Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery

Obesity and anastomotic leak rates in colorectal cancer: a meta-analysis

PURPOSE

Anastomotic leak (AL) following colorectal cancer resection is associated with considerable morbidity and mortality with an impact on recurrence rates and survival. The impact of obesity on AL rates is debated. This meta-analysis aims to investigate the relationship between obesity and AL.

METHODS

A search was conducted of the PubMed/MEDLINE, and Web of Science databases and included studies were split into Western and Asian groups based on population-specific body mass index (BMI) ranges for obesity. A meta-analysis was performed to assess the impact of obesity on AL rate following colorectal cancer resection.

RESULTS

Two thousand three hundred and four articles were initially screened. Thirty-one studies totaling 32,953 patients were included. Patients with obesity had a statistically significant increase in AL rate in all Western and Asian study groups. However, this increase was only clinically significant in the rectal anastomotic subgroups-Western: 10.8% vs 8.4%, OR 1.57 (1.01-2.44) and Asian: 9.4% vs 7.4%, OR 1.58 (1.07-2.32).

CONCLUSIONS

The findings of this analysis confirm that obesity is a significant risk factor for anastomotic leak, particularly in rectal anastomoses. This effect is thought to be primarily mediated via technical difficulties of surgery although metabolic and immunological factors may also play a role. Obesity in patients undergoing restorative CRC resection should be discussed and considered as part of the pre-operative counselling.

Bowel Anastomosis After or Before HIPEC: A Comparative Study in Patients Undergoing CRS+HIPEC for Peritoneal Surface Malignancy

BACKGROUND

Anastomotic leak after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. There is no consensus statement regarding the optimal timing for bowel anastomoses to perform after or before HIPEC.

METHODS

Patients who underwent CRS+HIPEC and had at least one bowel anastomosis were retrospectively analyzed to evaluate if timing of anastomosis done after or before HIPEC had an impact on bowel complication rates (anastomotic leak and perforation).

RESULTS

From 2013 to 2019, 214 of 370 patients underwent CRS+HIPEC and had at least one bowel anastomosis. Of these 214 patients, 104 and 110 patients had anastomosis after and before HIPEC, respectively. A total of 324 anastomoses were performed, with a mean of 0.87 anastomoses per patient (range 1-4). The incidence of anastomotic leaks was comparable between the pre- and post-HIPEC groups (3.6% vs. 4.8%; p > 0.05), as was the bowel complication rate (7.6% vs. 7.2%). After multivariate analysis, prior surgical score >1 (odds ratio [OR] 4.3), recurrent cancers (OR 7.4), and more than two anastomosis (OR 3.8) were considered independent risk factors for bowel complications.

CONCLUSION

Anastomosis of the bowel performed after or before HIPEC does not affect bowel complication rates (leak/perforation). Higher prior surgical score, surgery for recurrent cancers, and more than two bowel anastomosis are independent risk factors for predicting bowel complications. Prehabilitation, standardization of steps, immediate attention and repair of serosal tears, and thorough inspection of the bowel before closure helps to decrease bowel complications. The timing of anastomosis can be at the discretion of the surgeon.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

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.

Management of Leaks Following Laparoscopic Sleeve Gastrectomy Using Specifically Designed Large Covered Metal Stents

BACKGROUND

Leaks are the major complication associated with laparoscopic sleeve gastrectomy.

OBJECTIVE

The study aimed to assess the efficacy and safety of specifically designed large covered metal stents for the management of post-laparoscopic sleeve gastrectomy leaks.

METHODS

Prospectively collected databases from three Italian Endoscopy Units were reviewed. The primary outcome of the study was to evaluate the clinical success of stents placement, defined as complete resolution of clinical and laboratory signs of sepsis with radiological evidence of leak closure. Secondary outcomes were stent-related adverse events and mortality.

RESULTS

Twenty-one patients (67% females, mean age 45 years) were included in the study and a total of 26 stents were placed. Technical success of stent placement was achieved in all cases (100%). Clinical success was observed in 85.5% of patients. Stent-related adverse events occurred in 9 patients (43%), with stent migration as the most frequent complication (33%). Adverse events were more frequently observed in patients who had undergone bariatric surgery prior to laparoscopic sleeve gastrectomy compared to patients without previous surgery (83% et al. 27%, p=0.018).

CONCLUSION

The placement of specifically designed covered metal stents appears to be an effective and safe therapeutic approach for post-laparoscopic sleeve gastrectomy leaks. Stent migration can be a frequent complication.

Lipopolysaccharides increase the risk of colorectal cancer recurrence and metastasis due to the induction of neutrophil extracellular traps after curative resection

BACKGROUND

Intra-abdominal infection after curative surgery for colorectal cancer is a serious complication associated with an increased risk of recurrence. Lipopolysaccharides (LPS)-an essential component of the cell wall of Gram-negative bacteria-were found to exert a protumorigenic effect by stimulating the inflammatory pathology and formation of neutrophil extracellular traps (NETs). This study was conducted to test whether LPS-induced formation of NETs promotes the development of cancer and metastasis.

