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Mejía-Rivera S, Pérez-Marroquín SA, Cortés-González R, Medina-Franco H. Contrast-enhanced swallow study sensitivity for anastomotic leak detection in post-esophagectomy patients. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018. [PMID: 29525701 DOI: 10.1016/j.rgmx.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION AND AIMS Esophagectomy is a highly invasive surgery and one of its postoperative complications is anastomotic leakage, occurring in 53% of cases. The aim of the present study was to determine the sensitivity of the contrast-enhanced swallow study as a method for diagnosing anastomotic leak in patients that underwent esophagectomy. MATERIAL AND METHODS The present retrospective study included the case records of patients that underwent esophagectomy with reconstruction and cervical anastomosis at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán within the time frame of January 1, 2000 and May 31, 2016. Demographic, clinical, and laboratory data emphasizing clinical and radiographic anastomotic leak detection were identified. Descriptive statistics were carried out and contrast-enhanced swallow study sensitivity for diagnosing leakage was calculated. RESULTS Seventy patients were included in the analysis. The mean age of the patients was 50.6 years, 51 of the patients were men (72.86%), and 19 were women (27.14%). Indications for surgery were benign lesion in 29 patients (41.4%) and malignant lesion in 41 (58.6%). A total of 44.3% of the patients presented with a comorbidity, with diabetes mellitus and high blood pressure standing out. Thirty patients (42.85%) presented with anastomotic leak. Contrast-enhanced swallow study sensitivity for leak detection was 43.33%. CONCLUSIONS The diagnostic sensitivity of the contrast-enhanced swallow study was very low. Therefore, we recommend the discontinuation of its routine use as a method for diagnosing anastomotic leaks.
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Affiliation(s)
- S Mejía-Rivera
- Cirugía Oncológica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - R Cortés-González
- Cirugía Oncológica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - H Medina-Franco
- Cirugía Oncológica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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An V, Chandra R, Lawrence M. Anastomotic Failure in Colorectal Surgery: Where Are We at? Indian J Surg 2018; 80:163-170. [DOI: 10.1007/s12262-018-1745-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/12/2018] [Indexed: 12/22/2022] Open
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153
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Cosse C, Rebibo L, Brazier F, Hakim S, Delcenserie R, Regimbeau JM. Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy. Br J Surg 2018; 105:570-577. [DOI: 10.1002/bjs.10732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 01/30/2023]
Abstract
Abstract
Background
Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure.
Methods
Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis.
Results
One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure.
Conclusion
DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.
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Affiliation(s)
- C Cosse
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- Institut National de la Santé et de la Recherche Médicale U1088, Jules Verne University of Picardie, Amiens, France
| | - L Rebibo
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - F Brazier
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - S Hakim
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - R Delcenserie
- Department of Gastroenterology, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
| | - J M Regimbeau
- Department of Digestive Surgery, Amiens South Hospital, Jules Verne University of Picardie, Amiens, France
- EA4294, Jules Verne University of Picardie, Amiens, France
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154
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Kumar T, Krishanappa R, Pai E, Sringeri R, Singh TB, Swain J, Kondapavuluri S, Pandey M. Completely Linear Stapled Versus Handsewn Cervical Esophagogastric Anastomosis After Esophagectomy. Indian J Surg 2018; 80:134-139. [PMID: 29915479 DOI: 10.1007/s12262-018-1732-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 01/22/2018] [Indexed: 01/17/2023] Open
Abstract
Very limited data is present which compares completely linear stapled to handsewn cervical esophagogastric anastomosis. Primary objective was to determine whether linearly stapled (LS) anastomosis has lower clinically apparent leaks, when compared to handsewn anastomosis (HS). Secondary objectives were morbidity, mortality, overall leak and stricture rates, and presence of a symptomatic cervical stricture. This is a comparative study of 77 patients who underwent LS (n = 29) and HS (n = 48) cervical anastomosis. Anastomotic leak was found to be 19.4% (15/77). In the HS group, 27.08% (13/48) and in the LS group, 6.89% (2/29), respectively, leaked (p = 0.03), relative risk (RR)-3.93 (95% CI 1.21-15.25). 32.5% (23/77) patients remained admitted for more than 14 days. 52.1% (25/48) patients in the HS group were discharged within 14 days of surgery; whereas; 93.1% (27/29) were discharged in LS group (p = 0.001), RR-6.95 (95% CI 2.13-25.94). Overall, 90-day mortality was 7.8% (6/77). In the HS group, 8.3% (4/48) patients died while in the LS group, 6.8% (2/29) patients died (p = 0.82), RR-1.21(95% CI 0.27-5.53). In the HS group, 6.25% (3/48) patients were diagnosed with stricture compared to 6.8% (2/29) patients in the LS group (p = 0.9), RR-0.91 (95% CI 0.19-4.44). Overall stricture rate was 6.4% (5/77). Cervical anastomosis done with linear staplers has less leak rates compared to handsewn anastomosis.
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Affiliation(s)
- Tarun Kumar
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Ravi Krishanappa
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - Esha Pai
- 3Department Of Surgical Oncology, Tata Memorial Hospital, E Borges Road, Parel, Mumbai, 400012 India
| | - Raxith Sringeri
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - T B Singh
- 4Department of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Jyoti Swain
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Sindhuri Kondapavuluri
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - Manoj Pandey
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
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155
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Gooszen JAH, Goense L, Gisbertz SS, Ruurda JP, van Hillegersberg R, van Berge Henegouwen MI. Intrathoracic versus cervical anastomosis and predictors of anastomotic leakage after oesophagectomy for cancer. Br J Surg 2018; 105:552-560. [PMID: 29412450 PMCID: PMC5900725 DOI: 10.1002/bjs.10728] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/07/2017] [Accepted: 09/18/2017] [Indexed: 12/18/2022]
Abstract
Background Studies comparing the anastomotic leak rate in patients with an intrathoracic versus a cervical anastomosis after oesophagectomy are equivocal. The aim of this study was to compare clinical outcome after oesophagectomy in patients with an intrathoracic or cervical anastomosis, and to identify predictors of anastomotic leakage in a nationwide audit. Methods Between January 2011 and December 2015, all consecutive patients who underwent oesophagectomy for cancer were identified from the Dutch Upper Gastrointestinal Cancer Audit. For the comparison between an intrathoracic and cervical anastomosis, propensity score matching was used to adjust for potential confounders. Multivariable logistic regression modelling with backward stepwise selection was used to determine independent predictors of anastomotic leakage. Results Some 3348 patients were included. After propensity score matching, 654 patients were included in both the cervical and intrathoracic anastomosis groups. An intrathoracic anastomosis was associated with a lower leak rate than a cervical anastomosis (17·0 versus 21·9 per cent; P = 0·025). The percentage of patients with recurrent nerve paresis was also lower (0·6 versus 7·0 per cent; P < 0·001) and an intrathoracic anastomosis was associated with a shorter median hospital stay (12 versus 14 days; P = 0·001). Multivariable analysis revealed that ASA fitness grade III or higher, chronic obstructive pulmonary disease, cardiac arrhythmia, diabetes mellitus and proximal oesophageal tumours were independent predictors of anastomotic leakage. Conclusion An intrathoracic oesophagogastric anastomosis was associated with a lower anastomotic leak rate, lower rate of recurrent nerve paresis and a shorter hospital stay. Risk factors for anastomotic leak were co‐morbidities and proximal tumours. Lower leak rates after intrathoracic anastomosis
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Affiliation(s)
- J A H Gooszen
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - L Goense
- Department of Surgery, University Medical Centre, Utrecht, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Centre, Utrecht, The Netherlands
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Chen BP, Bennett S, Bertens KA, Balaa FK, Martel G. Use and acceptance of the International Study Group for Pancreatic Fistula (ISGPF) definition and criteria in the surgical literature. HPB (Oxford) 2018; 20:69-75. [PMID: 28927654 DOI: 10.1016/j.hpb.2017.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/07/2017] [Accepted: 08/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature. METHODS A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria. RESULTS From 2006 to 2009, 6%-63% of primary papers were compliant with the ISGPF definition compared to 84%-98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions. CONCLUSION The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.
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Affiliation(s)
- Brian P Chen
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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157
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Kim TH, Suh YS, Huh YJ, Son YG, Park JH, Yang JY, Kong SH, Ahn HS, Lee HJ, Slankamenac K, Clavien PA, Yang HK. The comprehensive complication index (CCI) is a more sensitive complication index than the conventional Clavien-Dindo classification in radical gastric cancer surgery. Gastric Cancer 2018; 21:171-181. [PMID: 28597328 DOI: 10.1007/s10120-017-0728-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The comprehensive complication index (CCI) integrates all complications of the Clavien-Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC. METHODS Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution. RESULTS From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p < 0.05). The CCI demonstrated a stronger relationship with hospital stay (ρ = 0.721, p < 0.001) than did the CDC (ρ = 0.634, p < 0.001). For prolonged hospital stays (≥30 days), only the CCI showed a moderate correlation (ρ = 0.544, p = 0.024), although the CDC did not. The CUSUM-CCI model displayed dynamic time-event differences in individual and comparison monitoring models. In the institution monitoring model, a gradual decrease in the CCI was observed. CONCLUSIONS The CCI is more strongly correlated with postoperative hospital stay than is the conventional CDC. The CUSUM-CCI model can be used for the continuous monitoring of surgical quality.
