Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation

Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients

BACKGROUND

Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice.

METHODS

Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge.

RESULTS

Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar.

CONCLUSIONS

Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.

Anastomotic leak in patients with acute complicated diverticulitis undergoing primary anastomosis: risk factors and the role of diverting loop ileostomy

BACKGROUND

Recent data has suggested that primary anastomosis (PA), with or without a diverting loop ileostomy (DLI), is a safe option for the treatment of acute complicated diverticulitis. This study aimed to evaluate risk factors associated with anastomotic leak in patients who underwent a sigmoid colectomy with PA and to determine whether a DLI was protective against a clinically significant anastomotic leak.

METHODS

Patients with acute complicated diverticulitis who underwent a laparoscopic or open sigmoid colectomy with PA, with or without a DLI, were identified in the NSQIP PUF(2016-2017). The rates of anastomotic leak, receipt of DLI, and type of leak management were compared. Multivariate logistic regression was performed.

RESULTS

There were 497 patients identified. Seventy-nine(15.9%) patients had a DLI, while 418 (84.1%) did not. Twenty-six anastomotic leaks were identified (5.2%). On multivariate analysis, current smoking (OR 4.02; 95% CI 1.44-11.26) and chronic steroid use (OR 3.84; 95% CI 1.16-12.69) were significantly associated with an increased risk of leak. Of the 26 patients with anastomotic leaks, 5 (19.2%) had a DLI. There was no significant difference in the rate of leak between those with a DLI(5; 6.3%) and those without(21; 5.3%; p = 0.59). Patients who had a DLI were significantly less likely to experience an anastomotic leak requiring re-operation (p < 0.01).

CONCLUSIONS

Regardless of the presence of a DLI, chronic steroid use and smoking are associated with an increased risk of anastomotic leak in patients with acute complicated diverticulitis undergoing colectomy with PA. The presence of a diverting loop ileostomy is protective against re-operation.

An Italian individual-level data study investigating on the association between air pollution exposure and Covid-19 severity in primary-care setting

BACKGROUND

Several studies have been focusing on the potential role of atmospheric pollutants in the diffusion and impact on health of Covid-19. This study's objective was to estimate the association between ≤10 μm diameter particulate matter (PM10) exposure and the likelihood of experiencing pneumonia due to Covid-19 using individual-level data in Italy.

METHODS

Information on Covid-19 patients was retrieved from the Italian IQVIA® Longitudinal Patient Database (LPD), a computerized network of general practitioners (GPs) including anonymous data on patients' consultations and treatments. All patients with a Covid-19 diagnosis during March 18th, 2020 - June 30th, 2020 were included in the study. The date of first Covid-19 registration was the starting point of the 3-month follow-up (Index Date). Patients were classified based on Covid-19-related pneumonia registrations on the Index date and/or during follow-up presence/absence. Each patient was assigned individual exposure by calculating average PM10 during the 30-day period preceding the Index Date, and according to GP's office province. A multiple generalized linear mixed model, mixed-effects logistic regression, was used to assess the association between PM10 exposure tertiles and the likelihood of experiencing pneumonia.

RESULTS

Among 6483 Covid-19 patients included, 1079 (16.6%) had a diagnosis of pneumonia. Pneumonia patients were older, more frequently men, more health-impaired, and had a higher individual-level exposure to PM10 during the month preceding Covid-19 diagnosis. The mixed-effects model showed that patients whose PM10 exposure level fell in the second tertile had a 30% higher likelihood of having pneumonia than that of first tertile patients, and the risk for those who were in the third tertile was almost doubled.

CONCLUSION

The consistent findings toward a positive association between PM10 levels and the likelihood of experiencing pneumonia due to Covid-19 make the implementation of new strategies to reduce air pollution more and more urgent.

Colonic pouch confers better bowel function and similar postoperative outcomes compared to straight anastomosis for low rectal cancer

BACKGROUND

With advancements in laparoscopic technology and the wide application of linear staplers, sphincter-saving procedures are increasingly performed for low rectal cancer. However, sphincter-saving procedures have led to the emergence of a unique clinical disorder termed anterior rectal resection syndrome. Colonic pouch anastomosis improves the quality of life of patients with rectal cancer > 7 cm from the anal margin. But whether colonic pouch anastomosis can reduce the incidence of rectal resection syndrome in patients with low rectal cancer is unknown.

AIM

To compare postoperative and oncological outcomes and bowel function of straight and colonic pouch anal anastomoses after resection of low rectal cancer.

