Review of Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage after colorectal surgery is a serious complication leading to increased morbidity and mortality. Multiple studies have found as risk factors for anastomotic leakage: male gender, obesity, preoperative steroid and non-steroidal anti-inflammatory drug use, longer duration of operation, surgical experience and preoperative blood transfusion. The laparoscopic approach is not inferior to open surgery in terms of rate of anastomotic fistula. Several studies have also shown the ASA score and tumor distance from the anal verge as predictors for increased operative time and morbidity after laparoscopic total mesorectal excision. There is strong evidence that preoperative radiochemotherapy for rectal cancer increases the risk for anastomotic leakage. The preoperative bowel preparation does not reduce the incidence of postoperative leaks. The use of diversion stoma has not been shown to reduce leak rate, but mitigates the clinical effects of fistula.

Morbidity after reversal of Hartmann operation: retrospective analysis of 56 patients

BACKGROUND

Despite patient selection, postoperative morbidity after reversal of Hartmann's procedure remains significant.

AIM

The objective of this study was to investigate risk factors associated with morbidity after conversion of Hartmann's operation.

PATIENTS AND METHODS

We retrospectively analyzed data of 56 patients who underwent reversal procedures between January 2004 and May 2015 in a single center. We evaluated the following variables: demographic characteristics, medical comorbidities, etiology for Hartmann operation, preoperative lab values, intraoperative surgical details and short-term outcomes (hospital stay, medical and surgical complications, mortality).

RESULTS

There were 37 men (66.1%) and the mean age was 57 years. The most frequent indications for Hartmann's procedure were colorectal cancer in 25 patients (44.6%) and complicated diverticulitis in 10 patients (17.9%). The mean time to the reversal procedure was 9 months. Morbidity rate was 16.1% (9 patients) with an anastomotic leakage rate of 3.6% (2 patients) and mortality rate was 3.6% (2 patients). The most common medical complication was diarrhea (4 patients, 7.2%). Bivariate analysis demonstrated that the only factor significantly associated with postoperative complications was presence of multiple comorbidities.

CONCLUSIONS

Multiple medical comorbidities is the only predictive factor for postoperative complications after Hartmann's reversal and therefore patient selection for this type of surgery is critical.

Clinico-biochemical factors to early predict biliary etiology of acute pancreatitis: age, female gender, and ALT

Background/ Aims: Despite the existence of an easy tool to diagnose biliary tract disease as an etiology for acute pancreatitis (AP), the sensitivity of abdominal ultrasound is around 80%, which can be even lower in certain conditions.

METHODOLOGY

We have retrospectively reviewed data of 146 patients admitted for acute pancreatitis between 1999 and 2013. Bivariate analysis for clinical and biochemical variables was performed with respect to etiology of AP (biliary versus non-biliary). Multivariate analysis was performed by using binary logistic regression.

RESULTS

There were 87 males (59.6%) and 59 females (40.4%), with a median age of 51. The etiology of acute pancreatitis was biliary in 71 patients (48.6%). Bivariate analysis found the following as significant association (p=0.001) with biliary pancreatitis: older age, female gender, and elevated AST, ALT. A binary logistic regression analysis identified as predictor factors for biliary etiology of acute pancreatitis: age OR = 1.031 (95% CI 1.004 - 1.059, p = 0.024), sex (female) OR = 2.34 (95% CI 1.022 - 5.359, p = 0.044) and ALT OR = 1.004 (95% CI 1.001 - 1.007, p =0.004). The two clinical scores included the three variables (A.S.ALT scores) in categorical format were generated and then checked with the ROC curves (areas under curve are 0.768 and 0.778).

CONCLUSIONS

Age, female gender, and elevated ALT can help identifying cases with biliary etiology of acute pancreatitis.

Primary aortoenteric fistula: case report

We report the case of an elderly woman, 81 years old, who was admitted in our department for hematemesis, hematochezia and lower abdominal pain. The abdominal ultrasound and the CT scan diagnosed a primary aortoenteric fistula between an abdominal aortic aneurysm (AAA) and the second part of the duodenum, which is a very rare localization regarding this condition. Surgical pathology,diagnosis and management are discussed.