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Affiliation(s)
- Tae-Han Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon-Ju Huh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Gil Son
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Ho Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jun-Young Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Seong Ahn
- Department of Surgery, Seoul National University-SMG Boramae Medical Center, Seoul, Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | | | | | - Han-Kwang Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. .,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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158
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de Geus-Oei LF, Hendriks T, van Goor H, Bremers AJA, Oyen WJG, Bleichrodt RP, Teeuwen PHE. Hybrid 18F-FDG PET/CT of colonic anastomosis. Nuklearmedizin 2017; 51:252-6. [DOI: 10.3413/nukmed-0493-12-04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 07/23/2012] [Indexed: 11/20/2022]
Abstract
Summary18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a known method to diagnose inflammatory processes and thus may be a promising imaging technique to detect anastomotic bowel leak. The aim of this study was to assess postoperative FDG uptake in colorectal anastomosis in patients without suspicion of active infection or anastomotic leakage. Patients, methods: Design of a prospective observational pilot study in order to assess normal FDG uptake in the patient anastomosis after colorectal surgery. Patients that underwent colorectal surgery with primary anastomosis received FDG-PET of the abdomen, 2–6 days postoperatively. Results: 35 patients met the inclusion criteria. Three patients were not scanned for various reasons. Of the remaining 32 patients, one demonstrated an increased uptake of FDG at the site of the anastomosis. In the other 31 patients FDG uptake was negligible (n = 17) or scored as physiological (n = 14). None of the scanned patients developed a clinical relevant anastomotic leakage within the first 30 days after surgery. Conclusion: The present study shows that FDG uptake in colorectal anastomosis remains low within the first six days after surgery in patients without anastomotic leakage. Therefore, FDG-PET might be useful to investigate further as a tool to detect anastomotic leakage in an the early postoperative phase.
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159
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Guerra F, Giuliani G, Coletta D, Boni M, Rondelli F, Bianchi PP, Coratti A. A Meta-Analysis of Randomized Controlled Trials on the Use of Suction Drains Following Rectal Surgery. Dig Surg 2017; 35:482-490. [PMID: 29232658 DOI: 10.1159/000485139] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 11/09/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage is one of the most feared complications of rectal resections. The role of drains in limiting this occurrence or facilitating its early recognition is still poorly defined. We aimed to study whether the presence of prophylactic pelvic drains affects the surgical outcomes of patients undergoing rectal surgery with extraperitoneal anastomosis. METHODS PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials comparing drained with undrained anastomoses following rectal surgery. We evaluated possible differences on the relative incidences of anastomotic leakage, pelvic collection or sepsis, bowel obstruction, reoperation rate, and overall mortality. A meta-analysis of relevant studies was performed with RevMan 5.3. RESULTS A total of 760 patients from 4 randomized controlled studies were considered eligible for data extraction. The use of drains did not show any advantage in terms of anastomotic leak (OR 0.99), pelvic complications (OR 0.87), reintervention (OR 0.84) and mortality. Contrariwise, the incidence of postoperative bowel obstruction was significantly higher in the drained group (OR 1.61). CONCLUSIONS The routine utilization of pelvic drains does not confer any significant advantage in the prevention of postoperative complications after rectal surgery with extraperitoneal anastomosis. Moreover, a higher risk of postoperative bowel obstruction can be of concern.
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Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Diego Coletta
- Division of General Surgery, Umberto I University Hospital, Rome, Italy
| | - Marcello Boni
- Division of General Surgery, San Giovanni Battista Hospital, Foligno, Italy
| | - Fabio Rondelli
- Division of General Surgery, San Giovanni Battista Hospital, Foligno, Italy.,Division of General Surgery, University of Perugia, Perugia, Italy
| | - Paolo Pietro Bianchi
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
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Feroci F, Giani I, Baraghini M, Romoli L, Zalla T, Quattromani R, Cantafio S, Scatizzi M. Barbed versus traditional suture for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis: a case–control study. Updates Surg 2017; 70:433-439. [DOI: 10.1007/s13304-017-0502-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/21/2017] [Indexed: 11/24/2022]
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161
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What Is the Risk of Anastomotic Leak After Repeat Intestinal Resection in Patients With Crohn's Disease? Dis Colon Rectum 2017; 60:1299-1306. [PMID: 29112566 DOI: 10.1097/dcr.0000000000000946] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of Crohn's patients require intestinal resection, and many need repeat resections. OBJECTIVE The purpose of this study was to evaluate the increased risk of clinical anastomotic leak in patients with a history of previous intestinal resection undergoing repeat resection with anastomosis for Crohn's disease. DESIGN This was a retrospective analysis of prospectively collected departmental data with 100% capture. SETTINGS The study was conducted at the department of colorectal surgery in a tertiary care teaching hospital between July 2007 and March 2016. PATIENTS A cohort of consecutive patients with Crohn's disease who were treated with intestinal resection and anastomosis, excluding patients with proximal fecal diversion, were included. The cohort was divided into 2 groups, those with no previous resection compared with those with previous resection. MAIN OUTCOME MEASURES Clinical anastomotic leak within 30 days of surgery was measured. RESULTS Of the 206 patients who met criteria, 83 patients had previous intestinal resection (40%). The 2 groups were similar in terms of patient factors, immune-suppressing medication use, and procedural factors. Overall, 20 clinical anastomotic leaks were identified (10% leak rate). There were 6 leaks (5%) detected in patients with no previous intestinal resection and 14 leaks (17%) detected in patients with a history of previous intestinal resection (p < 0.005). The OR of anastomotic leak in patients with Crohn's disease with previous resection compared with no previous resection was 3.5 (95% CI, 1.3-9.4). Patients with 1 previous resection (n = 53) had a leak rate of 13%, whereas patients with ≥2 previous resections (n = 30) had a leak rate of 23%. The number of previous resections correlated with increasing risk for clinical anastomotic leak (correlation coefficient = 0.998). LIMITATIONS This was a retrospective study with limited data to perform a multivariate analysis. CONCLUSIONS Repeat intestinal resection in patients with Crohn's disease is associated with an increased rate of anastomotic leakage when compared with initial resection despite similar patient, medication, and procedural factors. See Video Abstract at http://links.lww.com/DCR/A459.
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162
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Polonioli A. A plea for minimally biased naturalistic philosophy. SYNTHESE 2017; 196:3841-3867. [PMID: 31404228 PMCID: PMC6656791 DOI: 10.1007/s11229-017-1628-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/13/2017] [Indexed: 06/10/2023]
Abstract
Naturalistic philosophers rely on literature search and review in a number of ways and for different purposes. Yet this article shows how processes of literature search and review are likely to be affected by widespread and systematic biases. A solution to this problem is offered here. Whilst the tradition of systematic reviews of literature from scientific disciplines has been neglected in philosophy, systematic reviews are important tools that minimize bias in literature search and review and allow for greater reproducibility and transparency. If naturalistic philosophers wish to reduce bias in their research, they should then supplement their traditional tools for literature search and review by including systematic methodologies.
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Affiliation(s)
- Andrea Polonioli
- Department of Philosophy, University of Birmingham, 3 Elms Road, Edgbaston, Birmingham, B15 2TT UK
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163
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Zheng CH, Lu J, Zheng HL, Li P, Xie JW, Wang JB, Lin JX, Chen QY, Cao LL, Lin M, Tu RH, Huang CM. Comparison of 3D laparoscopic gastrectomy with a 2D procedure for gastric cancer: A phase 3 randomized controlled trial. Surgery 2017; 163:300-304. [PMID: 29195739 DOI: 10.1016/j.surg.2017.09.053] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 08/20/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the relative safety and efficacy of 3D laparoscopic gastrectomy and 2D laparoscopic surgery in patients with gastric cancer. BACKGROUND There is still a lack of randomized controlled trials regarding the safety and efficacy of 3D versus 2D laparoscopic surgery for gastric cancer. METHODS A large-scale, phase 3, prospective, randomized controlled trial was conducted. (ClinicalTrials.gov number NCT02327481). RESULTS A total of 438 patients were randomized (3D group: 219 cases; 2D group: 219 cases) between January 1, 2015, and April 1, 2016; 19 patients were excluded. Finally, data from 419 patients were analyzed (3D group: 211 cases; 2D group: 208 cases). There were no differences between the 2 groups regarding the operation time (3D versus 2D, 176 ± 35 min vs. 174 ± 33 min, P = .562). The intraoperative blood loss in the 3D group was somewhat less than in the 2D group (61 ± 83 mL vs. 82 ± 119 mL, P = .045). Further analysis suggested that the use of 3D laparoscopic surgery was a protective factor against excessive blood loss (≥200 mL). CONCLUSION 3D laparoscopic gastrectomy did not shorten the operation time compared with 2D laparoscopic gastrectomy, but provided the benefit of less intraoperative blood loss and a lesser occurrence of excessive bleeding than the conventional 2D laparoscopic gastrectomy; the clinical value of the difference is limited.
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Affiliation(s)
- Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Hua-Long Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China
| | - Ru-Hong Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China; Department of General Surgery, Fujian Medical University Union Hospital, Fujian Province, China; Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fujian Province, China; Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fujian Province, China.