METHODS

We conducted a retrospective study of 72 patients with low rectal cancer who underwent sphincter-saving procedures with either straight or colonic pouch anastomoses. Functional evaluations were completed preoperatively and at 1, 6, and 12 mo postoperatively. We also compared perioperative and oncological outcomes between two groups that had undergone low or ultralow anterior rectal resection.

RESULTS

There were no significant differences in mean operating time, blood loss, time to first passage of flatus and excrement, and duration of hospital stay between the colonic pouch and straight anastomosis groups. The incidence of anastomotic leakage following colonic pouch construction was lower (11.4% vs 16.2%) but not significantly different than that of straight anastomosis. Patients with colonic pouch construction had lower postoperative low anterior resection syndrome scores than the straight anastomosis group, suggesting better bowel function (preoperative: 4.71 vs 3.89, P = 0.43; 1 mo after surgery: 34.2 vs 34.7, P = 0.59; 6 mo after surgery: 22.70 vs 29.0, P < 0.05; 12 mo after surgery: 15.5 vs 19.5, P = 0.01). The overall recurrence and metastasis rates were similar (4.3% and 11.4%, respectively).

CONCLUSION

Colonic pouch anastomosis is a safe and effective procedure for colorectal reconstruction after low and ultralow rectal resections. Moreover, colonic pouch construction may provide better functional outcomes compared to straight anastomosis.

Intra-operative assessment of left-sided colorectal anastomotic integrity: a systematic review of available techniques

AIM

Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer-related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought.

METHOD

A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990-2020. Additional papers were detected by scanning references of relevant papers.

RESULTS

A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air-leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra-operatively provides the opportunity for either suture reinforcement or formal takedown with or without re-do of the anastomosis and consideration of diversion. Suture repair alone of a positive air-leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future.

CONCLUSION

Although over reliance on any assessment tool should be avoided, intra-operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra-operatively for mechanical failure, particularly distal anastomoses.

Double-layered Nanofibrous Patch for Prevention of Anastomotic Leakage and Peritoneal Adhesions, Experimental Study

BACKGROUND/AIM

Anastomotic leakage is a feared complication in colorectal surgery. Postoperative peritoneal adhesions can also cause life-threatening conditions. Nanofibrous materials showed their pro-healing properties in various studies. The aim of the study was to evaluate the impact of double-layered nanofibrous materials on anastomotic healing and peritoneal adhesions formation.

MATERIALS AND METHODS

Two versions of double-layered materials from polycaprolactone and polyvinyl alcohol were applied on defective anastomosis on the small intestine of healthy pigs. The control group remained with uncovered defect. Tissue specimens were subjected to histological analysis and adhesion scoring after 3 weeks of observation.

RESULTS

The wound healing was inferior in the experimental groups, however, no anastomotic leakage was observed and the applied material always kept covering the defect. The extent of adhesions was larger in the experimental groups.

CONCLUSION

Nanofibrous materials may prevent anastomotic leakage but delay healing.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

Anastomotic leak after colorectal surgery: does timing affect failure to rescue?

BACKGROUND

Anastomotic leak (AL) is a common complication after colectomy with a relatively high failure to rescue rate (FTR), or death after major complications. There is emerging evidence to suggest an early AL may be associated with increased technical difficulty. Whether the timing of an AL is associated with higher FTR has not been established.

METHODS

Patients who underwent a colectomy between 2012 and 2017 were identified from the American College of Surgeons National Quality Improvement Program (ACS NSQIP database). The primary outcome was FTR after AL. The predictor variable used was day of post-operative leak (POD) categorized into early (POD ≤ 3), intermediate (3 < POD ≤ 20) and late (20 < POD ≤ 30) AL. These POD groups were compared to generate hypotheses to explain any association observed between timing of AL and FTR.

RESULTS

Of 135,539 identified patients, 4613 patients experienced an AL (3.4%) with an overall FTR of 6.4%. FTR differed by timing of AL: early AL was found to have a FTR of 28/195 (12.6%), with a FTR in intermediate AL of 152/2550 (5.6%) and 3/356 (0.8%) in late AL patients (p < 0.0001). When compared by timing of AL, patients differed by sex, pre-operative bowel preparation, de-functioning ostomy rates and re-operation rates (p < 0.05). Controlling for age, ASA, sex, emergency status, operative approach, indication, de-functioning ostomy, re-operation and concurrent procedure, an early AL was found to have a 2.3-fold increased risk of FTR (95% CI 1.38-3.84, p = 0.001), with a late AL having a 0.15-fold decreased risk (95% CI 0.04-0.49, p = 0.002), both compared to an intermediate AL.

