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

Does Routine Endoscopy or Contrast Swallow Study After Esophagectomy and Gastric Tube Reconstruction Change Patient Management?

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.

Development of a nomogram for predicting the risk of anastomotic leakage after a gastrectomy for gastric cancer

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.

Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years

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.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

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.

Management of Peritonitis After Minimally Invasive Colorectal Surgery: Can We Stick to Laparoscopy?

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.

Simple Technique of Circular Stapled Anastomosis in Ivor Lewis Esophagectomy

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.

[Impact of anastomotic leakage on long-term survival in mid-to-low rectal cancer]

BACKGROUND

The occurrence of anastomotic leakage (AL) after sphincter preserving anterior rectal resection in patients with rectal cancer is associated with increased morbidity and mortality. The impact of AL on long-term survival has, however, still not been sufficiently investigated and is currently the subject of controversial discussion.

OBJECTIVES

The aim of this study was to investigate the impact of AL on long-term survival in patients with Union of International Cancer Control (UICC) (y)0-III stage mid-to-low rectal cancer who underwent sphincter preserving rectal resection.

MATERIAL AND METHODS

A total of 108 patients with a mid-to-low rectal cancer (UICC stage (y)0-III) who underwent sphincter preserving surgery between January 2003 and October 2010 were identified within the institutional prospective colorectal cancer database. The impact of AL on 5-year overall (OS), cancer specific (CSS) and relapse-free survival (RFS) was investigated.

RESULTS

The overall leakage rate was 17.6 % (grade A 4.6 %, grade B 4.6 % and grade C 8.3 %). After a median follow-up of 70 months (range 24-123 months), patients with an anastomotic leakage had a significantly decreased 5-year OS (63.6 % versus 87.8 %, p = 0.02), CSS (72.2 % versus 93.5 %, p = 0.02) and RFS rate (61.1 % versus 84.2 %, p = 0.01). In univariable Cox regression analysis AL was associated with an unfavorable OS (hazard ratio HR 3.05, 95 % CI: 1.11-8.39, p = 0.03), CSS (HR 4.21, 95 % CI: 1.13-15.70, p = 0.03) and RFS (HR 3.02, 95 % CI: 1.20-7.58, p = 0.02).

CONCLUSION

In the study cohort anastomotic leakage after sphincter preserving anterior resection in patients with mid-to-low rectal cancer was associated with a significantly unfavorable impact on overall and oncological survival.

Complications and failure to rescue following laparoscopic or open gastrectomy for gastric cancer: a propensity-matched analysis

BACKGROUND

To investigate the incidence of and factors associated with postoperative complications and failure to rescue following laparoscopic and open gastrectomy for gastric cancer.

STUDY DESIGN

We analyzed the records of 4124 patients who underwent a laparoscopic or open gastrectomy for gastric cancer. One-to-one propensity score matching was performed to compare the difference between the two groups.

RESULTS

A total of 4124 patients were included in the study, 627 of whom (15.2 %) developed postoperative complications. Postoperative deaths occurred in 23 (0.6 %) patients with serious complications. In the propensity score matching analysis with 1361 pairs, no significant differences in the rates of overall complications (14.2 vs. 16.5 %, p = 0.093) were observed between laparoscopic and open gastrectomy group. In-hospital mortality decreased in patients who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy (0.3 vs. 1.2 %, p = 0.004). Failure to rescue rates were lower in patients who underwent laparoscopic gastrectomy (2.1 vs. 7.6 %, p = 0.008). Multivariate analysis showed that older age, tumor location, TNM stage classification, extent of gastric resection, operative time and intra-operative blood loss were adverse risk factors for postoperative complications. Laparoscopic gastrectomy was found to be a protective factor for failure to rescue. Complications associated with failure to rescue included abdominal bleeding, anastomotic leakage and cardiac events. In-hospital mortality increased as the number of complications per patient increased.

CONCLUSIONS

Assuming equal competence with open and laparoscopic approaches of a surgeon, the proportion of patients with postoperative complications were similar among those who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy. However, when complications occurred, patients with open gastrectomy were more likely to die.