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Ramos Fernández M, Rivas Ruiz F, Fernández López A, Loinaz Segurola C, Fernández Cebrián JM, de la Portilla de Juan F. Proteína C reactiva como predictor de fuga anastomótica en cirugía colorrectal. Comparación entre cirugía abierta y laparoscópica. Cir Esp 2017; 95:529-535. [DOI: 10.1016/j.ciresp.2017.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 06/05/2017] [Accepted: 08/21/2017] [Indexed: 01/27/2023]
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165
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Caballero Y, López-Tomassetti E, Castellot A, Hernández JR. Endoscopic management of a gastric leak after laparoscopic sleeve gastrectomy using the over-the-scope-clip (Ovesco®) system. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:746-750. [PMID: 26864585 DOI: 10.17235/reed.2016.3901/2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Laparoscopic sleeve gastrectomy is currently used for the management of morbid obesity. Gastric fistula is the primary life-threatening complication, and its resolution continues to be a strong challenge for surgeons. Multiple treatment options are available, ranging from conservative therapy to endoscopic use of clips or stents, and even surgical reoperation involving total gastrectomy or conversion to a different bariatric technique. The applicability of each individual option will depend on the type of fistula and the patient clinical status. A clinical case is reported of a 29-year-old male patient with a body mass index at 49% who following laparoscopic sleeve gastrectomy had a delayed gastric fistula that failed to respond to conservative management but was successfully treated using the over-the-scope clip (Ovesco®) system.
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Affiliation(s)
- Yurena Caballero
- Servicio de Cirugía General y del Aparat Digestivo, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar, España
| | - Eudaldo López-Tomassetti
- Cirugía General y Digestiva, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
| | - Ana Castellot
- Medicina del Aparato Digestivo, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
| | - Juan Ramón Hernández
- Cirugía General y Digestiva, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
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166
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Terterov D, Leung PHY, Twells LK, Gregory DM, Smith C, Boone D, Pace D. The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks. Can J Surg 2017; 60:335-341. [PMID: 28742012 DOI: 10.1503/cjs.015216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.
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Affiliation(s)
- Dimitry Terterov
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Philemon Ho-Yan Leung
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Laurie K Twells
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Deborah M Gregory
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Chris Smith
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - Darrell Boone
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
| | - David Pace
- From the Eastern Health Sciences Centre, St. John's, NL (Terterov, Leung, Boone, Pace); the Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL (Terterov, Leung, Twells, Gregory, Smith, Boone, Pace); and the School of Pharmacy, Memoral University of Newfoundland, St. John's, NL (Twells)
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167
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Schaible A, Brenner T, Hinz U, Schmidt T, Weigand M, Sauer P, Büchler MW, Ulrich A. Significant decrease of mortality due to anastomotic leaks following esophageal resection: management makes the difference. Langenbecks Arch Surg 2017; 402:1167-1173. [PMID: 28975494 DOI: 10.1007/s00423-017-1626-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Anastomotic leakage is the most frequent cause of postoperative mortality following esophageal surgery. However, no gold standard for diagnosing and managing leakage has been established. Continuous clinical judgment is extremely important; therefore, to optimize the management of leakage, we established a special group for decision-making in cases of suspected leakage in the early postoperative period. METHODS Between January 2010 and December 2016, 234 consecutive patients underwent elective esophageal resection with a thoracoabdominal incision. In 2014, we established a group consisting of a surgeon, surgical endoscopist, and anesthesiologist for decision-making in cases of suspected leakage. They discussed emerging problems and decided on further diagnostics or therapy. The data were documented prospectively and compared to the years prior to 2014. RESULTS Two hundred and thirty-four consecutive patients were enrolled in the study, 110 in the years 2010-2013 (group A), and 124 in the years 2014-2016 (group B). Neither patients' characteristics nor the rate of anastomotic leakage differed significantly between the two study groups. The hospital mortality rate was 10% (11 patients) in group A and 4.8% (six patients) in group B. Most interestingly, mortality due to anastomotic leakage was 35% in group A (9/26), whereas it decreased significantly to 6.5% (2/31 patients) (P < 0.001) in group B. CONCLUSIONS Our data clearly demonstrated that optimizing the management of anastomotic leakage by making team decisions can lead to a significant decrease in mortality.
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Affiliation(s)
- Anja Schaible
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany.
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Markus Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Internal Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
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168
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Examination of anastomotic leak with aqueous contrast swallow after total gastrectomy: Should it be carried out routinely? Contemp Oncol (Pozn) 2017; 21:224-227. [PMID: 29180930 PMCID: PMC5701583 DOI: 10.5114/wo.2017.70112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/25/2017] [Indexed: 11/23/2022] Open
Abstract
Aim of the study Examination of esophagojejunal (EJ) anastomosis with aqueous contrast swallow after total gastrectomy is still routinely conducted by many centres. The present study aimed to answer the question: Is it necessary to evaluate EJ anastomosis in terms of leakage by having every patient drink oral contrast agent before initiation of oral food intake after total gastrectomy (TG) performed due to gastric cancer? Material and methods Clinical and radiological results of patients on whom total gastrectomy was performed due to gastric cancer between January 2013 and December 2016 were retrospectively reviewed. Diagnostic method used for patients in whom leak developed and therapeutic interventions were assessed. Evaluation results from aqueous contrast agent and clinical, laboratory, and tomographic findings were studied. Results Sixty of the 69 patients who underwent total gastrectomy with a diagnosis of gastric adenocarcinoma swallowed aqueous contrast agent on postoperative day 7 ±2 days and were evaluated in terms of anastomotic leak. Leak developed in 14 patients (20.2 %), 10 of whom ingested contrast agent. Leak was identified in 6 of those patients; however, diagnosis was made with multislice computed tomography (CT) in four patients (40%). The sensitivity of the examination with aqueous contrast agent was 60%. Conclusions Evaluating anastomotic leak with aqueous contrast agent after TG has low sensitivity, and it would be wise to resort to this procedure in cases with clinical suspicion, rather than routinely performing it in every patient.
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169
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van Rooijen SJ, Jongen ACHM, Wu ZQ, Ji JF, Slooter GD, Roumen RMH, Bouvy ND. Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons. World J Gastroenterol 2017; 23:6172-6180. [PMID: 28970733 PMCID: PMC5597509 DOI: 10.3748/wjg.v23.i33.6172] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/28/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the level of consensus on the definition of colorectal anastomotic leakage (CAL) among Dutch and Chinese colorectal surgeons.
METHODS Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as > 80% agreement between respondents on various statements regarding a general definition of CAL, and regarding clinical and radiological diagnosis of the complication.
RESULTS Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan’. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation’, and ‘a radiological collection treated with percutaneous drainage’. No consensus was found for all other proposed elements that may be included in a general definition.
CONCLUSION There is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical’ leaks as CAL, which partly explains the higher reported Dutch CAL rates.
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Affiliation(s)
- Stefanus J van Rooijen
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Audrey CHM Jongen
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Zhou-Qiao Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Ward I of Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Jia-Fu Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Ward I of Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
| | - Rudi MH Roumen
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
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Fistula Following Laparoscopic Sleeve Gastrectomy: a Proposed Classification and Algorithm for Optimal Management. Obes Surg 2017; 28:656-664. [DOI: 10.1007/s11695-017-2905-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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171
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Zhang Y, Zhang YX, Hu JW, Yao GY, Xue L, Fan H, Zhang YQ, Wang Q. Endoscopic naso-leakage drainage: a safe and effective method for the management of intrathoracic anastomotic leakage after esophagectomy. J Thorac Dis 2017; 9:3052-3061. [PMID: 29221279 DOI: 10.21037/jtd.2017.08.47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Intrathoracic anastomotic leakage (IAL) remains a major complication of esophagectomy. Main non-surgical options of management include chest drainage and endoscope interventions. This study is aim to present our experience and assess the efficacy of endoscopic naso-leakage drainage (ENLD) in patients with IAL. Methods From June 2011 to January 2017, 67 patients who developed IAL after esophagectomy and managed by non-surgical approaches were analyzed retrospectively. IAL was confirmed by clinical presentations combined with the evidence of CT scan, radiography and endoscopy. Thirty-eight patients were treated by conventional chest drainage (CD group) and 29 patients underwent ENLD with or without chest drainage (ENLD group), while other treatments including enteral nutrition and antibiotics had no difference between the two groups. In ENLD group, a 12 Fr naso-leakage tube was placed through the leakage to the bottom of vomica under ultra-slim electronic gastroscope. The naso-leakage tube was then connected to a gastrointestinal decompression device for drainage and was also used for rinse. When the vomica diminished and the drainage was also clean, the naso-leakage tube could be pulled back gradually. Finally, healing of the leakage was confirmed endoscopically. Clinical records of the two groups were analyzed. Results In ENLD group, naso-leakage tubes were successfully placed under endoscope in all 29 patients without any procedure-related complications. In CD group, the mortality is 7.9% (three patients) and five patients (13.2%) developed to systemic inflammatory response syndrome (SIRS) due to insufficient drainage. While in ENLD group, there was only one patient (3.4%) developed to SIRS and no death was observed, but the difference was not statistically significant. When compared with the CD group, the ENLD group had a shorter healing course (44.2±18.3 vs. 60.5±27.7 days, P=0.008), duration of antibiotics usage (16.4±7.8 vs. 11.8±3.8 days, P<0.001) and duration of fever (4.3±2.2 vs. 9.5±8.6 days, P=0.002). Conclusions To our initial experience, ENLD is an ideal option with safety and efficacy in management of IAL after esophagectomy.