CONCLUSION

Early ALs, occurring within three days of surgery, may carry a significant risk of FTR. Given the findings identified here, this may support the use of early detection algorithms and interventions of AL to minimize the risk of FTR.

The safety and efficacy of laparoscopic surgery versus laparoscopic NOSE for sigmoid and rectal cancer

BACKGROUND

Laparoscopic surgery with natural orifice specimen extraction (La-NOSE) is being performed more frequently for the minimally invasive management of sigmoid and rectal cancer. The objective of this meta-analysis was to compare the clinical and oncological safety and efficacy of La-NOSE versus conventional laparoscopy (CL).

METHODS

A search of the PubMed, Web of Science, and Cochrane databases was performed for studies that compared clinical or oncological outcomes of conventional laparoscopic resection using NOSE with conventional laparoscopic resection for sigmoid and rectal cancer.

RESULTS

Compared with CL group, the length of hospital stay and the pain score on the first day were shorter in the La-Nose group. The La-NOSE group had a lower incidence of total perioperative complications (OR 0.46; 95% CI [0.32 to 0.66]; I² = 0%; P < 0.0001) and a lower incidence of surgical site infections (SSIs) (OR 0.11; 95% CI [0.04 to 0.29]; I² = 0%; P < 0.0001) than the CL group, while the anastomotic leakage showed no significant difference between the La-Nose group and the CL group (P = 0.19). 5-year disease-free survival (DFS) and 5-year overall survival (OS) were no significant difference between the La-Nose group and the CL group (P = 0.43, P = 0.40, respectively).

CONCLUSIONS

La-NOSE can achieve oncological and surgical safety comparable to that of CL for patients with sigmoid and rectal cancer. La-NOSE in patients was associated with a shorter hospital stay, shorter time to first flatus or defecation, less postoperative pain, and fewer surgical site infections (SSIs) and total perioperative complications. In general, the operative time in La-NOSE was longer than that in CL. The long-term oncological efficacy of La-NOSE seems to be equivalent to that of CL.

Defining Anastomotic Leaks After Colorectal Surgery: Results of a National Survey

BACKGROUND

Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist.

MATERIALS AND METHODS

A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery.

RESULTS

Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak.

CONCLUSIONS

These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

The assessment of perioperative risk factors of anastomotic leakage after intestinal surgeries; a prospective study

Background

Anastomotic leaks (AL) are among the most serious complications due to the substantial impact on the quality of life and mortality. Inspite of the advance in diagnostic tools such as laboratory tests and radiological adjuncts, only moderate improvement has been recorded in the rate of detected leaks. The purpose of the research was to assess the perioperative risk factors for AL.

Methods

This study was achieved at MUH and MIH/Egypt within the period between January 2016 and January 2019 for the candidates who underwent bowel anastomosis for small intestinal (except duodenal one) and colorectal pathology. The collected data were analyzed using SPSS of V-26.

Results

This study included 315 cases, among them, 27 cases (8.57%) developed AL. The percentage of covering stoma was significantly higher in the non-leakage group vs leakage one (24.3% vs 11.1% respectively). lower albumin, operative timing, perforation, and covering stoma were shown as significant risk factors for leakage, but with multivariate analysis for these factors, the emergency operation, and serum albumin level was the only independent risk factors that revealed the significance consequently (p = 0.043, p = 0.015). The analysis of different predictors of AL on the third day showed that the cut-off point in RR was 29 with 83% sensitivity and 92% specificity in prediction of leakage, the cut-off point in RR was 118 with 74% sensitivity and 87% specificity in prediction of leakage and the cut-off point in CRP was 184.7 with 82% sensitivity and 88% specificity in prediction of AL and all had statistically significant value.

Conclusions

The preoperative serum albumin level and the emergency operations are independent risk factors for anastomotic leakage. Moreover, leakage should be highly suspected in cases with rising respiratory rate, heart rate, and CRP levels.

Primary Medical Effects and Economic Impact of Anastomotic Leakage in Patients with Colorectal Cancer. A Middle-Income Country Perspective

Introduction: Anastomotic leakage is one of the most serious surgical complications that can increase the potential postoperative morbidity, mortality, and overall costs of patient care. Aim of study: To assess the economic burden of anastomotic leakage and to estimate its major clinical effects on patient evaluation.

Materials and methods: We retrospectively reviewed single-surgeon data about patients who underwent surgical intervention for colorectal cancer at the 2nd Surgery Department of the Mureș County Emergency Clinical Hospital between January 2019 and July 2020. We assessed general characteristics, surgical data, postoperative information, oncologic results, and financial aspects for each patient. Depending on the presence of anastomotic leakage, patients were divided into two groups: a study group (SG) – patients with postoperative anastomotic failure, and a control Group (CG) – patients without postoperative anastomotic failure.