Standardized reporting of adverse events after microvascular decompression of cranial nerves; a population-based single-institution consecutive series

OBJECTIVE

To investigate frequencies of adverse events occurring within 30 days after microvascular decompression (MVD) surgery using a standardized report form of adverse events.

METHODS

We conducted a retrospective review of 98 adult patients (≥16 years) treated with MVD between 1 January 1994 and 1 June 2013. Adverse events occurring within 30 days were classified according to the Landriel Ibanez classification for neurosurgical complications: grade I represents any non-life threatening complication treated without invasive procedures; grade II is complications requiring invasive management; grade III is life-threatening adverse events requiring treatment in an intensive care unit (ICU); grade IV is death as a result of complications. We sought to compare our results with reports from the literature.

RESULTS

Patients' median age was 61 years (range 26-83), and 64 (65 %) were females. Indications for MVD were trigeminal neuralgia (n = 77, 79 %), glossopharyngeal neuralgia (n = 4, 4 %), hemifacial spasm (n = 16, 16 %) and combined trigeminal neuralgia and hemifacial spasm (n = 1, 1 %). The overall 30-day complication rate was 20 %, with 14 % grade I complications, 5 % grade II complications and 1 % grade III complications. The comparison with the literature was hampered by the diverse and unsystematic way of reporting complications.

CONCLUSION

We provide a standardized report of postoperative complications in a consecutive patient series undergoing MVD. Due to the heterogeneous and non-standardized reporting of complications in the literature, it is difficult to know if our 20 % complication rate is low or high. Standardized reporting is a necessity for meaningful and more valid comparisons across studies. The safety of MVD, a fairly standardized neurosurgical procedure, is well suited for comparisons across centers provided that complications are reported in a standardized manner.

Evaluation of peripheral blood and abdominal fluid variables as predictors of intestinal surgical site failure in dogs with septic peritonitis following celiotomy and the placement of closed-suction abdominal drains

OBJECTIVE To evaluate peripheral blood and abdominal fluid variables as predictors of intestinal surgical site failure in dogs with septic peritonitis following celiotomy and closed-suction abdominal drain (CSAD) placement. DESIGN Prospective study. ANIMALS 26 dogs with septic peritonitis that underwent celiotomy and CSAD placement. PROCEDURES Abdominal fluid and blood samples were collected prior to surgery and daily thereafter until CSAD removal. Abdominal fluid was collected through the CSAD. Analysis of all samples included pH, PCO2, PO2, PCV, WBC count, and total solids, glucose, lactate, and electrolyte concentrations. Abdominal fluid samples also underwent cytologic evaluation and bacterial culture, and the volume of fluid removed through the drain was recorded daily. The blood-to-fluid glucose and lactate differences, fluid-to-blood lactate ratio and blood-to-fluid WBC and neutrophil ratios were determined daily. Dogs were categorized into 2 groups on the basis of whether they had an uneventful recovery (UR) or developed postoperative septic peritonitis (POSP). RESULTS 23 dogs had a UR and 3 developed POSP. On the third day after surgery, the abdominal fluid WBC count was significantly lower and the blood-to-fluid WBC and neutrophil ratios were significantly higher for dogs in the POSP group, compared with those for dogs in the UR group. None of the other blood and abdominal fluid variables assessed differed significantly between the 2 groups. CONCLUSIONS AND CLINICAL RELEVANCE Results failed to identify any objective predictive indicators for POSP in dogs with CSADs. Use of blood-to-fluid WBC and neutrophil ratios as predictive indicators for POSP requires further investigation.

Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment

BACKGROUND

Esophagojejunal anastomosis leakage after total gastrectomy (TG) for esophagogastric junction (EGJ) adenocarcinoma (ADC) constitutes one of the most serious and sometimes life-threatening complications. Management remains controversial and still challenging.

METHODS

A total of 198 patients operated for type I and II EGJ ADC were reviewed. Diagnosis of leakage was based on a combination of clinical and radiological findings. It was classified including objective endoscopic and clinical parameters requiring different type of treatment.

RESULTS

Anastomotic leakage was diagnosed in 14 patients (7%). Two cases recovered with conservative therapy. Six cases underwent endoscopy with clips placement in 2 and partially covered self-expandable metal stent placement in 4. Other two cases underwent reoperation with reconstruction of anastomosis and primary repair respectively. In the last four cases emergency surgery with total esophagectomy and diversion was required. Mortality occurred only in 3 of these patients and overall treatment was successful in 11 patients (78.5%).