[Perioperative immunologic changes in colorectal cancer patients]

The aim of the study was to investigate the perioperative immunological profile in colon cancer patients and possible correlations with disease. To investigate the changes in immune mediators profile induced by tumor resection, we assessed the serum levels of cytokines (IL-6, IL-8, IL-10, IFN-gamma, TNF-alpha), chemokines (MIP-1alpha, MCP-1, ENA-78) and growth factors (VEGF, bFGF) in colon cancer patients before, during and after surgery and compared the results with those measured for a group of healthy controls. We have used XMap profiling technology (Luminex) that allows simultaneous measurement of multiple parameters in small volumes of samples. Circulating levels of proinflammatory cytokines IL-1, IL-6, IL-8 and antiinflamatory cytokine IL-10 were elevated in cancer patients with respect to healthy controls. Before surgery, serum levels of MCP-1 and MIP-1alpha positively correlated with the levels of proinflammatory cytokines. During surgery, an increase in serum concentration of all determined mediators was noticed, with positive correlation between TNF-alpha, IL-8, MCP-1 and MIP-1alpha. Interestingly, these correlations were no more noticed one week after operation. Postoperatively, cytokines levels decreased as compared to those noticed before surgery, but still higher than in control group. These preliminary results suggest that both tumor and surgical act may influence immune mediators' network.

Large thigh liposarcoma--diagnostic and therapeutic features

We are presenting the case of a 44-year old patient with large, well-differentiated liposarcoma of the right thigh. We are discussing the clinical findings, diagnosis and surgical treatment. The large dimensions (27/25 cm) and the origin of the tumor in popliteal fossa, migrating through the adductor canal (Hunter's canal) in the anterolateral muscular space of the right thigh, represent the particularity of this case.

ExpIR-RO: A Collaborative International Project for Experimenting Voluntary Incident Reporting In the Public Healthcare Sector in Romania

BACKGROUND

Patient safety within healthcare systems is a central aspect of health policy in most developed countries. From April 2007 to May 2009, the pilot project ExpIR-RO tested a voluntary incident reporting system in a public hospital in Bucharest Romania, in collaboration with two Italian hospitals (in Genoa and Milan).

METHODS

Data were collected anonymously through a form based on the Australian Incident Monitoring System. After appropriate training in reporting adverse events (AEs), staff in the participating Departments voluntarily completed the form. The study lasted 12 months in the Bucharest and Genoa hospitals and 3 months in the Milan hospital. Frequency distributions of replies and AE rates per 1,000 hospitalization days per month were assessed.

RESULTS

Overall, 185 AEs were reported (58 in Bucharest, 75 in Genoa and 52 in Milan). The corresponding rates (per 1,000 hospitalization days per month) were 1 in Bucharest, 3 in Genoa and 15 in Milan. Most AEs were related to diagnostic (28%) and surgical (14%) procedures and patient falls (12%) in Bucharest; patient falls (32%), nursing care (20%) and diagnostic procedures (19%) in Genoa; and nursing care (25%), drug prescription/administration (21%) and diagnostic procedures (17%) in Milan. Seventy-three per cent of respondents in Bucharest informed the patient of the AE, versus 64% in Genoa and 43% in Milan. Conversely, 75% of respondents in Genoa entered AEs in medical records versus 53% in Bucharest and 36% in Milan.

CONCLUSION

ExpIR-RO experience suggests that incident reporting could be introduced on a larger scale in Romania.

Giant lipomatous tumors of the upper extremities--a series of 8 consecutive cases

We present a series of eight consecutive patients evaluated in our department from 2002 to 2007 with giant lipomatous tumors (as defined in medical studies as greater than 5 cm) of upper extremities. There were three male and five female, ranged in age from 17 to 77 years (mean age of 55). The tumor's size ranged from 5 to 34 cm. All patients underwent total excision of the tumors with free margins. All specimens were sent to pathology: seven patients had benign tumors and one patient had liposarcoma. There were no recurrences of the tumors. Appropriate preoperative evaluation and complete surgical excision are mandatory for successful treatment of these tumors.

Serum levels of adipokines resistin and leptin in patients with colon cancer

Adipose tissue displays characteristics of an endocrine organ releasing a number of adipocyte-specific factors known as adipocytokines. It has been recently suggested that adipocytokines may play a role in pathogenesis and progression of certain cancers, in particular in colorectal cancer. The aim of this study was to investigate the association between several blood adipocytokine levels and clinicopathological characteristics of colon cancer patients undergoing surgery. The study group comprised of 29 patients who underwent surgical resection for colon cancer at Emergency University Hospital Bucharest and 27 healthy volunteers. The serum levels of adipocytokines were measured using multianalyte xMap profiling technology (Luminex). Resistin levels were significantly higher in colon cancer patients while leptin serum levels were significantly lower as compared to controls. Leptin levels decreased gradually with tumor stage and aggressiveness. Taken together, these results of this study suggest that adipokines, in particular resistin and leptin may be involved in development and progression of colon cancer.