Results: Patients with anastomotic leakage presented increased use of antibiotics, greater number of surgical reinterventions, longer period of intensive care treatment, prolonged hospitalization, increased overall costs, and significantly greater financial loss for the hospital.

Conclusion: Anastomotic leakage leads to important negative effects, including longer hospitalization, prolonged intensive care unit stay, greater incidence of surgical reintervention, increased hospitalization costs, and significant financial loss.

Review of Colonic Anastomotic Leakage and Prevention Methods

Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.

The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence - A Case Report

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

Preoperative C-reactive protein-to-albumin ratio predicts anastomotic leak in elderly patients after curative colorectal surgery

BACKGROUND

Anastomotic leak (AL), as one of the most devastating complications, is the leading cause of mortality in colorectal cancer (CRC) patients after resection. This study was aimed to investigate potential risk factors for AL in elderly surgical CRC patients.

METHODS

A total of 1068 elderly subjects who underwent elective curative colorectal surgery from 2012 to 2018 were retrospectively evaluated and enrolled into this study population. The predictive value of C-reactive protein-to-albumin ratio (CAR) for AL in surgical CRC patients was evaluated by receiver operating characteristic (ROC) curve analysis. Potential risk factors for AL were assessed by the univariate and multivariate logistic regression analyses.

RESULTS

Of all the 1068 enrolled patients, 81 patients have developed AL with an incidence of 7.6% (81/1068). Preoperative CAR was an effective predictor for AL with an area under the curve (AUC) of 0.758, 95% CI of 0.700-0.817, a cut-off value of 2.44, a sensitivity of 61.09% and a specificity of 80.25%, respectively (P< 0.001). Duration of operation (OR: 2.05, 95% CI: 1.21-3.44, P= 0.013) and preoperative CAR (OR: 1.94, 95% CI: 1.21-3.11, P= 0.007) were two independent risk factors for AL by the multivariate logistic regression analysis.

CONCLUSIONS

Our study indicate that preoperative CAR level and duration of operation were two independent predictors for AL among elderly surgical CRC patients.

Provider caseload volume and short-term outcomes following colorectal surgeries in New Brunswick: a provincial-level cohort study

BACKGROUND

American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick.

METHODS

We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics.

RESULTS

Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes.

CONCLUSION

Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.

Will My Patient Survive an Anastomotic Leak? Predicting Failure to Rescue Using the Modified Frailty Index

IMPORTANCE

Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care.

OBJECTIVE

To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer.

DESIGN

Retrospective cohort study.

SETTING

Multicenter interrogation of the 2012-2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS AND METHODS

A total of 50,944 patients who underwent colectomy for colorectal cancer.

EXPOSURE

Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3).

MAIN OUTCOME AND MEASURE

Primary outcome was FTR after AL.

RESULTS

A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28-65.58 years), median ASA was 3 (IQR 2-3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72-0.81), model 2 (AUROC 0.77; 95% CI 0.73-0.82), and model 3 (AUROC 0.79; 95% CI 0.75-0.83) to predict FTR was not different (p = 0.44).

CONCLUSIONS AND RELEVANCE

Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.

Asociación entre desenlaces clínicos y cumplimiento del protocolo de recuperación mejorada después de la cirugía (ERAS) en procedimientos colorrectales: estudio multicéntrico

Introducción. Los protocolos de recuperación mejorada después de cirugía se han diseñado como una innovación en salud tras demostrarse que la mejora en los dispositivos médicos y la depuración de técnicas alcanzaron la meseta en disminución de complicaciones. Con estas estrategias de la medicina perioperatoria, en cirugía colorrectal se reducen la morbilidad y estancia hospitalaria. El objetivo del estudio fue evaluar si la tasa de adherencia al programa de recuperación mejorada después de la cirugía (ERAS) está asociada con los resultados quirúrgicos. Métodos. Estudio multicéntrico, observacional, retrospectivo de cohorte (2015-2019), en cinco hospitales latinoamericanos certificados por la sociedad ERAS. Se calculó la incidencia de complicaciones quirúrgicas durante el posquirúrgico inmediato (30 días) y la duración de la estancia hospitalaria. Se utilizaron análisis bivariado y regresión logística multivariada para evaluar los factores asociados con la tasa de complicaciones. Resultados. Fueron incluidos en el estudio 648 pacientes en cinco hospitales ERAS, con edad promedio de 61 años y mayor porcentaje de hombres (51 %). El cumplimiento global al protocolo ERAS fue de 75 % y la estancia promedio de 6,2 días (mediana: 4 días). Se tuvo un cumplimiento óptimo del protocolo ERAS (igual o mayor al 80 %) en 23,6 % de los pacientes. Se documentó fuga de la anastomosis en 4 %, complicaciones infecciosas en 8,4 %, íleo en 5,7 %, reingreso en 10,2 % y mortalidad de 1,1 %. El análisis multivariado mostró que los niveles de adherencia óptima al protocolo ERAS reducen significativamente la aparición de complicaciones como fuga de la anastomosis (OR 0,08; IC95% 0,01-0,48; p=0,005) y complicaciones infecciosas (OR 0,17; IC95% 0,03-0,76; p=0,046). Discusión. Los resultados sugieren que un cumplimiento del programa ERAS mayor al 80 % se asocia a menor frecuencia de complicaciones en pacientes con cirugía electiva colorrectal.