CONCLUSIONS

No consensus has been reached on the best method of esophagojejunal anastomosis leakage management and the rate of failure remains significant. Different options of treatment are available but early detection and multidisciplinary approaches are the keys to obtain successful results irrespective of the employed strategy.

Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis

BACKGROUND AND AIMS

There is a paucity of evidence in ulcerative colitis [UC] comparing the traditional two-stage [total proctocolectomy with ileal pouch-anal anastomosis [IPAA] and diverting ileostomy, followed by ileostomy closure] vs the modified two-stage restorative proctocolectomy [subtotal colectomy with end ileostomy, followed by completion proctectomy and IPAA, without diverting ileostomy]. This study examines the risk of anastomotic leak following IPAA in traditional vs modified two-stage IPAA for UC patients.

METHODS

This was a single-institution, retrospective study of all UC patients who underwent a traditional or modified two-stage IPAA between 2002 and 2013. The primary outcome was anastomotic leak following IPAA.

RESULTS

In all, 460 patients had a two-stage IPAA procedure; 223 [48.5%] patients underwent traditional two-stage IPAA and 237 [51.5%] patients received the modified two-stage procedure. There was more preoperative enteral corticosteroid use [44.7% vs 33.2%, p = 0.04] before the first surgery in the modified two-stage group compared with the traditional two-stage group. The modified two-stage group had higher UC disease severity at presentation [86.9% patients with moderate/severe UC vs 73.1%, p < 0.01]. However, the modified two-stage group had a lower rate of anastomotic leak following IPAA [4.6% vs 15.7%, p < 0.01] and was associated with a lower risk of anastomotic leak on univariate (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.13, 0.52] and multivariate analysis [OR 0.27, 95% CI 0.12, 0.57].

CONCLUSIONS

Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure.

Bile Leakage After Hepatectomy for Liver Tumors

This study aimed to clarify the predictive factors for bile leakage after hepatectomy for liver tumor in terms of the International Study Group of Liver Surgery (ISGLS) definition. Between August 2006 and July 2012, 242 patients with a diagnosis of liver tumor underwent hepatectomy in our department, and the total bilirubin level of peritoneal drainage fluid prior to removal of the abdominal drains was examined. The data on all of the patients were analyzed retrospectively to identify the factors that might significantly affect the postoperative bile leakage. There was no grade C bile leakage, and grade A was documented in 65 patients (26.9%) and grade B in 7 patients (2.9%) in terms of the ISGLS definition. Although there was no significant difference in postoperative hospital stay between grade A bile leakage only and those without bile leakage (P = 0.933), a significant difference was noted between grades A and B (median, 11.0 versus 21.0 days; P &lt; 0.001). Multivariate analysis revealed 4 independent significant predictive factors: prolonged operation time (P = 0.040), cholecystectomy (P = 0.048), non–portal vein embolization (P = 0.010), and preoperative chemotherapy (P = 0.021). The ISGLS definition of bile leakage is clinically useful. Prolonged operation time, cholecystectomy, non–portal vein embolization, and preoperative chemotherapy were significant independent risk factors of bile leakage in this study.

Intraoperatively Testing the Anastomotic Integrity of Esophagojejunostomy Using Methylene Blue

Background:

Intraoperative testing of gastrointestinal anastomosis effectively ensures anastomotic integrity. This study investigated whether the routine use of methylene blue intraoperatively identified leaks to reduce the postoperative proportion of clinical leaks.

Methods:

This study retrospectively analyzed consecutive total gastrectomies performed from January 2007 to December 2014 in a university hospital setting by a general surgical group that exclusively used the methylene blue test. All surgeries were performed for gastric or junctional cancers (n = 198). All reconstructions (Roux-en Y esophagojejunostomy) were performed using a stapler. The methylene blue test was used in 108 cases (group 1) via a nasojejunal tube. No test was performed for the other 90 cases (group 2). Intraoperative leakage rate, postoperative clinical leakage rate, length of hospitalization, and mortality rate were the outcome measures.