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Affiliation(s)
- Yi Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yong-Xing Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guang-Yu Yao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Liang Xue
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hong Fan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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172
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Green R, Charman SC, Palser T. Early definitive treatment rate as a quality indicator of care in acute gallstone pancreatitis. Br J Surg 2017; 104:1686-1694. [PMID: 28792589 DOI: 10.1002/bjs.10578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/26/2016] [Accepted: 04/04/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Early definitive treatment (cholecystectomy or endoscopic sphincterotomy in the same admission or within 2 weeks after discharge) of gallstone disease after a biliary attack of acute pancreatitis is standard of care. This study investigated whether compliance with early definitive treatment for acute gallstone pancreatitis can be used as a care quality indicator for the condition. METHODS A retrospective cohort study was conducted using the Hospital Episode Statistics database. All emergency admissions to National Health Service hospitals in England with a first time diagnosis of acute gallstone pancreatitis in the financial years 2008, 2009 and 2010 were examined. Trends in early definitive treatment between hospital trusts were examined and patient morbidity outcomes were determined. RESULTS During the study interval there were 19 510 patients with an overall rate of early definitive treatment at 34·7 (range 9·4-84·7) per cent. In the 1-year follow-up period, 4661 patients (23·9 per cent) had one or more emergency readmissions for complications related to gallstone pancreatitis. Of these, 2692 (57·8 per cent) were readmissions for acute pancreatitis; 911 (33·8 per cent) were within the first 2 weeks of discharge, with the remaining 1781 (66·2 per cent) occurring after the point at which definitive treatment should have been received. Early definitive treatment resulted in a 39 per cent reduction in readmission risk (adjusted risk ratio (RR) 0·61, 95 per cent c.i. 0·58 to 0·65). The risk was further reduced for acute pancreatitis readmissions to 54 per cent in the early definitive treatment group (adjusted RR 0·46, 0·42 to 0·51). CONCLUSION In acute gallstone pancreatitis, compliance with recommended early definitive treatment varied considerably, with associated variation in outcomes. Compliance should be used as a quality indicator to improve care.
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Affiliation(s)
- R Green
- Anaesthetics Department, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S C Charman
- Clinical Effectiveness Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - T Palser
- Department of Upper Gastrointestinal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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173
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Ferrando C, Soro M, Unzueta C, Canet J, Tusman G, Suarez-Sipmann F, Librero J, Peiró S, Pozo N, Delgado C, Ibáñez M, Aldecoa C, Garutti I, Pestaña D, Rodríguez A, García del Valle S, Diaz-Cambronero O, Balust J, Redondo FJ, De La Matta M, Gallego L, Granell M, Martínez P, Pérez A, Leal S, Alday K, García P, Monedero P, Gonzalez R, Mazzinari G, Aguilar G, Villar J, Belda FJ. Rationale and study design for an individualised perioperative open-lung ventilatory strategy with a high versus conventional inspiratory oxygen fraction (iPROVE-O2) and its effects on surgical site infection: study protocol for a randomised controlled trial. BMJ Open 2017; 7:e016765. [PMID: 28760799 PMCID: PMC5642673 DOI: 10.1136/bmjopen-2017-016765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Surgical site infection (SSI) is a serious postoperative complication that increases morbidity and healthcare costs. SSIs tend to increase as the partial pressure of tissue oxygen decreases: previous trials have focused on trying to reduce them by comparing high versus conventional inspiratory oxygen fractions (FIO2) in the perioperative period but did not use a protocolised ventilatory strategy. The open-lung ventilatory approach restores functional lung volume and improves gas exchange, and therefore it may increase the partial pressure of tissue oxygen for a given FIO2. The trial presented here aims to compare the efficacy of high versus conventional FIO2 in reducing the overall incidence of SSIs in patients by implementing a protocolised and individualised global approach to perioperative open-lung ventilation. METHODS AND ANALYSIS This is a comparative, prospective, multicentre, randomised and controlled two-arm trial that will include 756 patients scheduled for abdominal surgery. The patients will be randomised into two groups: (1) a high FIO2 group (80% oxygen; FIO2 of 0.80) and (2) a conventional FIO2 group (30% oxygen; FIO2 of 0.30). Each group will be assessed intra- and postoperatively. The primary outcome is the appearance of postoperative SSI complications. Secondary outcomes are the appearance of systemic and pulmonary complications. ETHICS AND DISSEMINATION The iPROVE-O2 trial has been approved by the Ethics Review Board at the reference centre (the Hospital Clínico Universitario in Valencia). Informed consent will be obtained from all patients before their participation. If the approach using high FIO2 during individualised open-lung ventilation decreases SSIs, use of this method will become standard practice for patients scheduled for future abdominal surgery. Publication of the results is anticipated in early 2019. TRIAL REGISTRATION NUMBER NCT02776046; Pre-results.
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Affiliation(s)
- Carlos Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carmen Unzueta
- Department of Anesthesiology and Critical Care, Hospital de la Santa Creu i Sant Pau, Valencia, Spain
| | - Jaume Canet
- Department of Anesthesiology and Critical Care, Hospital Germans Tries i Pujol, Badalona, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden
| | - Julian Librero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Navarrabiomed Fundación Miguel Servet, Pamplona, Spain
| | - Salvador Peiró
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Centro Superior de Investigación en Salud Pública (CSISP FISABIO), Valencia, Spain
| | - Natividad Pozo
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carlos Delgado
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Maite Ibáñez
- Department of Anesthesiology, Hospital de Villajoyosa, Villajoyosa, Spain
| | - César Aldecoa
- Department of Anesthesiology and Critical Care, Hospital de Villajoyosa, Villajoyosa, Spain
| | - Ignacio Garutti
- Department of Anesthesiology and Critical Care, Hospital General Gregorio Marañon, Madrid, Spain
| | - David Pestaña
- Anesthesiology and Critical Care, Hospital Ramón y Cajal, Madrid, Spain
| | - Aurelio Rodríguez
- Anesthesiology and Critical Care, Hospital Dr. Negrín, Gran Canaria, Spain
| | | | | | - Jaume Balust
- Anesthesiology and Critical Care, Hospital Clínic i Provincial, Barcelona, Spain
| | | | - Manuel De La Matta
- Anesthesiology and Critical Care, Hospital Vírgen del Rocio, Seville, Spain
| | - Lucía Gallego
- Anesthesiology and Critical Care, Hospital Miguel Servet, Zaragoza, Spain
| | - Manuel Granell
- Anesthesiology and Critical Care, Hospital General, Valencia, Spain
| | - Pascual Martínez
- Anesthesiology and Critical Care, Hospital de Albacete, Albacete, Spain
| | - Ana Pérez
- Anesthesiology and Critical Care, Hospital of Elche, Elche, Spain
| | - Sonsoles Leal
- Anesthesiology and Critical Care, Hospital Povisa, Vigo, Spain
| | - Kike Alday
- Anesthesiology and Critical Care, Hospital La Princesa, Madrid, Spain
| | - Pablo García
- Anesthesiology and Critical Care, Hospital 12 de Octubre, Madrid, Spain
| | - Pablo Monedero
- Anesthesiology and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Rafael Gonzalez
- Anesthesiology and Critical Care, Hospital Universitario de León, León, Spain
| | - Guido Mazzinari
- Anesthesiology and Critical Care, Hospital de Manises, Manises, Spain
| | - Gerardo Aguilar
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Gran Canaria, Spain
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francisco Javier Belda
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
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174
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Zheng HL, Lu J, Li P, Xie JW, Wang JB, Lin JX, Chen QY, Cao LL, Lin M, Tu R, Huang CM, Zheng CH. Effects of Preoperative Malnutrition on Short- and Long-Term Outcomes of Patients with Gastric Cancer: Can We Do Better? Ann Surg Oncol 2017; 24:3376-3385. [PMID: 28699132 DOI: 10.1245/s10434-017-5998-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effects of preoperative malnutrition and preoperative correction of hypoalbuminemia (PCH) on the short- and long-term outcomes in patients with gastric cancer are unclear. OBJECTIVE This study aimed to examine the effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy, and also explored the role of PCH in malnourished patients with gastric cancer. METHODS We prospectively reviewed data from patients with gastric cancer who were treated in our department between January 2009 and December 2014. The effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy was investigated, and we explored whether PCH could improve the short- and long-term outcomes of these patients. RESULTS A total of 1976 patients were analyzed, including 412 patients in the malnourished group and 1564 in the well-nourished group. The overall incidence of complications in the malnourished group was significantly higher than the well-nourished group (21.4 vs. 15.5%, p = 0.005). Except for incision infection (3.2 vs. 1.6%, p = 0.041), there were no significant differences for other complications. In the malnourished group, 98 cases of preoperative hypoproteinemia were corrected (PCH group), whereas 314 cases were not (NPCH group). The incidence of incision infection in the PCH group was significantly lower than in the NPCH group (0 vs. 4.1%, p = 0.041). The median follow-up time was 39 months (1.0-88.0 months), and the 3-year overall survival (OS; 59.1 vs. 75%, p < 0.001) and disease-free survival (DFS; 54.8 vs. 72.5%, p < 0.001) rates were significantly lower in the malnourished group than in the well-nourished group. A multivariate Cox regression analysis showed that malnutrition was an independent prognostic factor for 3-year OS (hazard ratio [HR] 1.211, 95% confidence interval [CI] 1.01-1.452, p = 0.039) and DFS (HR 1.168, 95% CI 1.013-1.398, p = 0.043). For the malnourished group with stage I gastric cancer, the PCH and NPCH groups showed no significant differences in 3-year OS (90.0 vs. 89.0%, p = 0.227) or DFS (90.0 vs. 87.3%, p = 0.363); however, for the malnourished group with stages II-III gastric cancer, the 3-year OS (69.9 vs. 47.6%, p = 0.013) and DFS (55.4 vs. 43.6%, p = 0.046) rates were significantly higher in the PCH group than in the NPCH group. CONCLUSIONS The incidence of incision infection was significantly higher in patients with malnutrition than in well-nourished patients. The 3-year OS and DFS rates were significantly lower in malnourished patients than in well-nourished patients. PCH may both reduce the incidence of incisional infection in patients with malnutrition and improve 3-year OS and DFS rates for malnourished patients with stages II-III gastric cancer; however, to confirm our findings, further studies are warranted.