METHODS

The clinical characteristics, incidence of relapse, and serum myeloperoxidase-DNA complexes of 40 patients with infection and 40 patients without infection after curative surgery were analyzed. The effects of LPS on the induction of NETs were evaluated in a mouse model of colorectal cancer and liver metastasis. The toll-like receptor 9 (TLR9)-a DNA receptor-was knocked down to assess its effect on the mitogen-activated protein kinase pathway and activities implicated in the formation of NETs.

RESULTS

Analysis of the clinical data obtained from these patients showed the significant relation of the formation of NETs and incidence of metastasis and survival rates. Subsequent in vitro experiments revealed an increased level of citrullinated-histone H3 and myeloperoxidase-DNA in LPS-injected mice with colorectal cancer. In the mimic metastatic model, injection of LPS enhanced the metastatic capacity, which was then attenuated by DNase I. This suggested that the formation of NETs was activated by LPS. Injection of TLR9-knockdown HCT116 cells in mice, followed by induction through LPS, mitigated the level of citrullinated-histone H3 and myeloperoxidase-DNA. This finding implied that the formation of NETs was suppressed.

CONCLUSION

These findings shed light on the mechanism underlying the relationship between the elevated rate of colorectal cancer recurrence in patients who underwent surgery and the incidence of infection. This mechanism involves the protumorigenic activities of LPS-induced formation of NETs. The NETs which could be mediated by the TLR9 and the mitogen-activated protein kinase signaling pathway.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

Early diagnosis of anastomotic leakage in colorectal surgery: prospective observational study of the utility of inflammatory markers and determination of pathological levels

Procalcitonin (PCT) and C-Reactive Protein (CRP) are acute-phase reactants that indicate the presence and severity of an infection. The aim of this study was to verify the utility of CRP and PCT as tools for early diagnosis of anastomotic leakage (AL) in patients undergoing elective colorectal surgery. A prospective observational study including 95 patients undergoing elective colorectal surgery with anastomosis, where patients were divided into two groups according to whether or not AL happened. Different variables were compared using a uni- and multivariate analyses to identify the risk factors for AL. Receiver Operating Characteristic (ROC) curves were added to establish a cut-off point for CRP and PCT. The inflammatory marker levels were analysed in other complications different from AL. AL was detected in 11 patients (14%), 7 required an emergency reoperation. The overall morbidity rate was 42.1% and the mortality was 3.2%. In the univariate study, increased CRP on days 3 and 5, male sex and intraoperative complications were significantly associated with AL. In the multivariate study, CRP on day 5 was the only factor related to AL. AUC at ROC curves showed that CRP results ≥ 15.3 mg/dL on day 3 and 9.1 mg/dL on day 5 were predictors of AL. Normal CRP and PCT values had a high negative predictive value. CRP on postoperative day 5 is a reliable marker for early detection of anastomotic leakage in colorectal surgery. Both CRP and PCT on days 3 and 5 have a high negative predictive value.Trial registration: The study has been registered at ClinicalTrials.gov. Code: NCT04632446.

Safe Anastomoses without Ostomies in Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy: Technical Considerations and Modifications

BACKGROUND

Gastrointestinal complications, predominantly anastomotic leak (AL), are the most frequent source of severe morbidity after cytoreductive surgery (CRS).

OBJECTIVE

The aim of this study was to present the technical standards for colorectal anastomoses developed and systematically applied to all patients undergoing CRS in a high-volume tertiary center, and the associated AL rates.

METHODS

This was a descriptive study reporting the technical characteristics of a standardized protocol for three types of colorectal anastomoses (colorectal, ileorectal, and ileocolic) in CRS with heated intraperitoneal chemotherapy (HIPEC), and a retrospective analysis of prospectively collected data on anastomotic outcomes. All patients (1172) undergoing CRS with HIPEC from September 2006 to September 2020 were included. The anastomotic complications were classified according to the International Study Group of Rectal Cancer Surgery (ISGRCS) classification.

RESULTS

Overall, 1172 patients underwent 1300 procedures and 1359 gastrointestinal anastomoses. An ileocolic anastomosis was performed in 408 patients, colorectal anastomosis in 469 patients, and ileorectal anastomosis in 16 patients, none with diverting ileostomy; 345 other gastrointestinal reconstructions and 82 urinary reconstructions were performed in these patients. The AL rate was 1% (4/408) for the ileocolic anastomosis, 0.85% (4/469) for the colorectal anastomosis, and 0% (0/16) for the ileorectal anastomosis. One patient died postoperatively due to AL.

CONCLUSIONS

Systematic application of standardized techniques adapted to ensure optimal tissue healing (stapled anastomoses avoiding overlap, accurate staple deployment, and hand-sewn reinforcement) are associated with a very high level of anastomotic safety in a large cohort of patients undergoing CRS and HIPEC.

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.

Incidence and treatment outcomes of leakage after gastrectomy for gastric cancer: Experience of 14,075 patients from a large volume centre

INTRODUCTION

Leakage is a serious and potentially fatal complication of gastrectomy for gastric cancer. However, comprehensive reports regarding leakage after gastrectomy remain limited. We aimed to evaluate the incidence and treatment outcomes of leakage after gastrectomy for cancer.