Abnormal vital signs after laparoscopic colorectal surgery: More common than you think

BACKGROUND

Anastomotic leak is a feared complication. The presence of abnormal vital signs is often cited as an important overlooked predictive clue in retrospective settings once the diagnosis of leak has already been established. We aimed to determine the prevalence of abnormal vital signs following colorectal resection and assess its predictive value.

METHODS

We retrospectively studied patients undergoing colorectal resection. The performance of vital signs in predicting anastomotic leak was assessed using discrete-time survival analysis and receiver operator characteristic curve.

RESULTS

1662 patients (841 laparoscopic, 821 open) were included. Clinical anastomotic leak was diagnosed in 50 patients (3.1%). 96.8% of patients of the entire cohort had at least one abnormal vital sign during their postoperative course. No individual vital sign was a strong predictor of anastomotic leak in either laparoscopic or open cohorts.

CONCLUSION

Vital sign abnormalities are extremely common following open and laparoscopic colorectal surgery and alone are poor predictors of anastomotic leak.

The History of Wound Healing

Since the dawn of humanity, wounds have afflicted humans, and healers have held responsibility for treating them. This article tracks the evolution of wound care from antiquity to the present, highlighting the roles of surgeons, scientists, culture, and society in the ever-changing management of traumatic and iatrogenic injuries.

Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients.

METHODS

A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors.

RESULTS

Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30 days and 100 days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6-31.5, p = 0.011, and OR = 16.4, 95% CI: 3-88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7-53, p < 0.0001, and OR = 17.2, 95% CI: 3.8-78.6, p < 0.0001).

CONCLUSIONS

Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.

Risk factors for adverse events after elective colorectal surgery: beware of blood transfusions

Purpose of the present study is to analyze risk factors for adverse events after elective colorectal resection. A wide range of adverse events after elective colorectal surgery was reported, anastomotic leakage (AL) and related morbidity and mortality being the most feared ones. Clear definition of risk factors is crucial to limit the related mortality. Prospective, 1-year multicenter enrollment of 1546 elective colorectal resections with anastomosis. Endpoints were anastomotic leakage (AL), overall morbidity, major morbidity and mortality rates (ClinicalTrials.gov; Identifier: NCT03560180). AL rate was 4.92%. Overall morbidity, major morbidity and mortality rates were 30.20%, 9.76% and 1.29%, respectively. Intra- and/or postoperative blood transfusion(s) was the only variable independently influencing all the endpoints: Odds ratios (OR) were 8.15 for AL, 19.33 for overall morbidity, 10.17 for major morbidity and 3.70 for mortality); overall morbidity rates were also independently influenced by American Society of Anesthesiologists class III vs I-II and extra- vs intra-corporeal anastomosis (OR 1.57 and 1.49, respectively); major morbidity rates were also independently influenced by female vs male gender and by the length of the procedure (OR 0.60 and 1.004, respectively); mortality rates were also independently influenced by increasing age (OR 1.16). This study clearly identifies intra- and/or postoperative blood transfusion(s) as an independent risk factor for all adverse events after elective colorectal surgery.

Impact of implementation of the ERAS program in colorectal surgery: a multi-center study based on the "Lazio Network" collective database

BACKGROUND

ERAS implementation improved outcomes in patients undergoing colorectal surgery. The process of incorporating this pathway in clinical practice may be challenging. This observational study investigated the impact of systematic ERAS implementation on surgical outcomes in patients undergoing colorectal resections in a regional network of 10 institutions.

METHODS

Implementation of ERAS pathway was designed using regular audits and a common protocol. All patients undergoing elective colorectal surgery between 2016 and 2017 were considered eligible. A collective database including 18 ERAS items, clinical and surgical data, and outcomes was designed. Univariate and multivariate analyses were performed for the following outcomes: morbidity, anastomotic leak, reinterventions, hospital stay, and readmissions.