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Affiliation(s)
- Hua-Long Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Ruhong Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China.,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China. .,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China. .,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China. .,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China.
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China. .,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China. .,Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China. .,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, Fujian Province, China.
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175
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Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database. Dis Colon Rectum 2017; 60:706-713. [PMID: 28594720 DOI: 10.1097/dcr.0000000000000800] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant. OBJECTIVE This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer. DESIGN All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit. SETTINGS Data were derived from the Dutch Surgical Colorectal Audit. MAIN OUTCOME MEASURES The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured. RESULTS Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage. LIMITATIONS Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database. CONCLUSIONS Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.
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176
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Wright EC, Connolly P, Vella M, Moug S. Peritoneal fluid biomarkers in the detection of colorectal anastomotic leaks: a systematic review. Int J Colorectal Dis 2017; 32:935-945. [PMID: 28401350 DOI: 10.1007/s00384-017-2799-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak (AL) in colorectal surgery leads to significant morbidity, mortality and poorer oncological outcomes. Diagnosis of AL is frequently delayed as current methods of detection are not 100% sensitive or specific. 'Biomarkers', such as cytokines and markers of ischaemia, from the milieu of the anastomosis may aid early detection. This paper aims to review the evidence for their role in AL detection, allowing identification of targets for future research. METHODS A systematic review was performed using PubMed, MEDLINE and Cochrane Library databases. Papers concerning detection or prediction of AL with biomarkers were identified. References within the papers were used to identify further relevant articles. RESULTS Research has taken place in small cohorts with varying definitions of AL. Lactate has consistently been shown to be elevated in patients with intra-abdominal complications and ALs. pH on post-operative day 3 showed excellent specificity. Despite mixed results, a meta-analysis found that the cytokines tumour necrosis factor-α and interleukin-6 were elevated early in AL. Detection of bacteria in drain fluid by RT-PCR has good specificity but a high rate of false positives. CONCLUSIONS Peritoneal cytokines, lactate and pH have the potential to identify AL early. The consistency of the results for lactate and pH, alongside the fact that they are easy, quick and inexpensive to test, makes them the most attractive targets. Studies in larger cohorts with standardized definitions of AL are required to clarify their usefulness. Emerging biosensor technology may facilitate the development of small, low-cost and degradable intra-abdominal devices to measure peritoneal fluid biomarkers.
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Affiliation(s)
- Emma C Wright
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK.
| | - Patricia Connolly
- Department of Biomedical Engineering, Wolfson Centre, University of Strathclyde, Glasgow, G4 0NW, UK
| | - Mark Vella
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK
| | - Susan Moug
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK
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177
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Ha GW, Kim JH, Lee MR. Oncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3289-3299. [DOI: 10.1245/s10434-017-5881-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Indexed: 12/15/2022]
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178
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Sukho P, Boersema GSA, Cohen A, Kops N, Lange JF, Kirpensteijn J, Hesselink JW, Bastiaansen-Jenniskens YM, Verseijden F. Effects of adipose stem cell sheets on colon anastomotic leakage in an experimental model: Proof of principle. Biomaterials 2017. [PMID: 28628777 DOI: 10.1016/j.biomaterials.2017.06.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The most dreaded complication of colorectal surgery is anastomotic leakage. Adipose tissue-derived stem cell sheets (ASC sheets) prepared from temperature-responsive culture surfaces can be easily transplanted onto tissues. These sheets are proposed to improve cell transplant efficiency and enhance wound healing. The aim of this study was to investigate whether application of ASC sheets could prevent leakage of sutured colorectal anastomoses. Insufficient suturing of colorectal anastomoses was performed in Wistar rats to create a colorectal anastomotic leakage model. Rats were randomized to ASC sheet application or control group. Leakage, abscess formation, adhesion formation, anastomotic bursting pressure (ABP), and histology were evaluated on postoperative day 3 or 7. ASC sheet application significantly reduced anastomotic leakage compared to controls, without increased adhesion formation. ASC sheet transplantation resulted in more CD3+ T-cells and CD163+ anti-inflammatory macrophages at the anastomotic site than the control group. ABP, vessel density and collagen deposition were not different between groups. Using cell sheet technology, we generated ASC sheets that prevented disruption of sutured colorectal anastomoses as shown by reduced leakage. Increased numbers of anti-inflammatory macrophages and T-cells might have contributed to this positive effect.
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Affiliation(s)
- Panithi Sukho
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands; Department of Otorhinolaryngology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand
| | - Geesien S A Boersema
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Abigael Cohen
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nicole Kops
- Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jolle Kirpensteijn
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands; Hill's Pet Nutrition Inc, Topeka, Kansas, USA
| | - Jan Willem Hesselink
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | | | - Femke Verseijden
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands; Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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179
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Moschetti L, Ghezzi TL, Müller BG, Dias AB, Corleta OC. Fluorescent test accurately predicts leak of ischemic colon anastomosis in rats. Acta Cir Bras 2017; 32:440-448. [DOI: 10.1590/s0102-865020170060000004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/16/2017] [Indexed: 01/09/2023] Open
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180
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Kanamori J, Okada N, Fujiwara H, Mayanagi S, Fujita T, Nagino M, Daiko H. Leak grading and percutaneous transanastomotic drainage for the treatment of cervical anastomotic leakage after esophagectomy. Dis Esophagus 2017; 30:1-7. [DOI: 10.1093/dote/dow029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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181
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Routine Radiologic Contrast Agent Examination After Gastrectomy for Gastric Cancer Is Not Useful. J Gastrointest Surg 2017; 21:801-806. [PMID: 28205124 DOI: 10.1007/s11605-017-3384-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/31/2017] [Indexed: 01/31/2023]
Abstract
Many studies have showed that routine upper gastrointestinal contrast agent examinations (RCE) for testing the patency of the anastomosis after esophagectomy or the stapler line after sleeve gastrectomy cannot be recommended due to low sensitivity. However, the clinical value of RCE after gastrectomy for gastric cancer remains unclear. We have retrospectively analyzed the clinical course of 377 consecutive patients who underwent gastrectomy for gastric cancer in our institution between 2005 and 2015. To date, we have performed a RCE on the fifth postoperative day before removal of the nasogastric tube and return to oral intake. In total, we have observed 14 anastomotic leaks (AL) (4%) after oncologic gastrectomy. Four AL (28.6%) occurred before the scheduled RCE on the fifth postoperative day (POD) and 7 (50%) late AL after POD 5. Three patients (21.4%) without any clinical symptoms were diagnosed by the RCE. Sensitivity of RCE was 50%. A significant percentage of patients with AL was diagnosed by computed tomography (CT) of the abdomen (50%). The standard therapy for AL after gastrectomy was endoscopic stent placement (n = 11), including three cases of stenting after surgical revision. Based on our data, we cannot recommend a RCE after gastrectomy for gastric cancer. The majority of AL occurs before or after a RCE and the sensitivity of the examination is low. In case of clinical suspicion of AL, a CT scan (with oral contrast agent) should be performed. In unclear cases, endoscopy is the preferable method providing the option of direct treatment.
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182
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Alonso S, Mayol X, Nonell L, Salvans S, Pascual M, Pera M. Peripheral blood leucocytes show differential expression of tumour progression-related genes in colorectal cancer patients who have a postoperative intra-abdominal infection: a prospective matched cohort study. Colorectal Dis 2017; 19:O115-O125. [PMID: 28214365 DOI: 10.1111/codi.13635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 12/22/2016] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leak is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. We hypothesized that the infection-induced inflammatory response may induce overexpression of tumour progression-related genes in immune cells. The aim was to investigate the effect of postoperative intra-abdominal infection on the gene expression patterns of peripheral blood leucocytes (PBL) after surgery for colorectal cancer. METHOD Prospective matched cohort study. Patients undergoing surgery for colorectal cancer were included. Patients who had anastomotic leak or intra-abdominal abscess were included in the infection group (n = 23) and matched with patients without complications for the control group (n = 23). PBL were isolated from postoperative blood samples. Total RNA was extracted and hybridized to the Affymetrix Human Gene 1.0 ST microarray. RESULTS Patients in the infection group displayed 162 upregulated genes and 146 downregulated genes with respect to the control group. Upregulated genes included examples coding for secreted cytokines involved in tumour growth and invasion (S100P, HGF, MMP8, MMP9, PDGFC, IL1R2). Infection also upregulated some proangiogenic genes (CEP55, TRPS1) and downregulated some inhibitors of angiogenesis (MME, ALOX15, CXCL10). Finally, some inhibitors (HP, ORM1, OLFM4, IRAK3) and activators (GNLY, PRF1, FGFBP2) of antitumour immunity were upregulated and downregulated, respectively, suggesting that the inflammatory environment caused by a postoperative infection favours immune evasion mechanisms of the tumour. CONCLUSION Analysis of PBL shows differential expression of certain tumour progression-related genes in colorectal cancer patients who have a postoperative intra-abdominal infection, which in turn may promote the growth of residual cancer cells to become recurrent tumours.