METHODS

We reviewed the prospectively collected data of 14,075 Patients who underwent gastrectomy for gastric cancer between 2005 and 2017. Outcomes included incidence, risk factors of leakage, and leakage treatment outcomes.

RESULTS

The median day of leakage detection was postoperative day 7 (range 1-29days). The overall leakage incidence was 1.51% (213/14,075), and the most frequent location was the oesophagojejunostomy (2.07%). Leakage after total gastrectomy was more frequent with minimally invasive surgery (open:1.64%, laparoscopic:3.56%, robotic:5.83%; P < 0.001). Leakage incidence was higher in the surgeon's initial 100 cases than in later cases (2.4 vs. 1.3%; P < 0.001), especially with minimally invasive surgery. Early leakage (within 4 days of surgery) occurred more often after minimally invasive surgery (open:12.7%, laparoscopic:35.4%, robotic:29.0%; P = 0.006). The success rate for initial treatment of leakage was 70.4% (150/213). Surgery after initial treatment failure demonstrated a higher success rate for early leakage than for late leakage (80.0 vs. 22.2%). Among 213 patients who experienced leakage, fifteen patients (7.0%) died, and leakage-related mortality accounted for 38.5% (15/39) of all surgery-related mortality after gastrectomy.

CONCLUSIONS

Leakage after gastric cancer surgery is associated with high mortality. Improved surgeon experience using minimally invasive techniques is required to reduce the risk of leakage. Surgery is an effective treatment for early leakage, although further studies are needed to establish the most appropriate treatment strategies.

Association of Low Muscle Mass and Low Muscle Radiodensity With Morbidity and Mortality for Colon Cancer Surgery

Importance

Given the risks of postoperative morbidity and its consequent economic burden and impairment to patients undergoing colon resection, evaluating risk factors associated with complications will allow risk stratification and the targeting of supportive interventions. Evaluation of muscle characteristics is an emerging area for improving preoperative risk stratification.

Objective

To examine the associations of muscle characteristics with postoperative complications, length of hospital stay (LOS), readmission, and mortality in patients with colon cancer.

Design, Setting, and Participants

This population-based retrospective cohort study was conducted among 1630 patients who received a diagnosis of stage I to III colon cancer from January 2006 to December 2011 at Kaiser Permanente Northern California, an integrated health care system. Preliminary data analysis started in 2017. Because major complication data were collected between 2018 and 2019, the final analysis using the current cohort was conducted between 2019 and 2020.

Exposures

Low skeletal muscle index (SMI) and/or low skeletal muscle radiodensity (SMD) levels were assessed using preoperative computerized tomography images.

Main Outcomes and Measures

Length of stay, any complication (≥1 predefined complications) or major complications (Clavien-Dindo classification score ≥3), 30-day mortality and readmission up to 30 days postdischarge, and overall mortality.

Results

The mean (SD) age at diagnosis was 64.0 (11.3) years and 906 (55.6%) were women. Patients with low SMI or low SMD were more likely to remain hospitalized 7 days or longer after surgery (odds ratio [OR], 1.33; 95% CI, 1.05-1.68; OR, 1.39; 95% CI, 1.05-1.84, respectively) and had higher risks of overall mortality (hazard ratio, 1.40; 95% CI, 1.13-1.74; hazard ratio, 1.44; 95% CI, 1.12-1.85, respectively). Additionally, patients with low SMI were more likely to have 1 or more postsurgical complications (OR, 1.31; 95% CI, 1.04-1.65) and had higher risk of 30-day mortality (OR, 4.85; 95% CI, 1.23-19.15). Low SMD was associated with higher odds of having major complications (OR, 2.41; 95% CI, 1.44-4.04).

Conclusions and Relevance

Low SMI and low SMD were associated with longer LOS, higher risk of postsurgical complications, and short-term and long-term mortality. Research should evaluate whether targeting potentially modifiable factors preoperatively, such as preserving muscle mass, could reverse the observed negative associations with postoperative outcomes.

Gastric leak after sleeve gastrectomy: risk factors for poor evolution under conservative management

BACKGROUND

Gastric leak (GL) is the most highly feared early postoperative complication after sleeve gastrectomy (SG), with an incidence of 1% to 2%. This complication may require further surgery/endoscopy, with a risk of management failure that may require additional surgery, including total gastrectomy, leading to a risk of mortality of 0% to 9%.

OBJECTIVES

Assess the impact of factors that may lead to a poorer evolution of GL.

SETTING

University Hospital, France, public practice.

METHODS

This was a retrospective, single-center study of a group of patients managed for GL after SG between November 2004 and January 2019 (n = 166). Forty-three patients were excluded. The population study was divided into 2 groups: patients with easy closing of the GL (n = 73) and patients with difficult closing of the GL or failure to heal (n = 50). Patients were allocated to 1 of 2 groups depending on the time to heal (median time of 84 days). The study's primary efficacy endpoint was to determine the risk factors for a poorer evolution of GL.