Results:

The intraoperative leakage rate was 7.4% in group 1. The postoperative clinical leakage rate was 8.6%. The postoperative clinical leakage rate was 3.7% in group 1 and 14.4% in group 2 (p = 0.007). There were no postoperative clinical leaks when an intraoperative leak led to concomitant intraoperative repair. The median length of hospital stay was 6 days in group 1 and 8 days in group 2 (p < 0.001). One death occurred in each group. No test-related complications were observed.

Conclusion:

The methylene blue test for esophagojejunostomy is a safe and reliable method for the assessment of anastomosis integrity, especially in cases with difficult esophagojejunostomic construction.

Using the Comprehensive Complication Index to Assess the Impact of Neoadjuvant Chemoradiotherapy on Complication Severity After Esophagectomy for Cancer

Background

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with esophageal or junctional cancer has become a standard of care. The comprehensive complication index (CCI) has recently been developed and accounts for all postoperative complications. Hence, CCI better reflects the burden of all combined postoperative complications in surgical patients than the Clavien–Dindo score alone, which incorporates only the most severe complication. This study was designed to evaluate the severity of complications in patients treated with nCRT followed by esophagectomy versus in patients who underwent esophagectomy alone using the comprehensive complication index.

Study-design

All patients included in the CROSS trial—a randomized, clinical trial on the value of nCRT followed by esophagectomy—were included. Complications were assessed and graded using the Clavien–Dindo classification. CCI was derived from these scores, using the CCI calculator available online (www.assessurgery.com). CCI of patients who underwent nCRT followed by surgery was compared with the CCI of patients who underwent surgery alone.

Results

In both groups 161 patients were included. The median (and interquartile range) CCI of patients with nCRT and surgery was 26.22 (17.28–42.43) versus 25.74 (8.66–43.01) in patients who underwent surgery alone (p = 0.58). There also was no difference in CCI between subgroups of patients with anastomotic leakage, pulmonary complications, cardiac complications, thromboembolic events, chyle leakage, and wound infections.

Conclusions

Neoadjuvant chemoradiotherapy according to CROSS did not have a negative impact on postoperative complication severity expressed by CCI compared with patients who underwent surgery alone for potentially curable esophageal or junctional cancer.

Management and outcomes of anastomotic leaks after oesophagectomy

BACKGROUND

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality.

METHODS

All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database.

RESULTS

A total of 390 oesophagectomies were performed (median age 65 (range 32-81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52-80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15-159) days; none of these patients died.

CONCLUSION

Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.

New endoscopic technique for the treatment of large gastric fistula or gastric stenosis associated with gastric leaks after sleeve gastrectomy

BACKGROUND

Covered stent (CS) is required when gastric leak (GL) after sleeve gastrectomy is combined with gastric stenosis (GS) or when a large (>2 cm in diameter) gastric fistula is present (increasing the likelihood of double pigtail stent [DPS] migration).

OBJECTIVE

To compare the results of our previous endoscopic management of large GL or GS associated with GL (using CS only) with those of our new endoscopic treatment (using combined CS and DPS).

SETTING

University hospital, France, public practice.

MATERIAL AND METHODS

Between January 2009 and June 2015, all patients treated for large GL or GS associated with GL after sleeve gastrectomy (n = 20 patients) were included. Our previous endoscopic management required CS placement (CS group), whereas our new endoscopic treatment required combined CS and DPS placement (CS+DPS group). The primary efficacy endpoint was the treatment duration after CS placement until closure of the GL. The secondary efficacy endpoints were the number of endoscopic procedures, the stent migration rate, and the failure rate.

RESULTS

Nine patients were treated by CS only (CS group), whereas 11 patients were treated by both CS and DPS (CS+DPS group). The median time to GL closure after CS placement was 84 days (33-130) in the CS group and 32 days (26-89) in the CS+DPS group (P≤.05). The median number of endoscopic procedures at the time of CS placement was 2 (1-3) in the CS group and 1 (1-2) in the CS+DPS group (P≤.05). The stent migration rate after CS placement was 33.3% in the CS group and 0% in the CS+DPS group (P = .21), and the failure rate was 11% and 0% (P = .36).