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Affiliation(s)
- S Alonso
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - X Mayol
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - L Nonell
- Microarray Analysis Service, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - S Salvans
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M Pascual
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M Pera
- Section of Colon and Rectal Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain
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183
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Banasiewicz T, Dziki A, Lampe P, Lorenc Z, Szczepkowski M, Zieliński J, Wallner G. Anastomotic leaks in gastrointestinal surgery and their prevention. POLISH JOURNAL OF SURGERY 2017; 89:49-56. [PMID: 28537563 DOI: 10.5604/01.3001.0009.8979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.
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Affiliation(s)
- Tomasz Banasiewicz
- Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej Uniwersytetu Medycznego im. K. Marcinkowskiego w Poznaniu
| | - Adam Dziki
- Klinika Chirurgii Ogólnej i Kolorektalnej UM w Łodzi
| | - Paweł Lampe
- Katedra i Klinika Chirurgii Przewodu Pokarmowego Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Zbigniew Lorenc
- Katedra i Oddział Kliniczny Chirurgii Ogólnej, Kolorektalnej i Urazów Wielonarządowych w Sosnowcu; Wydział Nauk o Zdrowiu Śląskiego Uniwersytetu Medycznego w Katowicach
| | - Marek Szczepkowski
- Klinika Chirurgii Kolorektalnej, Ogólnej i Onkologicznej Centrum Medycznego Kształcenia Podyplomowego w Warszawie
| | | | - Grzegorz Wallner
- II Katedra i Klinika Chirurgii Ogólnej, Gastroenterologicznej i Nowotworów Układu Pokarmowego Uniwersytetu Medycznego w Lublinie
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184
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Su'a BU, Mikaere HL, Rahiri JL, Bissett IB, Hill AG. Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery. Br J Surg 2017; 104:503-512. [PMID: 28295255 DOI: 10.1002/bjs.10487] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL. METHODS A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016. RESULTS Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960. CONCLUSION Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.
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Affiliation(s)
- B U Su'a
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - H L Mikaere
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - J L Rahiri
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - I B Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - A G Hill
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand.,Department of General Surgery, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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185
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Smith SR, Pockney P, Holmes R, Doig F, Attia J, Holliday E, Carroll R, Draganic B. Biomarkers and anastomotic leakage in colorectal surgery: C-reactive protein trajectory is the gold standard. ANZ J Surg 2017; 88:440-444. [PMID: 28304142 DOI: 10.1111/ans.13937] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/05/2017] [Accepted: 01/07/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak. METHODS C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers. RESULTS A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961. CONCLUSION This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.
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Affiliation(s)
- Stephen R Smith
- Department of Colorectal Surgery, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Pockney
- Department of Colorectal Surgery, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Ryan Holmes
- The University of Newcastle, Newcastle, New South Wales, Australia
| | - Fiona Doig
- The University of Newcastle, Newcastle, New South Wales, Australia
| | - John Attia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Elizabeth Holliday
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Rosemary Carroll
- Department of Colorectal Surgery, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Brian Draganic
- Department of Colorectal Surgery, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
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186
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The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit. Colorectal Dis 2017; 19. [PMID: 28263043 DOI: 10.1111/codi.13646] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 02/02/2017] [Accepted: 02/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomosis technique following right sided colonic resection is widely variable and may affect patient outcomes. This study aimed to assess the association between leak and anastomosis technique (stapled versus handsewn) METHODS: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a two-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, using a pre-specified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random effect variable. RESULTS This study included 3208 patients, of whom 78.4% (n=2515) underwent surgery for malignancy and 11.7% (n=375) for Crohn's disease. An anastomosis was performed in 94.8% (n=3041) of patients, which was handsewn in 38.9% (n=1183) and stapled in 61.1% (n=1858) cases. Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn versus 12.9% stapled) and to undergo open surgery (54.7% versus 36.6%). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (p=0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted odds ratio 1.43, 95% confidence interval 1.04-1.95, p=0.03). DISCUSSION Despite being used in lower risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. This article is protected by copyright. All rights reserved.
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187
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Bruns BR, Morris DS, Zielinski M, Mowery NT, Miller PR, Arnold K, Phelan HA, Murry J, Turay D, Fam J, Oh JS, Gunter OL, Enniss T, Love JD, Skarupa D, Benns M, Fathalizadeh A, Leung PS, Carrick MM, Jewett B, Sakran J, O’Meara L, Herrera AV, Chen H, Scalea TM, Diaz JJ. Stapled versus hand-sewn. J Trauma Acute Care Surg 2017; 82:435-443. [DOI: 10.1097/ta.0000000000001354] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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188
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Parthasarathy M, Greensmith M, Bowers D, Groot-Wassink T. Risk factors for anastomotic leakage after colorectal resection: a retrospective analysis of 17 518 patients. Colorectal Dis 2017; 19:288-298. [PMID: 27474844 DOI: 10.1111/codi.13476] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/12/2016] [Indexed: 12/12/2022]
Abstract
AIM A large, prospectively collected, clinical database was analysed to determine the various pre- and intra-operative factors affecting anastomotic leakage (AL) in colorectal surgery. METHOD Data on 17 518 patients having a colorectal resection with anastomosis, taken from the 2013 American College of Surgeons National Surgical Quality Improvement Program database, were included in the study. Multivariable logistic regression analysis was carried out to identify risk-adjusted predictive factors for AL. Statistical significance was set at P < 0.05 and confidence intervals were reported at the 95% level. RESULTS The AL rate was 3.9% (687/17 518). Younger patients, male gender and an American Society of Anesthesiology (ASA) score of ≥ 3 (P < 0.001), smoking (P = 0.001), diabetes (P = 0.035), a preoperative serum albumin level of < 4 g/dl (P = 0.030), elective rectal cancer surgery (P = 0.024), emergency colectomy for bleeding (P = 0.013) and splenic flexure mobilization (P = 0.043) were associated with an increased risk of AL. Preoperative oral antibiotics (P < 0.001), right hemicolectomy (open or laparoscopic) and laparoscopic partial colectomy were associated with a reduced risk of AL compared with the entire group. Body mass index, preoperative chemotherapy, emergency surgery and mechanical bowel preparation were not related to AL. CONCLUSION In contrast to most studies, younger age was found to be an independent risk factor for AL. The risk for AL was lower with laparoscopic partial colectomy and open or laparoscopic right hemicolectomy. Preoperative oral antibiotic preparation significantly reduces the risk of AL and should be incorporated as a standard protocol.
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Affiliation(s)
| | | | - D Bowers
- University of Essex, Colchester, UK
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189
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Chivot C, Rebibo L, Robert B, Dhahri A, Regimbeau JM, Yzet T. Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:758-765. [PMID: 28330791 DOI: 10.1016/j.soard.2017.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. OBJECTIVE Determine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SETTING University hospital, France, public practice. MATERIAL AND METHODS This study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. RESULTS A total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1-245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0-86). Uniform gastric shape was acquired after 30-32 SG procedures. CONCLUSION Routine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.
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Affiliation(s)
- Cyril Chivot
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Lionel Rebibo
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Brice Robert
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France; Jules Verne University of Picardie, Amiens, France; Clinical Research Center, Amiens University Hospital, Amiens, France.
| | - Thierry Yzet
- Department of Radiology, Amiens University Hospital, Amiens, France
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Abstract
BACKGROUND The impact of process improvement through surgeon feedback on outcomes is unclear. OBJECTIVE We sought to evaluate the effect of biannual surgeon-specific feedback on outcomes and adherence to departmental and Surgical Care Improvement Project process measures on colorectal surgery outcomes. DESIGN This was a retrospective analysis of prospectively collected 100% capture surgical quality improvement data. SETTING This study was conducted at the department of colorectal surgery at a tertiary care teaching hospital from January 2008 through December 2013. MAIN OUTCOME MEASURES Each surgeon was provided with biannual feedback on process adherence and surgeon-specific outcomes of urinary tract infection, deep vein thrombosis, surgical site infection, anastomotic leak, 30-day readmission, reoperation, and mortality. We recorded adherence to Surgical Care Improvement Project process measures and departmentally implemented measures (ie, anastomotic leak testing) as well as surgeon-specific outcomes. RESULTS We abstracted 7975 operations. There was no difference in demographics, laparoscopy, or blood loss. Adherence to catheter removal increased from 73% to 100% (p < 0.0001), whereas urinary tract infection decreased 52% (p < 0.01). Adherence to thromboprophylaxis administration remained unchanged as did the deep vein thrombosis rate (p = not significant). Adherence to preoperative antibiotic administration increased from 72% to 100% (p < 0.0001), whereas surgical site infection did not change (7.6%-6.6%; p = 0.3). There were 2589 operative encounters with anastomoses. For right-sided anastomoses, the proportion of handsewn anastomoses declined from 19% to 1.5% (p < 0.001). For left-sided anastomoses, without diversion, anastomotic leak testing adherence increased from 88% to 95% (p < 0.01). Overall leak rate decreased from 5.2% to 2.9% (p < 0.05). LIMITATIONS Concurrent process changes make isolation of the impact from individual process improvement changes challenging. CONCLUSIONS Nearly complete adherence to process measures for deep vein thrombosis and surgical site infection did not lead to measureable outcomes improvement. Process measure adherence was associated with decreased rate of anastomotic leak and urinary tract infection. Biannual surgeon-specific feedback of outcomes was associated with improved process measure adherence and improvement in surgical quality.