RESULTS

Among 123 patients included in this study, 103 patients had undergone primary SG (83.7%). The mean time to the appearance of GL was 15.1 days (range, 1-156 d). Seventy-four patients underwent a reoperation (60%). The mean number of endoscopies per patient was 2.7 (range, 2-7 endoscopies). The mean time to healing was 89.5 days (range, 18-386 d). There were 8 cases of healing failure (6.5%). Multivariate analysis identified body mass index (>47 kg/m²), time to referral (>2 d), and serum prealbumin level (<.1 g/dL) to be independent risk factors for a poorer evolution of GL.

CONCLUSION

Improvement of nutritional status before SG and early referral for GL could reduce the risk of delayed closure or the need for further surgery.

Outcomes of Intra- versus Extra-Corporeal Ileocolic Anastomosis after Minimally Invasive Right Colectomy for Cancer: An Observational Study

Intracorporeal anastomoses (IA) are increasingly being used in colorectal surgery. Some data suggest that these might confer benefits compared with extracorporeal anastomoses (EA). The aim of this study is to compare the short-term complications associated with IA versus EA for minimally invasive right colectomy. This is a single-centre, retrospective study on a prospective database. Patients who underwent minimally invasive right colectomy for cancer between January 2017 and December 2019 were assessed for inclusion. The primary outcome was global 30-day morbidity. Overall, 189 patients were included, of whom 102 had IA. Global morbidity and medical complications were higher in patients with EA (23.5% vs. 40.2%, p = 0.014; 5.9% vs. 14.9%, p = 0.039, respectively). None of the patients with IA had non-infectious surgical wound complications, compared to 4.6% in the EA group (p = 0.029). No differences were found in anastomotic leakage (9.8% vs. 10.3%, p = 0.55). At multivariable analysis, EA was an independent risk factor for both surgical (OR = 3.71 95% CI: 1.06-12.91, p = 0.04) and overall complications (OR = 3.58 95% CI: 1.06-12.12, p = 0.04). IA lowers the risk for global, medical, and surgical complications with minimum risk for wound complications, without increasing the risk of AL.

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.

Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment

Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.

Design and performance evaluation of a powered stapler for gastrointestinal anastomosis

OBJECTIVE

This paper reports the design of a powered stapler for gastrointestinal anastomosis and evaluates its performance. The proposed stapling instrument is intended to simplify and optimize the current procedure of mechanical stapling, while providing controllable operation for the powered stapling procedure, such as conditioning the tissue to the right stage before firing of the stapler.

MATERIAL AND METHODS

The feasibility and efficacy of the prototype were assessed by ex vivo experiments with porcine small intestine segments, where the tissue conditioning operation, burst pressure of the stapled intestine samples, and staple malformation rate were examined.

RESULTS

The functionality of the developed powered stapler was validated, where the theoretical, numerical, and experimental results agree well with each other. The preliminary results indicated that the proposed tissue conditioning operation could lower the clamping pressure with a maximum level of 1.35 g/mm². The average burst pressure of the stapled segments (16 samples) is 6.37 kPa, and the maximum malformation rate of the tested groups (five groups, each group with 90 staplers) was 5.56%.

CONCLUSION

The developed novel tissue conditioning procedure could reduce the pressure response of the intestine tissue samples. The proposed powered stapler proves effective for performing gastrointestinal anastomosis procedures.

Colorectal anastomosis during cytoreductive radical surgery in patients with peritoneal surface malignancies. Validation of a new technique (without stoma) to prevent anastomosis leakage in more than 1000 procedures

OBJECTIVE

To describe a novel end-to-end "true" reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer.

METHODS

Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were: (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) "cleaning" the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed.

RESULTS

According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis. Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%.

CONCLUSIONS

A technical modification to create a "true" end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Risk Factors for Postoperative Anastomosis Leak After Esophagectomy for Esophageal Cancer

BACKGROUND/AIM

The present study aimed to identify risk factors for anastomosis leak (AL) after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

One-hundred twenty-two patients who underwent esophagectomy for esophageal cancer between 2008 and 2018 were included. The rate of AL was measured based on the definition of leak as adapted from the Surgical Infection Study Group. To identify the risk factors for AL, logistic regression analysis was used.

RESULTS

AL was found in 44 of the 122 patients (36.1%). Among the factors examined, the lymph node dissection status (p=0.007) and preoperative serum albumin level (p=0.022) were significant independent risk factors for AL. The incidence of AL was 26.7% (20 of 75) among patients who received 2-field lymph node dissection and 51.1% (24 of 47) among those who received 3-field lymph node dissection. The incidence of AL was 29.9% (23 of 77) in the preoperative serum albumin levels ≥4.0 g/dl group and 46.7% (21 of 45) in the serum albumin levels <4.0 g/dl group.

CONCLUSION

Lymph node dissection status and preoperative serum albumin levels were risk factors for AL in patients who received esophagectomy for esophageal cancer.

Predictors of Anastomotic Leak After Esophagectomy for Cancer: Not All Leaks Increase Mortality

BACKGROUND

The impact of preoperative chemotherapy/radiation on esophageal anastomotic leaks (ALs) and the correlation between AL severity and mortality risk have not been fully elucidated. We hypothesized that lower severity ALs have a similar risk of mortality compared to those without ALs, and preoperative chemotherapy/radiation increases AL risk.