CONCLUSION

The combination of CS and DPS constitutes an effective treatment for large GL or GS associated with GL, allowing significantly fewer endoscopic procedures and a shorter treatment duration.

Prospective assessment of complications on a daily basis is essential to determine morbidity and mortality in routine pediatric surgery

AIMS OF THE STUDY

We aimed to assess postoperative complications prospectively on a daily basis and hypothesized that this would lead to an increase in the number of detected complications.

METHODS

Surgical complications were assessed prospectively during a period of 8months. Systematic documentation was carried out daily during a team meeting (period S). Data were compared to those of a preceding period of 8-months of nonsystematic assessment (period N) in which complications had been documented in a self-reporting fashion. Complications were classified according to the Clavien-Dindo classification.

RESULTS

A total of 1291 patients (mean age: 6.6years) were included. During period S complications were determined in 16% of 790 operations compared to 4% of 741 procedures in period N (p<0.01). This difference was owing to an increased detection of minor complications (grade I-III), i.e. wound infection, dysuria after hypospadias repair or postoperative bleeding. In contrast, the incidence of severe complications (grade IV+V) was not significantly different between the time periods (1.3% in period S and 0.8% in period N). Most frequent major complications were cardiopulmonary arrest, enterocolitis, and death. Severe complications accounted for 8% of complications discussed during weekly morbidity and mortality conferences in period S versus 22% in period N (p<0.05).

CONCLUSION

Our results indicate that a systematic documentation of complications on a daily basis reveals a more realistic picture of the incidence of pediatric surgical complications and should be the method of choice.

A Technique for Localizing Perforated Duodenal Ulcer During Laparoscopic Repair

Laparoscopic repair of duodenal ulcer perforation has certain advantages over open repair. However, the conversion rate to open surgery is still high. The most common reason for conversion is inadequate localization of the ulcer perforation site during laparoscopy. Here, a technique is described which will aid in localizing the perforation, make suturing and repair easier, and helps in checking the integrity of the repair at the end of the procedure. This is done by compressing the gall bladder with an instrument like a laparoscopic fan retractor and simultaneously depressing the first part of the duodenum with another instrument. This results in bile flowing out through the perforation and simultaneously depressing the duodenum downward, making it more easily visible and making identification easier. Suturing is easier due to the liver also getting retracted simultaneously and more space being available consequently. Integrity of the anastomoses is also easily ascertained by this maneuver.

Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques

BACKGROUND

Anastomotic complications after foregut surgery include leaks, fistulas, and late strictures. The management of these complications can be challenging, and it may be desirable to avoid complex reoperation.

OBJECTIVES

We aim to describe the indications and outcomes of the use of esophageal self-expanding metal stents in the management of postoperative anastomotic complications after foregut surgery.

SETTING

Tertiary-referral academic medical center.

METHODS

We performed a retrospective review of a prospectively managed database. Data was collected on patient demographic characteristics, work-up, intraprocedure findings, and outcomes.

RESULTS

From October of 2009 to November of 2014, 47 patients (mean age 51.1, 36 women and 11 men) underwent endoscopic stent placement for anastomotic complications following upper gastrointestinal (UGI) surgery. The median time from index operation to endoscopic stent placement was 52 days (range 1-5280 days). Indications were sleeve leak or stenosis, gastrojejunal leak or stenosis after Roux-en-Y gastric bypass (RYGB), pouch staple-line leak after RYGB, enterocutaneous fistula, perforation after endoscopic dilation, upper gastrointestinal bleeding after peroral endoscopic myotomy (POEM), and peptic stricture after POEM. Symptomatic improvement occurred in 76.6% of patients, and early oral intake was initiated in 66% of patients. 14 patients (29.8%) went on to require definitive surgical intervention for persistent symptomatology. The average follow-up was 354.1 days (range 25-1912 days).

CONCLUSION

This paper describes the use of endoscopic stent therapy for a variety of pathologies after upper gastrointestinal surgery. We demonstrate that, in the appropriate setting, it is an effective and less-invasive therapeutic approach.

Anastomotic Leaks After Restorative Resections for Rectal Cancer Compromise Cancer Outcomes and Survival

BACKGROUND

Anastomotic leaks after restorative resections for rectal cancer may lead to worse long-term outcomes.