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191
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Shuto K, Kono T, Akutsu Y, Uesato M, Mori M, Matsuo K, Kosugi C, Hirano A, Tanaka K, Okazumi S, Koda K, Matsubara H. Naso-esophageal extraluminal drainage for postoperative anastomotic leak after thoracic esophagectomy for patients with esophageal cancer. Dis Esophagus 2017; 30:1-9. [PMID: 27862613 DOI: 10.1111/dote.12492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Postoperative anastomotic leaks and subsequent mediastinal abscess are serious complications. The purpose of this study was to assess the efficacy of naso-esophageal extraluminal drainage after thoracic esophagectomy with gastric conduit reconstruction using a posterior mediastinal route. About 50 of 365 patients (13.7%) with esophageal cancer and postoperative anastomotic leak after curative esophagectomy was investigated. Beginning in June 2009, naso-esophageal extraluminal drainage by inserting a naso-esophageal aspiration tube into the abscess cavity when percutaneous abscess drainage was introduced which was ineffective or technically impossible. Twenty-five patients underwent naso-esophageal extraluminal drainage concomitantly with enteral nutrition. Twenty-one (84%) patients had major leaks, one (4%) minor leak and three (12%) had endoscopically proven conduit necrosis. None of the naso-esophageal extraluminal drainage cases (100%) required reintervention or reoperation and all experienced complete cure (100%) during hospitalization. Endoscopic balloon dilatation was performed for four patients after discharge because of anastomotic stricture. Patients with leaks were divided into two groups: current group (n = 32), treated after June 2009, and preceding group (n = 18), treated prior to the introduction of naso-esophageal extraluminal drainage. Significantly more patients in the preceding group suffered respiratory failure (28% vs. 61%, p = 0.024), and higher reoperation rate (0% vs. 17%, p = 0.042) and hospital mortality (0% vs. 22%, p = 0.013). In the current group, 31 (97%) patients experienced complete cure during hospitalization. Naso-esophageal extraluminal drainage and concomitant enteral nutritional support are less invasive, and effective and powerful methods to treat even major leakage after esophagectomy. These methods may be an alternative management to improve mortality for patients with esophageal cancer.
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Affiliation(s)
- Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan.,Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsuguaki Kono
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasunori Akutsu
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaya Uesato
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Mikito Mori
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Kenichi Matsuo
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Atsushi Hirano
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Kuniya Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Shinich Okazumi
- Department of Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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192
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Ding N, Mao Y, He J, Gao S, Zhao Y, Yang D, Sun K, Cheng G, Mu J, Xue Q, Wang D, Zhao J, Gao Y, Liu X, Fang D, Li J, Wang Y, Huang J, Wang B, Zhang L. Experiences in the management of anastomotic leakages and analysis of the factors affecting leakage healing in patients with esophagogastric junction cancer. J Thorac Dis 2017; 9:386-391. [PMID: 28275487 DOI: 10.21037/jtd.2017.02.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND It was reported in the literatures that the incidence of anastomotic leakage in patients with esophagogastric junction cancer decreased due to application of staplers and closure devices as well as gastric conduit technique in recent years, however, it increased slightly at our center since widely using the above devices and gastric conduit techniques from 2009. The objective of this study was to summarize our experiences in the management of anastomotic leakages and analyze the factors affecting leakage healing in the patients with esophagogastric junction cancer after surgical resection in recent 6 years. METHODS All patients who received surgical resections for esophagogastric junction cancer and diagnosed anastomotic leak at our center between January 2009 and December 2014 were retrospectively analyzed, we also enrolled the patients who had a longer hospital stay (>30 days) as they may develop anastomotic leak. The binary logistic regression in SPSS 16.0 was applied to analyze the factors that may affect leakage healing. RESULTS Of the 1,815 surgically treated esophagogastric junction cancer patients, 91 cases were diagnosed anastomotic leakage postoperatively. The patients were divided into two groups based on the median leakage healing time (40 days) in this series: fast healing group (37 cases) and slowly healing group (54 cases). All factors that may affect the leakage healing were put into analysis by using binary logistic regression. The results of the analysis showed that leakage size (OR =1.073, P=0.004), thoracic drainage (OR =12.937, P=0.037) and smoking index ≤400 (OR =1.001, P=0.04) significantly affected the healing time, while drinking history (P=0.177), duration of fever after anastomotic leak developed (P=0.084), and hypoproteinemia after leak (P=0.169) also apparently but not significantly affect the healing time. CONCLUSIONS Though many factors may affect leakage healing in the esophagogastric junction carcinoma patients, leakage size, thoracic drainage and smoking index (≤400) are the most important factors affecting the leakage healing. Placement of a chest tube beside the anastomosis area during operation for early identification and control of an anastomotic leak to minimize contamination of the mediastinum is the most important way to promote leakage healing. A chest tube placing into the purulent cavities after the patients experienced leaks is also important for the cure of leakage. More attention should be paid perioperatively to the patients who had a smoking index (≥400) and the patients who suffered fever or hypoproteinemia.
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Affiliation(s)
- Ningning Ding
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yousheng Mao
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jie He
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yue Zhao
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ding Yang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Kelin Sun
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Guiyu Cheng
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Juwei Mu
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qi Xue
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dali Wang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jun Zhao
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yushun Gao
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiangyang Liu
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dekang Fang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jian Li
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yonggang Wang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jinfeng Huang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Bing Wang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Liangze Zhang
- Department of Thoracic Surgery, Cancer Hospital (Institute), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Chen BP, Garland K, Roffey DM, Poitras S, Dervin G, Lapner P, Phan P, Wai EK, Kingwell SP, Beaulé PE. Can Surgeons Adequately Capture Adverse Events Using the Spinal Adverse Events Severity System (SAVES) and OrthoSAVES? Clin Orthop Relat Res 2017; 475:253-260. [PMID: 27511203 PMCID: PMC5174042 DOI: 10.1007/s11999-016-5021-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/03/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from-an aid that may improve adverse-event reporting by physicians. QUESTIONS/PURPOSES The primary objective was to compare surgeons' adverse-event reporting with reporting by independent clinical reviewers using SAVES Version 2 (SAVES V2) and OrthoSAVES in elective orthopaedic procedures. METHOD This was a 10-week prospective study where SAVES V2 and OrthoSAVES were used by six orthopaedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures to the point of patient discharge. Neither surgeons nor reviewers received specific training on adverse-event reporting. Surgeons were aware of the ongoing study, and reported adverse events based on their clinical interactions with the patients. Reviewers recorded adverse events by reviewing clinical notes by surgeons and other healthcare professionals (such as nurses and physiotherapists). Adverse events were graded using the severity-grading system included in SAVES V2 and OrthoSAVES. At discharge, adverse events recorded by surgeons and reviewers were recorded in our database. RESULTS Adverse-event data for 164 patients were collected (48 patients who had spine surgery, 51 who had hip surgery, 34 who had knee surgery, and 31 who had shoulder surgery). Overall, 99 adverse events were captured by the reviewers, compared with 14 captured by the surgeons (p < 0.001). Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers. A total of 93 of 99 (94%) adverse events reported by reviewers required only simple or minor treatment and had no long-term adverse effect. Three patients experienced adverse events that resulted in use of invasive or complex treatment that had a temporary adverse effect on outcome. CONCLUSION Using SAVES V2 and OrthoSAVES, independent reviewers reported more minor adverse events compared with surgeons. The value of third-party reviewers requires further investigation in a detailed cost-benefit analysis. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Brian P. Chen
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Katie Garland
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Darren M. Roffey
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Stephane Poitras
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Geoffrey Dervin
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Peter Lapner
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Philippe Phan
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Eugene K. Wai
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Stephen P. Kingwell
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Paul E. Beaulé
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
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194
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Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, Heald RJ, Kennedy RH, Moran B, Mortensen N, Motson RW, Novell R, O'Connell PR, Ris F, Rockall T, Senapati A, Windsor A, Jayne DG. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017; 19:O1-O12. [PMID: 27671222 DOI: 10.1111/codi.13534] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.
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Affiliation(s)
- A Vallance
- Royal College of Surgeons of England, London, UK
| | - S Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Cleveland Clinic Florida, Weston, Florida, USA
| | - R Cahill
- University College Dublin, Dublin, Ireland
| | | | - N Haboubi
- University Hospital of South Manchester, Manchester, UK
| | - R J Heald
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - B Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - R W Motson
- The ICENI Centre, Colchester University Hospital, Colchester, UK
| | - R Novell
- The Royal Free Hospital, London, UK
| | | | - F Ris
- Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T Rockall
- Royal Surrey County Hospital, Guildford, UK
| | | | - A Windsor
- University College Hospital, London, UK
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Nederlof N, de Jonge J, de Vringer T, Tran TCK, Spaander MCW, Tilanus HW, Wijnhoven BPL. Does Routine Endoscopy or Contrast Swallow Study After Esophagectomy and Gastric Tube Reconstruction Change Patient Management? J Gastrointest Surg 2017; 21:251-258. [PMID: 27844264 PMCID: PMC5258812 DOI: 10.1007/s11605-016-3268-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/29/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leakage is a severe complication after esophagectomy. The objective was to investigate the diagnostic and predictive value of routine contrast swallow study and endoscopy for the detection of anastomotic dehiscence in patients after esophagectomy. METHODS All patients who underwent contrast swallow and/or endoscopy within 7 days after oesophagectomy for cancer between January 2005 and December 2009 were selected from an institutional database. RESULTS Some 173 patients underwent endoscopy, and 184 patients underwent a contrast swallow study. The sensitivity of endoscopy for anastomotic leakage requiring intervention is 56 %, specificity 41 %, positive predictive value (PPV) 8 %, and negative predictive value (NPV) 95 %. The sensitivity of contrast swallow study for detecting leakage requiring intervention in patients without signs of leakage was 20 %, specificity 20 %, PPV 3 %, and NPV 97 %. CONCLUSIONS In patients without clinical suspicion of leakage, there is no benefit to perform routine examinations.