RESULTS

A total of 827 patients were included, and a mean of 11.3 ERAS items applied/patient was reported. Logistic regression indicated that an increased number of ERAS items applied reduced overall and severe morbidity (OR 0.86 and 0.87, respectively 95%CI 0.8197-0.9202 and 95%CI 0.7821-0.9603), hospitalization (OR 0.53 95%CI 0.4917-0.5845) and reinterventions (OR 0.84 95%CI 0.7536-0.9518) in the entire series. The same results were obtained for a prolonged hospitalization differentiating right-sided (OR 0.48 95%CI 0.4036-0.5801), left-sided (OR 0.48 95%CI 0.3984-0.5815), and rectal resections (OR 0.46 95%CI 0.3753-0.5851). An inverse correlation was found between the application of ERAS items and morbidity in right-sided and rectal procedures (OR 0.89 and 0.84, respectively 95%CI 0.7976-0.9773 and 95%CI 0.7418-0.9634).

CONCLUSIONS

Systematic implementation of the ERAS pathway using multi-institutional audits can increase protocol adherence and improve surgical outcomes in patients undergoing colorectal surgery.

A multicentre cohort study of serum and peritoneal biomarkers to predict anastomotic leakage after rectal cancer resection

AIM

Anastomotic leakage (AL) is one of the most feared complications after rectal resection. This study aimed to assess a combination of biomarkers for early detection of AL after rectal cancer resection.

METHOD

This study was an international multicentre prospective cohort study. All patients received a pelvic drain after rectal cancer resection. On the first three postoperative days drain fluid was collected daily and C-reactive protein (CRP) was measured. Matrix metalloproteinase-2 (MMP2), MMP9, glucose, lactate, interleukin 1-beta (IL1β), IL6, IL10, tumour necrosis factor alpha (TNFα), Escherichia coli, Enterococcus faecalis, lipopolysaccharide-binding protein and amylase were measured in the drain fluid. Prediction models for AL were built for each postoperative day using multivariate penalized logistic regression. Model performance was estimated by the c-index for discrimination. The model with the best performance was visualized with a nomogram and calibration was plotted.

RESULTS

A total of 292 patients were analysed; 38 (13.0%) patients suffered from AL, with a median interval to diagnosis of 6.0 (interquartile ratio 4.0-14.8) days. AL occurred less often after partial than after total mesorectal excision (4.9% vs 15.2%, P = 0.035). Of all patients with AL, 26 (68.4%) required reoperation. AL was more often treated by reoperation in patients without a diverting ileostomy (18/20 vs 8/18, P = 0.03). The prediction model for postoperative day 1 included MMP9, TNFα, diverting ileostomy and surgical technique (c-index = 0.71). The prediction model for postoperative day 2 only included CRP (c-index = 0.69). The prediction model for postoperative day 3 included CRP and MMP9 and obtained the best model performance (c-index = 0.78).

CONCLUSION

The combination of serum CRP and peritoneal MMP9 may be useful for earlier prediction of AL after rectal cancer resection. In clinical practice, this combination of biomarkers should be interpreted in the clinical context as with any other diagnostic tool.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters

BACKGROUND

Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia.

METHODS

We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared.

RESULTS

During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001).

CONCLUSION

Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

Acute primary testicular failure due to radiotherapy increases risk of severe postoperative adverse events in rectal cancer patients

AIM

The aim of this study is to analyze postoperative adverse events (AE) in relation to acute primary testicular failure after radiotherapy (RT) for rectal cancer.

METHOD

This relation was assessed in 104 men, included in a previous prospective cohort study of men treated with surgical resection of the rectum for rectal cancer stage I-III. Postoperative AE were graded according to Clavien-Dindo (2004). Grade 3 or more was set as cut-off for severe postoperative AE. The impact of primary testicular failure on postoperative AE was related to the cumulative mean testicular dose (TD) and the change in Testosterone (T) and Luteinizing hormone (LH) sampled at baseline and after RT.

RESULTS

Twenty-six study participants (25%) had severe postoperative AE. Baseline characteristics and endocrine testicular function did not differ significantly between groups with (AE+) and without severe postoperative AE (AE-). After RT, the LH/T-ratio was higher in AE+, 0.603 (0.2-2.5) vs 0.452 (0.127-5.926) (p = 0.035). The longitudinal regression analysis showed that preoperative change in T (OR 0.844, 95% CI 0.720-0.990, p = 0.034), LH/T-ratio (OR 2.020, 95% CI 1.010-4.039, p = 0.047) and low T (<8 nmol/L, OR 2.605, 95 CI 0.951-7.139, p = 0.063) were related to severe postoperative AE.

