS

This is a retrospective cohort study using prospectively gathered AD. The primary outcome was prolonged length of stay (LOS). Secondary outcomes were: inpatient mortality, return to theatre, discharge destination and need for mechanical ventilation/intensive care unit support. Outcomes were adjusted for potential confounders via multivariable logistic regression analysis.

RESULTS

This study of 18 470 patients found strong evidence for lower odds of prolonged LOS (odds ratio (OR) 0.53, 95% confidence interval (CI) 0.48-0.58, P ≤ 0.001) and inpatient mortality (OR 0.67, 95% CI 0.49-0.91, P = 0.01) in inner regional hospital compared with metropolitan hospitals. For outer regional hospitals, there was strong evidence of decreased odds of prolonged LOS (OR 0.64, 95% CI 0.52-0.77, P = <0.001) and return to theatre (OR 0.67, 95% CI 0.47-0.95, P = 0.03).

CONCLUSION

This is the largest and most detailed study concerning short-term outcomes following CRC resection in Victorian public hospitals. Inner and outer regional centres had similar or better short-term outcomes than metropolitan hospitals after CRC resection. AD with validated algorithms serves as a large accurate database to report on CRC outcomes.

The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage.

METHODS

The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I² , and bias was evaluated by funnel plot and Begg's test.

RESULTS

A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12).

CONCLUSIONS

The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.

Anastomotic leak in colorectal cancer patients: New insights and perspectives

Anastomotic leak (AL) remains a potentially life-threatening sequela of colorectal surgery impacting on mortality, short- and long-term morbidity, quality of life, local recurrence (LR) and disease-free survival. Despite technical improvements and the identification of several surgery- and patient-related factors associated to the risk of AL, its incidence has not significantly changed over time. In this context, the clarification of the mechanisms underlying anastomotic healing remains an important unmet need, crucial for improving patients' outcomes. This review concentrates on novel key findings in the etiopathogenesis of AL, how they can contribute in determining LR, and measures which may contribute to reducing its incidence. AL results from a complex, dynamic interplay of several factors and biological processes, including host genetics, gut microbiome, inflammation and the immune system. Many of these factors seem to act in concert to drive both AL and LR, even if the exact mechanisms remain to be elucidated. The next generation sequencing technology, including the microbial metagenomics, could lead to tailored bowel preparations targeting only those pathogens that can cause AL. Significant progress is being made in each of the reviewed areas, moving toward translational and targeted therapeutic strategies to prevent the difficult complication of AL.

Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer

PURPOSE

The aim of this study was to assess the effects of socioeconomic deprivation on short-term outcomes and long-term overall survival following major resection of colorectal cancer (CRC) at a tertiary hospital in England.

METHOD

This was an observational cohort study of patients undergoing resection for colorectal cancer from January 2010 to December 2017. Deprivation was classified into quintiles using the English Indices of Multiple Deprivation 2010. Primary outcome was overall complications (Clavien-Dindo grades 1 to 5). Secondary outcomes were the major complications (Clavien-Dindo 3 to 5), length of hospital stay and overall survival. Outcomes were compared between most affluent group and most deprived group. Multivariate regression models were used to establish the relationship taking into account confounding variables.

RESULTS

One thousand eight hundred thirty-five patients were included. Overall and major complication rates were 44.9% and 11.5% respectively in the most affluent, and 54.6% and 15.6% in the most deprived group. Most deprived group was associated with higher overall complications (odds ratio 1.48, 95% CI 1.13-1.95, p = 0.005), higher major complications (odds ratio 1.49, 1.01-2.23, p = 0.048) and longer hospital stay (adjusted ratio 1.15, 1.06-1.25, p < 0.001) when compared with most affluent group. Median follow period was 41 months (interquartile range 20-64.5). Most deprived group had poor overall survival compared with most affluent, but it was not significant at the 5% level (hazard ratio 1.27, 0.99-1.62, p = 0.055).

CONCLUSION

Deprivation was associated with higher postoperative complications and longer hospital stay following major resection for CRC. Its relationship with survival was not statistically significant.

The impact of anastomotic leakage on recurrence and long-term survival in patients with colonic cancer: A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Anastomotic leakage (AL) is one of the most severe complications following colorectal cancer surgery and is associated with increased short and long term mortality. The literature is conflicting regarding increased risk of recurrence after AL. The aim of this study was to systematically review the impact of anastomotic leakage on the risk of local or distant recurrence and overall survival, cancer specific survival, and disease-free survival.

METHODS

A systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. A systematic search in PubMed, EMBASE, CINHAL, and The Cochrane Library was performed and meta-analyses were performed on all outcomes including analysis based on time-to-event data.