METHODS

The 2016-2017 American College of Surgeons National Surgical Quality Improvement Program's procedure-targeted esophagectomy database was queried for patients undergoing any esophagectomy for cancer. A multivariable logistic regression analysis was performed for risk of ALs.

RESULTS

From 2042 patients, 280 (13.7%) had ALs. AL patients requiring intervention had increased mortality risk including those requiring reoperation, interventional procedure, and medical therapy (P < .05). AL patients requiring no intervention had similar mortality risk compared to patients without ALs (P > .05). Preoperative chemotherapy/radiation was not predictive of ALs (P > .05).

CONCLUSION

Preoperative chemotherapy/radiation does not contribute to risk for ALs after esophagectomy. There is a stepwise increased risk of 30-day mortality for ALs requiring increased invasiveness of treatment.

Clinical impact of leakage in patients with handsewn vs stapled anastomosis after right hemicolectomy: a retrospective study

AIM

Anastomotic leakage is a major complication after right hemicolectomy leading to increased morbidity, mortality, length of stay and hospital costs. Previous studies have shown that the type of anastomosis (handsewn or stapled) is a major risk factor for anastomotic leakage. The purpose of this study was to evaluate the clinical impact of anastomotic leakage depending on the type of anastomotic technique (handsewn vs stapled).

METHOD

This was an observational, retrospective, cross-sectional study. Data were collected at two major hospitals in Spain from January 2010 to December 2016. Patients had elective right colectomy for cancer with handsewn or stapled ileocolic anastomosis. The main outcome was the grading of postoperative treatments needed to manage anastomotic leakage according to two major classification systems. The other outcomes were demographics, time of hospitalization and death rate.

RESULTS

Patients (n = 961) underwent elective surgery for neoplasia of the right colon. Anastomotic leakage was diagnosed in 116 patients (12.07%). Patients with handsewn anastomosis had more Type IIIA surgical complications and received milder treatments than patients with stapled anastomosis (SA) who had more Type IIIB complications and more re-laparotomies (P = 0.004). The clinical impact of anastomotic leakage was significantly more severe (Grade C) in patients with SA than in patients with a handsewn anastomosis (P = 0.007). No differences were found for hospital stay of patients with anastomotic leakage depending on the type of anastomosis (P = 0.275). Death due to anastomotic leakage was similar in both groups.

CONCLUSIONS

The clinical impact of anastomotic leakage in patients with handsewn anastomosis is lower than in patients with SA.

Early drain removal after hepatectomy: an underutilized management strategy

BACKGROUND

Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy.

METHODS

Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed.

RESULTS

Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal.

CONCLUSION

Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.

A single blinded randomized controlled trial comparing semi-mechanical with hand-sewn cervical anastomosis after esophagectomy for cancer (SHARE-study)

OBJECTIVE

The aim was to compare leak rate between hand-sewn end-to-end anastomosis (ETE) and semi-mechanical anastomosis (SMA) after esophagectomy with gastric tube reconstruction.

BACKGROUND DATA

The optimal surgical technique for creation of an anastomosis in the neck after esophagectomy is unclear.

METHODS

Patients with esophageal cancer undergoing esophagectomy with gastric tube reconstruction and cervical anastomosis were eligible for participation after written informed consent. Patients were randomized in 1:1 ratio. Primary endpoint was anastomotic leak rate defined as external drainage of saliva from the site of the anastomosis or intra-thoracic manifestation of leak. Secondary endpoints included anastomotic stricture rate at one year follow up, number of endoscopic dilatations, dysphagia-score, hospital stay, morbidity, and mortality. Patients were blinded for intervention.

RESULTS

Between August 2011 and July 2014, 174 patients with esophageal cancer underwent esophagectomy. Ninety-three patients were randomized to ETE (n = 44) or SMA (n = 49). Anastomotic leak occurred in 9 of 44 patients (20%) in the ETE group and 12 of 49 patients (24%) in the SMA group (absolute difference 4%, 95% CI -13% to +21%; p = .804). There was no significant difference in dysphagia at 1 year postoperatively (ETE 25% vs. SMA 20%; p = .628), in stricture rate (ETE 25% vs. 19% in SMA, p = .46), nor in median hospital stay (17 days in the ETE group, 13 days in the SMA group), morbidity (82% vs. 73%, p = .460) or mortality (0% vs. 4%, p = .175) between the groups.

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.

Prospective Study Comparing Clinical vs Indocyanine Green Fluorescence-Based Assessment of Line of Transection in Robotic Rectal Cancer Surgery-Indian Study

Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.

Validation of MTL30 as a quality indicator for colorectal surgery

Background

Valid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course.

Methods

Patients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30.

Results

In univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course.

Conclusion

The MTL30 is a valid indicator of colorectal surgical quality.