CONCLUSION

Preoperative decline in T due to primary testicular failure induced by preoperative RT could be a risk factor regarding short-term outcome of surgery in men with rectal cancer.

Examining Utility of Routine Splenic Flexure Mobilization during Colectomy and Impact on Anastomotic Complications

BACKGROUND

Despite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy.

STUDY DESIGN

The 2005-2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL.

RESULTS

SFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p < 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p < 0.001), chemotherapy (OR 1.91; p < 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak.

CONCLUSIONS

SFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit.

Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis

Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.

Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.

Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.

Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.

Perioperative lymphocytopenia predicts mortality and severe complications after intestinal surgery

Background

Patterns of white blood cells differential count with low lymphocyte number have been associated with poor outcome following sepsis, burns and trauma. Lymphocytopenia, measured preoperatively or in response to surgical stress, may affect complications after bowel resection.

Methods

Clinical characteristics and white blood cells differential count values, measured both pre- and post-operatively of a cohort of patients submitted to intestinal resection and anastomosis from June 2014 to June 2017 in our General Surgery Division, were retrospectively analyzed. Multivariate logistic regression was used to determine the dependence of mortality and postoperative complications from the clinical characteristics of patients and white blood cells differential count values.

Results

A total of 301 consecutive patients were studied; 165 (54.8%) were male; mean age was 70 years. Overall, the rate of in-hospital 30-day mortality was 4%. Post-operative morbidity was observed in 124 (41.2%). On multivariate analysis, age adjusted Charlson Comorbidity Index, low preoperatively lymphocyte count, high preoperative monocyte count, high postoperative neutrophil count and anastomotic leak were independently associated with increased in-hospital mortality. Preoperative lymphocytopenia and rectal resection were independently associated with high morbidity rate, while low postoperative lymphocyte count was associated with an increased risk of anastomotic leak.

Conclusions

Perioperative lymphocytopenia is associated with 30-days mortality, severe complications and anastomotic leak after bowel resection surgery. These routinely available laboratory data could help to identify patients at high-risk for developing complications.

Do prolonged operative times obviate the benefits associated with minimally invasive colectomy?

BACKGROUND

Minimally invasive colectomy is associated with improved length of stay and decreased postoperative morbidity. Little is known regarding the impact of prolonged operative time on the benefits afforded by minimally invasive colectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program procedure targeted colectomy dataset was queried to identify elective right and left colectomies performed between 2011 and 2017. Multivariable modeling was used to compare rates of composite 30-day death or serious morbidity, overall morbidity, mortality, anastomotic leak, surgical site infection, and length of stay for prolonged minimally invasive cases to those for average duration open cases.

RESULTS

A total of 16,602 right colectomies and 36,557 left colectomies were identified. Median operative times for open and minimally invasive right colectomies were 107 min and 129 min (P < .01), while that for open left colectomies was 128 min and 156 min for minimally invasive left colectomies (P < .01). Cohorts were stratified by quartiles of operative time with the highest (fourth) quartile defined as a prolonged operating time. When compared with an average duration open colectomy, prolonged minimally invasive right colectomies and left colectomies were associated with decreased risk-adjusted rates of overall morbidity, surgical site infection, and with lesser lengths of stay (P < .05). Prolonged minimally invasive left colectomies were also associated with improved rates of composite 30-day death or serious morbidity relative to average open left colectomies (odds ratio 0.66, 95% confidence interval, 0.54-0.79).

CONCLUSION

Prolonged operating times of an minimally invasive approach do not obviate the benefits of an minimally invasive approach to colectomy.

The Clinical and Economic Burden of Colorectal Anastomotic Leaks: Middle-Income Country Perspective

Purpose

Anastomotic leaks (AL) present a significant source of clinical and economic burden on patients undergoing colorectal surgeries. This study was aimed at evaluating the clinical and economic consequences of AL and its risk factors.

Methods

A retrospective cohort study was conducted between 2012 and 2013 based on the billing information of 337 patients who underwent low anterior resection (LAR). The outcomes evaluated were the development of AL, use of antibiotics, 30-day readmission and mortality, and total hospital costs, including readmissions and length of stay (LOS). The risk factors for AL, as well as the relationship between AL and clinical outcomes, were analyzed using multivariable Poisson regression. Generalized linear models (GLM) were employed to evaluate the association between AL and continuous outcomes (LOS and costs).

