Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

[Pancreatic fistula after pancreaticoduodenectomy: risk factors and treatment]

AIM

Operative mortality rates after pancreaticoduodenectomy (PD) have decreased dramatically over the past 3 decades and recent series have reported no mortality. Nevertheless pancreatic leakage remains the major cause of morbidity with incidences varying between 6-16%. The aim of the study is to analyze the main etiopatogenetic factors and the treatment of this complication in the literature and, retrospectively, in own experience.

METHODS

At the Clinical Surgery of the University of Genoa, from 1991 to 1995, and then at the General Surgery Department of the Hospitals of Bordighera and Imperia, between 1995 and 2003, 30 PD were completed; there were 20 males (66.6%) and 10 females (33.3%), the average age being 64.6 years (range 50-81). Indications for surgery were pancreatic head adenocarcinoma (70%), ampullary adenocarcinoma (16.6%), duodenal adenocarcinoma (6.6%) and chronic pancreatitis (6.6%).The personal method of reconstruction after PD consisting of a double Roux-en-Y on the same jejunal loop without interruption of the mesentery and a third anatomical Roux-en-Y to reconstitute the alimentary tract. The gastric stump was anastomosed with the jejunum as a Billroth II-type reconstruction in older patients.

RESULTS

The mean hospital stay was 15 days (range 10-40), the operative time 397 min (range 295-500) and transfusion of red blood cells 0.2 (range 0-3). The incidence of perioperative mortality was 0; pancreaticojejunostomy leakage occurred in 3 patients (10%); one of this died 48 days after surgery for bleeding.

CONCLUSIONS

the level of pancreatic fibrosis and diameter of main pancreatic duct are the more important risk factors for complications after PD. Nowadays pancreaticojejunostomy remains the standard technique; pancreaticogastrostomy, occlusion of the pancreatic duct and two-stage pancreaticojejunostomy must be reserved to selected cases. The majority of pancreatic fistulas are uncomplicated and heal with conservative treatment. The skills of the interventional radiology team provide expert management of these complications, speeding recovery times and minimizing morbidity. If surgical re-exploration is necessary, an early completion pancreatectomy may maximize survival.

[Anastomotic leakage after traditional surgery of the colon and rectum]

BACKGROUND

Anastomotic leakage after traditional surgery of the colon and rectum represents one of the more frightening complications for its high incidence (5-10%) leading to a mortality of 10-33%. The aim of the study is to analyze the main etiopathogenetic factors of this complication in the literature and, retrospectively, in personal experience.

METHODS

At the General Surgery Department of the Hospital of Imperia, between September 1997 and August 2001, 278 laparotomic procedures with large bowel anastomosis were completed; 37 patients (13.3%) were treated in emergency. There were 153 males (55%) and 125 females (45%), the average age being 70.5 years (range 41-94). The mean hospital stay was 12 days (range 7-45).

RESULTS

The incidence of perioperative mortality was 1.1% (3 cases). Anastomotic leakage occurred in 4 patients (1.4%); one of these died. Analysis of the presented series confirms that factors contributing to leakage of colonic anastomoses are: distal rectum anastomoses, rectal cancer, experience of the surgeon and preoperative radiotherapy. Anastomotic leakage didn't occur in emergency, probably for a prudent attitude that considers multiple-stages surgical procedures in high-risk patients; besides a radical subtotal or total colectomy was performed in the treatment of obstructive cancer of the left colon and rectum.

CONCLUSIONS

The incidence of anastomotic leakage in colo-rectal surgery was lower when anastomoses were performed in ideal circumstances; it is necessary to know the main risk factors to reduce this complication.

[Acute pseudoabdomen and mitral stenosis. A clinical report of a very unique case]

Acute alithiasic cholecystitis is uncommon and often secondary to other pathologies. The authors report the case of a patient with mitral valvulopathy which had not been diagnosed until the onset of clinical symptoms of acute cholecystitis, confirmed by abdominal ultrasonography. Emergency cholecystectomy was chosen as the most suitable form of surgery, although the authors were "unaware" of the real circumstances: in hindsight it may be said that emergency surgery eliminated the risk of infective complications which might have led to a general deterioration of the patient's conditions already jeopardized by cardiac disorders. Hepatic biopsy performed during the course of the operation enabled the hepatic situation to be clarified with stenosis caused by impeded venous return to the heart.