C-reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study

BACKGROUND

Anastomotic leak is a common complication after colorectal surgery, associated with increased morbidity and mortality, and poorer long-term survival after oncological resections. Early diagnosis improves short-term outcomes, and may translate into reduced cancer recurrence. Multiple studies have attempted to identify biomarkers to enable earlier diagnosis of anastomotic leak. One study demonstrated that the trajectory of C-reactive protein (CRP) levels was highly predictive of anastomotic leak requiring intervention, with an area under the curve of 0·961. The aim of the present study was to validate this finding externally.

METHODS

This was a prospective international multicentre observational study of adults undergoing elective colorectal resection with an anastomosis. CRP levels were measured before operation and for 5 days afterwards, or until day of discharge if earlier than this. The primary outcome was anastomotic leak requiring operative or radiological intervention.

RESULTS

Between March 2017 and July 2018, 933 patients were recruited from 20 hospitals across Australia, New Zealand, England and Scotland. Some 833 patients had complete CRP data and were included in the primary analysis, of whom 41 (4·9 per cent) developed an anastomotic leak. A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0·85 for detecting a leak, and a high negative predictive value of 0·99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0·96-0·97, with positive likelihood ratios of 4·99-6·44 for a leak requiring intervention.

CONCLUSION

This study confirmed the value of CRP trajectory in accurately ruling out an anastomotic leak after colorectal resection.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

Background

Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research.

Purpose

The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery.

Conclusions

There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.

A prospective study of real-time identification of line of transection in robotic colorectal cancer surgery by ICG

Colorectal cancer is the second most common cancer in women and the third most common cancer in men in the world. Surgical resection is the gold standard treatment and minimally invasive surgery remains the standard of care. Anastomotic leakage is one of the most feared postoperative complications in colorectal surgery. Although several factors have been identified as possible causes of anastomotic leakage (i.e., surgical techniques, patient risk factors, suture material or devices), the complete pathogenesis is still unclear. The reported leak rate ranges from 1 to 30% and increases as the anastomosis is more distal. To date the most widely used methods to assess tissue perfusion includes the surgeon intraoperative visual judgement based on the colour; bleeding edges of resected margins; pulsation and temperature, thereby resulting in either excess or insufficient colonic resection. Earlier studies in colorectal surgery have suggested that assessment of tissue perfusion by the clinical judgment of the operating surgeon underestimated the risk of anastomotic leakage. Indocyanine green (ICG) is a intravenous dye which has shown promise in identifying the bowel vascularity real time. Earlier studies on colorectal cancer have shown that ICG based detection of bowel vascularity is technically possible and has reduced the anastomotic leak rates in 16.7% of patients. We conducted a prospective study on patients with ICG guided bowel perfusion during robotic colorectal cancer surgery. The method is technically easy, reproducible and safe. This technique has changed the intraoperative decision in 88% of patients. Larger studies are needed before this can become the standard of care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mixed Type Histology as a Predictive Factor for Esophagojejunostomy Leak in Advanced Gastric Cancer

Since esophagojejunostomy leak (EJL) after gastrectomy is a potentially fatal complication and may impact the survival of patients with advanced gastric cancer (GC), it is important to establish risk factors for the EJL and to prevent this surgical complication. The aim of this study was analysis of predictors for the postoperative clinically apparent EJL. All patients operated for advanced GC between October 2016 and December 2019 were analyzed from a prospectively maintained database. The evaluation of the EJL and postoperative complications according to the demographic and clinical (categorized) variables was performed with odds ratio test (multivariate analysis was performed with the use of logistic regression method). Among the 114 patients included in the study, 71.1% received neoadjuvant chemotherapy and 19.3% underwent gastrectomy followed by the hyperthermic intraperitoneal chemotherapy (HIPEC). Postoperative EJL was found in 4.6% patients. The risk of EJL was significantly higher for mixed-type GC (OR = 12.45, 95% CI: 1.03-150.10; p = 0.0472). The risk of other postoperative complications was significantly higher in patients undergoing HIPEC (OR = 3.88, 95% CI: 1.40-10.80, p = 0.0094). The number of lymph nodes removed (>38) was characterized by 80% sensitivity and 79.6% specificity in predicting EJL (AUC = 0.80, 95% CI: 0.72-0.87; p < 0.0001). Mixed histological type of GC is a tumor-related risk factor for the EJL. HIPEC was confirmed to be a risk factor for postoperative complications after gastrectomy.

Consensus on the definition of colorectal anastomotic leakage: A modified Delphi study

BACKGROUND

Despite the emerging knowledge about colorectal anastomotic leakage (CAL) through the increasing number of clinical and experimental studies, there is no generally accepted definition of CAL. Because of the wide variety of definitions used in literature, comparison of study outcomes and quality of care is complicated.

AIM

To reach consensus on the definition of CAL using a modified Delphi method.

METHODS

The RAND/UCLA appropriateness method was used. The expert panel consisted of international colorectal surgeons and researchers who had published three or more articles about CAL. The consensus process consisted of two online distributed questionnaires and a third round with a recommendation. In the questionnaires participants were asked to rate the appropriateness of statements using a 1-9 Likert scale. Consensus was defined as a panel median between 1-3 or 7-9 without disagreement. In the final round a recommendation was formed regarding the definition of CAL and the expert panel was asked if they agreed or disagreed.