[Postoperative pain management in elderly patient]

Pain is a common occurrence for the hospitalized elderly, and may often be under recognized and inadequately managed. Insufficient pain management can lead to the sequelae of emotional distress and depression, delirium, anxiety, sleep disturbances, and physical disabilities, as well as increased health care costs. Effective pain management of the older adult begins with pain assessment using the proper tools. Morphine is the analgesic of choice for the older adult, and is appropriate for the postoperative period. It is important to maintain a therapeutic serum level of opioids to prevent inadequate management of the acute pain. Side effects of opioids include hypotension, nausea, mood disturbances, ileus, histamine production, and respiratory depression. The adage for pain treatment in the elderly is "start low and go slow". Paracetamol is commonly prescribed and may be the drug of choice for mild to moderate postoperative pain. Older adults may enjoy the benefits of Patient-Controlled Analgesia and Patient Controlled Epidural Analgesia in the postoperative period; however, thorough and ongoing teaching must occur to ensure understanding and compliance with the therapy. Treating post-procedure pain in the elderly patient requires an understanding of the normal changes associated with aging and the impact on medications, and multimodal analgesia can be the best approach.

[Hereditary pancreatitis]

We present the cases of three brothers (a woman and two men) with recurrent attacks of necrotic acute pancreatitis that were treated in our clinic. Two of them have diabetes mellitus controlled through insulin treatment. All patients have presented the first episode of acute pancreatitis around age of 35. We have observed a high level of serum triglyceride at admission, without evidence of lipid disorder. In addition we couldn't identify other causes of these episodes of acute pancreatitis (biliary stones, alcohol, trauma, drugs, lipid disorders). During the last year two members of this family presented recurrent attacks of abdominal pain without any biochemical or imaging signs of acute pancreatitis.

[Gastric stromal tumors--Clinical and histopathological analysis of four cases]

BACKGROUND

The aim of this study is to present our experience concerning a rare form of gastric tumor--gastrointestinal stromal tumor (GIST).

METHODOLOGY

We reviewed data of four patients with gastric stromal tumors, which have been admitted in our department from 1998-2002.

RESULTS

There were two females and two males with age of 75, 70, 65 and 63 years old. The average duration of symptoms until hospital admission was 7 days. During surgery we discovered proximal gastric tumors with 4, 5, 10 and 20 cm in largest diameter. We performed excision of the whole tumor with a security limit of 2 cm or gastric resection (one case), without limphadenectomy. One patient developed an anastomotic fistula with a good evolution under conservative treatment. All patients left the hospital in a good condition. Histopathological and immunohistochemical study diagnosed gastric stromal tumors by identifying the CD 117 maker. Postoperatively neither one of our patients received chemotherapy or radiotherapy. One female and one male patient died of peritoneal metastasis at nine months and respectively two years after operation. The other two patients are in a good condition up to date, without metastasis, one and respectively three years after surgical treatment. CONCLUSIOUS: Correct diagnosis, complete tumor resection and surveillance are essential steps in management of gastric stromal tumors.

[Survival in a cohort of patients with rectal cancer]

BACKGROUND

The aim of our study is to analyze the five-year survival for patients with operated rectal cancer in our clinic during a five-year period (1997-2001).

METHODS

Our epidemiological clinical study is based on prospective analysis of 196 cases of rectal cancer operated between 1997 and 2001. Survival evaluation was prospective cohort follow-up study. We have used Epiinfo 2000 software package for data analysis.

RESULTS

The five-year survival was 54.08% if we take into account all deceases including other causes and 64.28% for exclusive deaths caused by rectal cancer and metastasis. The survival at 5 years (S5) was: stage A S5 = 85.3%; stage B1 S5 = 76.6%; stage B2 S5 = 71%; stage C S5 = 68.7% and stage D S5 = 8.6%. The follow-up in month (e5) was: stage A e5 = 58, stage B1 e5 = 46; stage B2 e5 = 36, stage C e5 = 20 and stage D e5 = 6. The values for S5 and e5 are in accordance with the literature.

CONCLUSIONS

Despite progresses of rectal cancer management, the five-year survival doesn't transcend much over 50%. Because the five-year survival for A stage is 85.3% in our study, we may conclude that at present introducing of screening program represents the only chance for improvement of results.