Management of thoracic duct complex lesions (chylothorax): experience in 16 patients

From our experience in 16 patients with persistent chylothorax from fistulas of the thoracic duct or its tributaries, we conclude that no standard treatment is uniformly successful and multimodality therapy should be considered. In selected patients, an anastomosis between ectatic lymphatics or hyperplastic lymph nodes and an adjacent vein may be attempted. Chylothorax from "leakage" of the thoracic duct or its tributaries is rare. Rupture of the thoracic duct superior to the sixth thoracic vertebrae generally results in a left-sided chylothorax; below that level, injury usually results in a right-sided chylothorax. The etiology is heterogeneous and includes blunt trauma, penetrating wounds (1), iatrogenic operative injury and lymphatic obstructions due to congenital abnormalities, inflammatory processes or neoplasms. Based on our experience in 16 patients with persistent chylothorax from thoracic duct complex lesions, we review the available treatment options.

A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a "P" loop. Rationale and radionuclide scanning evaluation

We propose a method of reconstruction after pancreaticoduodenectomy consisting of a double Roux en Y on the same jejunal loop without interruption of the mesentery and a third anatomical Roux en Y to reconstitute the alimentary tract. The construction of the double Roux en Y draining pancreas and bile ducts separately, requires a linear Stapler 3-4 centimeters from the biliary anastomosis. In this way, by employing the same loop without mesenteric interruption, two functional excluded loops will be obtained. The rationale of the suggested model is based on the separation of biliary and pancreatic secretions. This makes it possible to avoid a stagnant cul-de-sac coinciding with the pancreaticojejunal anastomosis and to obtain in the case of leakage, a pure biliary and/or pancreatic fistula as far as is possible. 99mTc HIDA scans demonstrated the efficiency, of the biliopancreatic limbs of the reconstruction, showing normal emptying time for the gastric remnant and the absence of radionuclide stagnation or any alkaline enterogastric reflux.

[Spectroscopic analysis of biliary calculi: correlations of the type of calculi and clinical data of 25 consecutive surgical patients]

The Authors considering cholelithiasis as an heterogenic pathological entity report their experience of 25 surgical consecutive patients: 20 with cholesterol or combination gallstones and 5 with black pigmented gallstones. In this series the most frequent factors associated with cholesterol gallstones were LDL hypercholesterolemia and hypertriglyceridemia; while the most frequent factors associated with black pigmented gallstones were hepatopathies. The most frequent symptom was dyspepsia. Only the black pigmented and the mixed gallstones were associated with jaundice and pancreatitis. According to the Literature infection is associated to brown pigment gallstones in 95% of cases, in this series infection is rarely associated with other types of gallstones. Treatment with oral bile salts is useful only in pure cholesterol gallstones, so the distinction among different types of gallstones is useful not only for a better knowledge of their pathogenesis but also for a correct choice of the therapeutic options.

[Pulmonary metastases. Their diagnosis and surgical therapy]

The Authors on the basis of their own experience and scientific literature, study the indications to the surgical treatment of pulmonary metastasis. Surgical treatment usually produces a palliative result, bettering the quality of life. For some other Authors, surgical treatment if there are no local recurrences and metastasis, could produce complete healing.

[Indications, value and limits of surgical therapy in the treatment of cancer of the gallbladder]

The authors analyze different therapeutic modalities for gallbladder can and discuss indications, value and limitations on the basis of the results obtained by their own experience on 13 cases as well as literature data.

[Primary tumors of the biliary hilum. Anatomical and therapeutic aspects]

The validity of a selective surgical attitude towards primary tumours of the hepatic hilus after accurate pre- and intra-operative staging is stressed. Moreover the active management for both radical and palliative purposes is justified by some personal observations of the specific anatomoclinical behaviour of these tumours.

[Sequential hepatic photoscintigraphy with 99mTc HIDA as a method for evaluating alkaline reflux after gastric resection by Quiroli's method and after total gastrectomy by Moricca's method]

The authors have utilized the hepatic sequential photoscintigraphy practiced with 99mTc HIDA to inquiry, into the optics of the alkaline backflow, two patterns of reconstruction after gastric surgery: 1) gastric resection by Quiroli (5 cases inquired); 2) gastrectomy by Moricca (5 cases inquired). The research has demonstrated that the reconstruction by Quiroli is utilizable in order to avoid the backflow and elides the possibility of after meal relaxation of the afferent ansa; the research applied to Moricca's method has shown that does not happen oesophageal backflow at fast and that a least and fleeting backflow happens in the first three minutes from the ingestion of the bole. The authors believe that, though applied to little cases, the practiced method is exact and electively qualified for the study of the surgery modifications of the digestive apparatus over-mesocolico.