RESULTS

Twenty-three authors participated in the first round and twenty-one finished the second round. After two rounds consensus was reached on 37 items (80%) in nine different categories. The International Study Group of Rectal Cancer definition is the most frequently advised general definition by our panel. Consensus was reached regarding the clinical symptoms of CAL, which serum markers contributes to the suspicion of CAL, which radiological and perioperative findings should be considered as CAL, which grading system is appropriate and if there should be a range of postoperative days in the definition. Eventually, 19 experts completed all three rounds of which 16 (84%) agreed with our final recommendations for the definition of CAL.

CONCLUSION

A consensus-based recommendation for the definition of CAL was formed using our modified Delphi method that can be widely incorporated in the field.

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.

Omental Free-Shaped Flap Reinforcement on Anastomosis and Dissected Area (OFFROAD) Following Reconstruction after Gastrectomy: A Retrospective Case-Control Study

Purpose

We devised omental free-shaped flap reinforcement on anastomosis and dissected area (OFFROAD) following reconstruction after gastrectomy. This study aimed to evaluate its safety and early clinical outcomes.

Methods

One hundred fifty-six patients who underwent totally laparoscopic distal gastrectomy with delta anastomosis from July 2016 to April 2018 were divided into the OFFROAD group (80 patients) and non-OFFROAD group (76 patients). Differences in short-term operative outcomes and surgical complications were compared between the groups. All patients’ inflammatory marker levels were measured to monitor flap necrotic change and inflammatory reactions. The clinical features of both groups in terms of anastomotic leakage were transcribed.

Results

Pain score in postoperative day1 was significantly lower in OFFROAD group. The serum WBC count on POD 1 was significantly lower in OG than in NOG. The mean duration of OFFROAD was shorter than five minutes. There were no statistical differences in short-term outcomes and surgical complications between two groups. Anastomotic leakage occurred in three patients in each group and there was no statistical difference in incidence. However, clinical features were notable when anastomotic leakage occurs. Unlike all three patients of non-OFFROAD group manifested every features of peritonitis, each patient of OFFROAD group just manifested only one of the three.

Conclusion

This study showed the safety and feasibility of OFFROAD procedure. It might mitigate septic complications when there is an anastomotic leakage. Additional large-scale study is needed to assess the versatile usefulness of OFFROAD aside from its role as a physical barrier.

Anastomotic leakage after elective colorectal surgery: a prospective multicentre observational study on use of the Dutch leakage score, serum procalcitonin and serum C-reactive protein for diagnosis

Background

The purpose of this study was to test use of the Dutch leakage score (DLS), serum C‐reactive protein (CRP) and serum procalcitonin (PCT) in the diagnosis of anastomotic leakage (AL) after elective colorectal resection in a prospective observational study.

Methods

Patients undergoing elective colorectal resection with anastomosis in 19 centres were enrolled over a 1‐year period from September 2017. The DLS and CRP and PCT levels were evaluated on postoperative day (POD) 2, POD3 and POD6. Statistical analysis, including determination of the area under the receiver operating characteristic (ROC) curve (AUC), was performed for the primary endpoint of AL; secondary endpoints were morbidity and mortality rates ( http://clinicaltrials.gov identifier: NCT03560180).

Results

Among 1546 patients enrolled, the AL rate was 4·9 per cent. Morbidity and mortality rates were 30·2 and 1·3 per cent respectively. With respect to AL, DLS performed better than CRP and PTC levels on POD2 and POD3 (AUC 0·75 and 0·84), whereas CRP levels were documented with better AUC values on POD6 (AUC 0·81). Morbidity was poorly predicted, whereas mortality was best predicted by PCT on POD2 (AUC 0·83) and by DLS on POD3 and POD6 (AUC 0·87 and 0·98 respectively). Overall, the combination of positive PCT, CRP and DLS values resulted in a probability of AL of 21·3 per cent on POD2, 33·4 per cent on POD3, and 47·1 per cent on POD6. However, the combination of their negative values excluded AL in 99·0 per cent of cases on POD2, 99·3 per cent on POD3, and 99·2 per cent on POD6.

Conclusion

DLS and CRP level are good positive and excellent negative predictors of AL; the addition of PCT improved the predictive value for diagnosis of AL.

Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis

Background

Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula.

Methods

A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines.

Results

Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90–95%). The overall proportion of stent migration was 23% (95% CI, 19–28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8–100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients.

Conclusions

Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07471-1) contains supplementary material, which is available to authorized users.

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.