RESULTS

A total of eighteen cohort studies, including 69,047 patients whereof 2,555 patients had anastomotic leakage, were included. Meta-analysis demonstrated no significant effects of anastomotic leakage on local recurrence (RR 1.16, 95% CI 0.84-1.59) or distant recurrence (RR 1.44, 95% CI 0.52-3.96). Anastomotic leakage decreased overall survival (RR 0.85, 95% CI 0.77-0.94), disease free survival (RR 0.80, 95% CI 0.72-0.89), and cancer specific survival (RR 0.90, 95% CI 0.83-0.97). A time-to-event analysis was conducted on available data and the results were congruent with the frequency analyses.

CONCLUSION

Anastomotic leakage following colonic resections is significantly associated with impaired overall survival, disease free survival and cancer specific survival. The study did not show any statistically significant association between anastomotic leakage and recurrence.

Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse

Background Anterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR). Patients and methods A series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed. Results AL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively. Conclusions Anastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.

Indocyanine Green Fluorescence Angiography and the Incidence of Anastomotic Leak After Colorectal Resection for Colorectal Cancer: A Meta-analysis

BACKGROUND

Anastomotic leak is a life-threatening complication of colorectal surgery. Recent studies showed that indocyanine green fluorescence angiography might be a method to prevent anastomotic leak.

OBJECTIVE

The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak.

DATA SOURCES

Potential relevant studies were identified from the following databases: PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure.

STUDY SELECTION

This meta-analysis included comparative studies investigating the association between indocyanine green fluorescence angiography and anastomotic leak in patients undergoing surgery for colorectal cancer where the diagnosis of anastomotic leak was confirmed by CT and the outcomes of the indocyanine green group were compared with a control group.

INTERVENTION

Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis.

MAIN OUTCOME MEASURES

The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies. ORs and 95% CIs were used to assess the association between indocyanine green and anastomotic leak.

RESULTS

In 4 studies with a total sample size of 1177, comparing the number of anastomotic leaks in the indocyanine green and control groups, the ORs were 0.45 (95% CI, 0.18-1.12), 0.30 (95% CI, 0.03-2.98), 0.17 (95% CI, 0.01-3.69), and 0.12 (95% CI, 0.03-0.52). The combined OR was 0.27 (95% CI, 0.13-0.53). The difference was statistically significant (p < 0.001), and there was no significant heterogeneity (p = 0.48; I = 0).

LIMITATIONS

Data could not be pooled because of the small number of studies; some differences between studies may influence the results. Also, the pooled data were not randomized.

CONCLUSIONS

The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery

BACKGROUND

Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery.

METHODS

This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone.

RESULTS

Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology.

CONCLUSION

Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Comorbidity and the risk of anastomotic leak in Chinese patients with colorectal cancer undergoing colorectal surgery

PURPOSE

Comorbidities had considerable effects on the prognosis in patients with colorectal cancer (CRC). The primary aim of the present study was to examine the influence of comorbidity on the risk of anastomotic leak (AL) in patients with CRC who underwent surgical resection.

METHODS

Using the electronic Hospitalization Summary Reports in the top-ranked public hospitals in China, we identified 11,397 patients with CRC undergoing resection surgery from 2013 through 2015. We estimated the risk of AL according to Charlson Comorbidity Index (CCI) score using logistic regression analysis, adjusting for age, sex, and geographic regions.

RESULTS

The incidence rate of AL in the study population was 1.8% (204/11,397). Multivariable analyses identified male sex and CCI score as independent risk factors for AL. The CCI score had a positive graded association with the risk of AL (P for trend = 0.006). The risk increased by an estimated 10.2% (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.18) for each additional 1 point in the CCI score. After adjusting for potential confounders, patients with a CCI score ≥3 had 1.82 times (95% CI, 1.24-2.69) higher risk of AL compared with patients with a CCI score of 0.

CONCLUSION

The findings suggested that CCI score was an independent risk factor for the development of AL in Chinese patients with CRC who underwent surgical resection.

Very Early Colorectal Anastomotic Leakage within 5 Post-operative Days: a More Severe Subtype Needs Relaparatomy

Early anastomotic leakage (AL), usually defined as leakage within 30 post-operative days, represents a severe entity. However, mounting evidence has indicated that majorities of leakage occur within one week after surgery, making late AL rarity. Here we analyzed 101 consecutive colorectal AL, all of which occurred within 30 post-operative days, during Jan 2013 and Dec 2015 in cancer hospital of Fudan University. AL occurring within 5 post-operative days was defined as very early AL (vE-AL). We evaluated risk factors of vE-AL compared with non-vEAL and correlated with post-leakage peritonitis and need of relaparatomy. We found that AL occurred at median time of 7 days after surgery. 23 cases were vE-AL. Reconstruction of post-peritoneum for mid-low rectal carcinoma significantly reduced incidence of vE-AL compared with non-vE-AL (p = 0.042). Patients with vE-AL was associated with presence of peritonitis (p = 0.031), the latter significantly correlated with increased re-operation rate (p = 6.8E-13). Besides, patients with vE-AL trended to correlate with increased re-operation rate after leakage (p = 0.088). In concludsion, vE-AL occurring within 5 post-operative days represents a severe subtype associated with general peritonitis and need of relaparatomy.