Results

AL was detected in 6.8% of the patients. Emergency surgery (aRR 2.56; 95% CI: 1.15-5.71, p = 0.021), blood transfusion (aRR 4.44; 95% CI: 1.86-10.64, p = 0.001), and cancer diagnosis (aRR 2.51; 95% CI: 1.27-4.98, p = 0.008) were found to be independent predictors of AL. Patients with AL showed higher antibiotic usage (aRR 1.69; 95% CI: 1.37-2.09, p < 0.001), 30-day readmission (aRR 3.34; 95% CI: 1.53-7.32, p = 0.003) and mortality (aRR 13.49; 95% CI: 4.10-44.35, p < 0.001), and longer LOS (39.6 days, as opposed to 7.5 days for patients without AL, p < 0.001). Total hospital costs amounted to R$210,105 for patients with AL in comparison with R$34,270 for patients without AL (p < 0.001). In multivariable GLM, the total hospital costs for AL patients were 4.66 (95% CI: 3.38-6.23, p < 0.001) times higher than those for patients without AL.

Conclusions

AL leads to worse clinical outcomes and increases hospital costs by 4.66 times. The risk factors for AL were found to be emergency surgery, blood transfusion, and cancer diagnosis.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection

BACKGROUND

Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home.

OBJECTIVE

We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection.

DESIGN

This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns.

SETTINGS

Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals.

PATIENTS

Patients undergoing colon and rectal resections were included.

MAIN OUTCOME MEASURE

The main outcome measure was hospital use patterns of nonhome discharge.

RESULTS

Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045).

LIMITATIONS

This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size.

CONCLUSIONS

This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

Necrotizing Fasciitis Resulting from an Anastomotic Leak after Colorectal Resection

One of the most feared complications in colorectal surgery is an anastomotic leak (AL) following a colorectal resection. While various recommendations have been proposed to prevent this potentially fatal complication, anastomotic leaks still occur. We present a case of an AL resulting in a complicated and fatal outcome. This case demonstrates the importance of high clinical suspicion, early recognition, and immediate management.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Analysis of Quality Indicators for Colorectal Cancer Surgery in Units Accredited by the Spanish Association of Coloproctology

INTRODUCTION

Currently, there is growing interest in analyzing the results from surgical units and the implementation of quality standards in order to identify good healthcare practices. Due to this fact, the Spanish Association of Coloproctology (AECP) has developed a unit accreditation program that contemplates basic standards. The aim of this article is to evaluate and analyze the specific quality indicators for the surgical treatment of colorectal cancer, established by the program. Data were collected from colorectal units during the accreditation process.

METHODS

We analyzed prospectively collected data from elective colorectal surgeries at 18 Spanish coloproctology units during the period 2013-2017. Three main and four secondary quality indicators were considered. Colon and rectal surgeries were analyzed independently; furthermore, results were compared according to surgical approach.

RESULTS

A total of 3090 patients were included in the analysis. The global anastomotic leak rate was 7.8% (6.6% colon vs 10.6% rectum), while the surgical site infection rate was 12.6% (11.4% colon vs 14.8% rectum). Overall 30-day mortality was 2.3%, and anastomotic leak-related mortality was 10.2%. There were higher surgical site infection and mortality rates in the patients operated by open approach, however there was no difference in the anastomotic leak rate when compared with minimally invasive approaches.

CONCLUSIONS

The evaluation of these results has determined optimal quality indices for the units accredited in the treatment of colorectal cancer. Furthermore, it allows us to establish realistic references in our country, thereby providing a better understanding and comparison of outcomes.

Obesity as a surgical risk factor

In recent years, both the actual number of overweight/obese individuals and their proportion of the population have steadily been rising worldwide and obesity-related diseases have become major health concerns. In addition, as obesity is associated with an increased incidence of gastroenterological cancer, the number of obese patients has also been increasing in the field of gastroenterological surgery. While the influence of obesity on gastroenterological surgery has been widely studied, very few reports have focused on individual organs or surgical procedures, using a cross-sectional study design. In the present review, we aimed to summarize the impacts of obesity on surgeries for the esophagus, stomach, colorectum, liver and pancreas. In general, obesity prolongs operative time. As to short-term postoperative outcomes, obesity might be a risk for certain complications, depending on the procedure carried out. In contrast, it is possible that obesity doesn't adversely impact long-term surgical outcomes. The influences of obesity on surgery are made even more complex by various categories of operative outcomes, surgical procedures, and differences in obesity among races. Therefore, it is important to appropriately evaluate perioperative risk factors, including obesity.

Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis.

METHODS

Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed.

RESULTS

Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03).

CONCLUSION

Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF.

LEVEL OF EVIDENCE

Therapeutic study, level III.