A Modified Side-to-Side Anastomosis Using a Circular Stapler Reduces Anastomotic Leakage in Colonic Surgery

Background. Anastomotic leakage (AL) remains one of the serious complications after colonic surgery. Method. A prospective interventional study to assess a modified technique of creating the ileocolic, colic-colic, and colorectal side-to-side anastomoses using a circular stapler. The primary endpoint was to evaluate the safety and efficacy of this technique in the reduction of AL. Computed tomography scan was performed when AL was clinically suspected. Result. One hundred and forty-five patients who underwent colonic resection between January 2015 and August 2018 were included. One patient underwent surgery for severe inflammatory bowel disease, and the others underwent surgery for colonic cancer. The procedures were open surgeries, including right hemicolectomy (n = 79 [54.5%]), left hemicolectomy (n = 29 [20%]), sigmoidectomy (n = 30 [20.7%]), and transverse colectomy (n = 7 [4.8%]). In 23 patients with ascending colonic obstruction, emergency right colectomy with primary anastomosis was performed. Two surgeons performed the operations (52.4% and 47.6%, respectively), and intraoperative blood loss was 50 to 100 mL. The operative time was 160 to 240 minutes. There was no mortality postoperatively, and 26 (17.9%) patients developed complications. One patient who underwent transverse colonic cancer resection developed a clinical AL (0.7%). After ileostomy, the patient was discharged with no other serious complication. The median of postoperative hospital stay was 8 days (range = 5-18 days). Conclusion. This modified technique is a safe and efficient method for anastomotic configuration in colonic surgery.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Management of anastomotic leakage after rectal surgery: a review article

Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.

Detection of early anastomotic leakage by intraperitoneal microdialysis after low anterior resection for rectal cancer: a prospective cohort study

AIM

Anastomotic leakage (AL) is a common and serious complication following sphincter-preserving surgery for rectal cancer. Early detection and intervention can improve clinical outcomes. The aim of this prospective cohort study was to compare intraperitoneal microdialysis with a clinical scoring system for early detection of AL.

METHOD

A microdialysis catheter was anchored near the anastomosis at low anterior resection (LAR) for rectal cancer. Peritoneal fluid samples were analysed (lactate, pyruvate, glucose and glycerol concentration) 4-hourly and compared with a daily clinical leak score (DULK = Dutch leakage). At day 7 a pelvic CT with rectal contrast enema was performed to establish if there had been a radiological leak.

RESULTS

In this two-centre study, 129 patients [median age 65 (26-82) years; 60.5% male] underwent LAR. The leak rate was 27% (grade A, n = 11; grade B, n = 12; grade C, n = 12). Receiver operator characteristic analysis demonstrated a lactate cut-off value of 9.8 mm and had 77% sensitivity, 82% specificity, 78% accuracy, a positive predictive value (PPV) of 58, a negative predictive value (NPV) of 88 (CI 79-94) and an area under the curve (AUC) of 0.9 for AL. This compared with a clinical score ≥ 4, which had 57% sensitivity, 79% specificity, 71% accuracy, a PPV of 46, a NPV of 82 and an AUC of 0.7 for AL. The mean day for a positive test when using delta lactate ≥ 6.3 mm was 1.6 days and for leak score ≥ 4 it was 3.3 days (NS).

CONCLUSION

When AL occurs, intraperitoneal lactate concentration increases over time, and at a certain cut-off has a higher sensitivity, specificity, accuracy, PPV and NPV than a clinical scoring system.

Effect of Biologic Material Reinforcement on Surgical Anastomosis After Gastrectomy-A Pilot Study

Background: Acellular dermal matrix is a biologic material derived from the skin of human cadaveric donors. It has been used successfully in the past to reduce complications in breast surgery and hernia repair. This investigation was aimed at assessing the feasibility of using acellular dermal matrix to support the anastomosis after gastrectomy with the aim of reducing anastomotic site leakage complications. Methods: Patients were randomly assigned to standard anastomotic reconstruction (control arm) or anastomotic reconstruction with acellular dermal matrix reinforcement (intervention arm). Surgical outcomes related to anastomotic complications were collected. Because actual anastomotic leaks found on imaging studies are infrequent and thus require a very high number of patient recruitment to detect statistically significant difference between the two groups, in this pilot investigation other clinical and laboratory measures that have been shown to correlate to or predict anastomotic leaks were also collected. Each surgical outcome was compared. Results: A total of 94 patients (intervention arm: 50, control arm: 44), were included in the analysis. Two patients in the control arm (4.55%) and one patient in the intervention arm (2.00%) experienced anastomotic leakage (p = 0.598), a difference without statistical significance. However, average postoperative C-reactive protein (CRP) levels and NUn scores, both of which have been shown to reflect likelihood of progressing to anastomotic leakage, were significantly lower for the intervention arm. The control arm showed an average CRP level of 128.77 mg/dL (SD: 97.08) while the intervention arm showed 77.38 mg/dL (SD: 49.08, p = 0.049). Conclusions: Leakage rate reduction with acellular dermal matrix reinforcement of anastomotic site was not detected in this investigation. However, postoperative inflammation levels and numerical predictors of anastomotic leakage development were significantly lower with acellular dermal matrix reinforcement of surgical anastomosis. This finding is worthy of further investigation, as reduction of inflammation with anastomotic site reinforcement is a novel finding, and more in-depth research may lead to discoveries on the physiologic role of the surgical anastomosis in post-gastrectomy patients. In addition, lower CRP and NUn scores for the intervention arm suggest potential for larger studies to detect reduction in clinical leak rates after acellular dermal matrix reinforcement.