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Affiliation(s)
- N. Nederlof
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - J. de Jonge
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - T. de Vringer
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - T. C. K. Tran
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - M. C. W. Spaander
- 000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - H. W. Tilanus
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - B. P. L. Wijnhoven
- 000000040459992Xgrid.5645.2Department of Surgery, Erasmus MC University Medical Centre Rotterdam, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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196
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Tu RH, Lin JX, Zheng CH, Li P, Xie JW, Wang JB, Lu J, Chen QY, Cao LL, Lin M, Huang CM. Development of a nomogram for predicting the risk of anastomotic leakage after a gastrectomy for gastric cancer. Eur J Surg Oncol 2016; 43:485-492. [PMID: 28041649 DOI: 10.1016/j.ejso.2016.11.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/16/2016] [Accepted: 11/30/2016] [Indexed: 12/16/2022] Open
Abstract
AIMS To investigate the incidence of and factors associated with anastomotic leakage (AL) following gastrectomy for gastric cancer. METHODS We retrospectively analyzed 3632 patients who underwent a laparoscopic gastrectomy or open gastrectomy for gastric cancer. A logistic regression model was used to identify the determinant variables, and a nomogram for AL was developed. RESULTS A total of 3632 patients were included in the study, 50 of whom (1.4%) developed AL. Postoperative deaths occurred in 6 (0.2%) patients with AL failure to rescue. Esophagojejunal AL (27/50) and Billroth I AL (20/50) were the most common types of AL. Gastrografin swallow was the main diagnostic method. The diagnosis was made a median of 9 days postoperatively. The median healing time for AL was 34.5 days. Of the 50 AL patients, 56% of patients could be managed nonsurgically, whereas 28% of patients required percutaneous radiologic drainage, 6% of patients were treated by endoscopy, and 10% of patients required a second surgery. A multivariate analysis showed the following adverse risk factors for AL: age ≥65 years, hemoglobin ≤8.0 g/dL and malnourishment. A multivariable model for AL showed a strong optimism-adjusted discrimination (concordance index, 0.675). The 5-year overall survival rates for patients without or with AL were 59.4% and 67.4%, respectively (p = 0.354). CONCLUSIONS AL was infrequent but was more prevalent in patients with age ≥65 years, hemoglobin ≤8.0 g/dL and malnourishment. We created a novel nomogram that can provide individualized prediction of AL in patients after a gastrectomy for gastric cancer, which may help clinicians in making treatment decisions.
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Affiliation(s)
- R-H Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - J-X Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - C-H Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - P Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - J-W Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - J-B Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - J Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Q-Y Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - L-L Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - M Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - C-M Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
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197
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Ryu SJ, Kim BW, Kim BG, Kim JH, Kim JS, Kim JI, Park JM, Oh JH, Kim TH, Kim JJ, Park SM, Park CH, Song KY, Lee JH, Kim SG, Kim DJ, Kim W. Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years. Surg Endosc 2016; 30:5283-5289. [PMID: 27338583 DOI: 10.1007/s00464-016-4877-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 03/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is an alternative to surgical resection for treating early gastric cancer (EGC). However, there have been limited reports on the long-term outcome of ESD compared to that of surgical resection. The aim of this study was to evaluate the immediate and long-term clinical and oncologic outcomes of ESD compared to surgical resection. METHOD We retrospectively reviewed data of patients in five centers who were treated with ESD or surgical resection for EGC within expanded criteria for ESD from 2006 to 2008. RESULT ESD group had significantly shorter procedure times, shorter fasting period, and shorter hospital stay than the surgical resection group. Immediate complications in the surgical resection group were more common compared to those in the ESD group. Five-year cancer recurrence rate of the ESD group was 12.3 % and significantly higher than 2.1 % of the surgical resection group (P = 0.001). Five-year disease-free survival rate of the surgical resection group was 97 %, which was significantly higher than 85 % of the ESD group (P = 0.001). Metachronous lesions were equally found every year during the follow-up period in the ESD group. Five-year overall survival rates were 100 % for both groups. CONCLUSION ESD might be an acceptable and effective treatment for EGC considering overall survival rates with fewer early complication rates and shorter duration of hospital stay compared to surgical resection. However, intensive and persistent endoscopic surveillance should be performed after ESD for early detection of metachronous lesions.
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Affiliation(s)
- Seung Jee Ryu
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 403-720, Republic of Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 403-720, Republic of Korea.
| | - Boo Gyeong Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 403-720, Republic of Korea
| | - Ji Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 403-720, Republic of Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-gu, Incheon, 403-720, Republic of Korea
| | - Jin Il Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jae-Myung Park
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jung-Hwan Oh
- Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Tae Ho Kim
- Department of Internal Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jin-Jo Kim
- Department of General Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Seung-Man Park
- Department of General Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Cho Hyun Park
- Department of General Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Kyo Young Song
- Department of General Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Jun Hyun Lee
- Department of General Surgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Sung Geun Kim
- Department of General Surgery, St. Paul's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Dong Jin Kim
- Department of General Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Wook Kim
- Department of General Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
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198
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Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
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199
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Marano A, Giuffrida MC, Giraudo G, Pellegrino L, Borghi F. Management of Peritonitis After Minimally Invasive Colorectal Surgery: Can We Stick to Laparoscopy? J Laparoendosc Adv Surg Tech A 2016; 27:342-347. [PMID: 27792472 DOI: 10.1089/lap.2016.0374] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although laparoscopy is becoming the standard of care for the treatment of colorectal disease, its application in case of postoperative peritonitis is still not widespread. The objective of this article is to evaluate the role of laparoscopy in the management of postoperative peritonitis after elective minimally invasive colorectal resection for malignant and benign diseases. MATERIALS AND METHODS Between April 2010 and May 2016, 536 patients received primary minimally invasive colorectal surgery at our Department. Among this series, we carried out a retrospective study of those patients who, having developed signs of peritonitis, were treated with a laparoscopic reintervention. Patient demographics, type of complication and of the main relaparoscopic treatment, and main outcomes of reoperation were recorded. RESULTS A total of 20 patients (3.7%) underwent relaparoscopy for the management of postoperative peritonitis, of which exact causes were detected by laparoscopy in 75% as follows: anastomotic leakage (n = 8, 40%), colonic ischemia (n = 2, 10%), iatrogenic bowel tear (n = 4, 20%), and other (n = 1, 5%). The median time between operations was 3.5 days (range, 2-8). The laparoscopic reintervention was tailored case by case and ranged from lavage and drainage to redo anastomosis with ostomy fashioning. Conversion rate was 10% and overall morbidity was 50%. No cases required additional surgery and 30-day mortality was nil. Three patients (15%) were admitted to intensive care unit for 24-hour surveillance. CONCLUSION Our experience suggests that in experienced hands and in hemodynamically stable patients, a prompt laparoscopic reoperation appears as an accurate diagnostic tool and an effective and safe option for the treatment of postoperative peritonitis after primary colorectal minimally invasive surgery.
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Affiliation(s)
- Alessandra Marano
- Department of General and Oncologic Surgery , ASO Santa Croce e Carle, Cuneo, Italy
| | | | - Giorgio Giraudo
- Department of General and Oncologic Surgery , ASO Santa Croce e Carle, Cuneo, Italy
| | - Luca Pellegrino
- Department of General and Oncologic Surgery , ASO Santa Croce e Carle, Cuneo, Italy
| | - Felice Borghi
- Department of General and Oncologic Surgery , ASO Santa Croce e Carle, Cuneo, Italy
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200
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Singhal S, Kailasam A, Akimoto S, Masuda T, Bertellotti C, Mittal SK. Simple Technique of Circular Stapled Anastomosis in Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2016; 27:288-294. [PMID: 27705608 DOI: 10.1089/lap.2016.0443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Advent of minimally-invasive esophagectomy necessitated the incorporation of stapled anastomotic techniques especially for intrathoracic anastomosis. We present our approach to the Ivor Lewis esophagectomy highlighting a simple modification in the anastomotic technique and review our experience with anastomotic outcomes. METHODS With IRB approval, patients who underwent Ivor Lewis esophagectomy with circular-stapled end-to-end anastomosis (EEA) were identified, divided into three equal sequential cohorts (A, B, and C), and compared for perioperative outcome. Cohorts were divided in a chronological order to have equal number of patients in each group. RESULTS Seventy-five patients underwent Ivor Lewis esophagectomy with circular stapled (EEA-25/28) anastomosis. Group A had longer median postoperative hospital stay and median postoperative ICU stay compared to Groups B and C. Ten patients (13%) had anastomotic leak-one patient required redo-anastomosis and other patients were managed with endoscopic interventions. There was significant decrease in rate of anastomotic leak with experience (8 versus 1 versus 1, P = .004). There were two perioperative deaths, one each in Groups A and C, including one death due to anastomotic leak (Group A). CONCLUSION Use of simple modifications to stapled EEA, as described here, has led to decrease in anastomotic leaks following Ivor Lewis esophagectomy.
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Affiliation(s)
- Saurabh Singhal
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona
| | - Aparna Kailasam
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Shunsuke Akimoto
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Takahiro Masuda
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona
| | - Carrie Bertellotti
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Sumeet K Mittal
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona.,2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
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