OBJECTIVE

The purpose of this study was to evaluate the best current evidence assessing anastomotic leaks in rectal cancer resections with curative intent and their impact on survival and cancer recurrence.

DATA SOURCES

A meta-analysis was performed using MEDLINE, EMBASE, and Cochrane search engines for relevant studies published between January 1982 and January 2015.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used to screen and select relevant studies for the review using key words "colorectal surgery; colorectal neoplasm; rectal neoplasm" and "anastomotic leak."

INTERVENTION

Anastomotic leak groups were compared with nonanastomotic leak groups.

MAIN OUTCOME MEASURES

ORs were calculated from binary data for local recurrence, distant recurrence, and cancer-specific mortality. A random-effects model was then used to calculate pooled ORs with 95% CIs.

RESULTS

Eleven studies with 13,655 patients met the inclusion criteria. This included 5 prospective cohort and 6 retrospective cohort studies. Median follow-up was 60 months. Higher cancer-specific mortality was noted in the leak group with an OR of 1.30 (95% CI, 1.04-1.62; p < 0.05). Local recurrences were more likely in rectal cancer resections complicated by anastomotic leaks (OR = 1.61 (95% CI, 1.25-2.09); p < 0.001). Distant recurrence was not more likely in the anastomotic leak group (OR = 1.07 (95% CI, 0.87-1.33); p = 0.52).

LIMITATIONS

All 11 studies are level 3 evidence cohort studies. Additional sensitivity analyses were performed to minimize cross-study heterogeneity.

CONCLUSIONS

Anastomotic leaks after restorative resections for rectal cancer adversely impact cancer-specific mortality and local recurrence.

Early Diagnosis of Colonic Anastomotic Leak With Peritoneal Endoscopy

Background and Objectives:

At present, we do not have a reliable method for the early diagnosis of colorectal anastomotic leakage (AL). We tested peritoneal flexible endoscopy through a port placed in the abdominal wall in the early postoperative course, as a new diagnostic method for detection of this complication and evaluated the suggested method for safety, feasibility, and accuracy.

Methods:

Ten swine were randomized into 2 groups: group A, colorectal anastomosis without leakage; and group B, colorectal anastomosis with leakage. A button gastrostomy feeding tube was inserted percutaneously into the peritoneal cavity. Colorectal anastomosis (with or without defect) was created 48 hours after the first operation. The swine were examined by peritoneal flexible endoscopy 8 and 24 hours after the colonic operation, by a consultant surgeon who was blinded to both the presence and the allocated location of the of the anastomotic defect.

Results:

None of the animals showed signs of illness 48 hours after the intraperitoneal gastrostomy tube placement. More than half of the anastomosis circumference was identified in 60 and 10% of the animals at endoscopy 8 and 24 hours, respectively, after the anastomosis was created. Excessive adhesion formation was observed in all animals, irrespective of AL. The sensitivity and specificity of endoscopy in detecting peritonitis 24 hours after AL were both 60%.

Conclusions:

Peritoneal endoscopy is a safe and simple procedure. Visualization of the peritoneal cavity in the early postoperative course was limited due to adhesion formation. Further studies are needed to clarify the accuracy of the procedure and to address additional methodological concerns.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors

PURPOSE

To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage.

METHODS

The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution.

RESULTS

The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator.

CONCLUSIONS

The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

Clinical, mechanical, and immunohistopathological effects of tissue adhesives on the colon: An in-vivo study

BACKGROUND

Tissue adhesives may be useful for sealing bowel anastomoses by preventing anastomotic leakage. Prior to clinical implementation, an in-depth analysis of the clinical and immunohistopathological effects of tissue adhesives on the target tissue and of the mechanical strength of the adhesive bond in an in vivo model is needed.

MATERIALS AND METHODS

In 84 rats, two bowel segments were glued using one of the following tissue adhesive: Bioglue, Gelatin-resorcinol-formaldehyde (GRF), Glubran 2, Histoacryl Flex, Omnex, Duraseal Xact, or Tissucol. Rats were followed for 7 or 28 days. Endpoints were clinical complication rate, mechanical strength, and immunohistopathological reactions.

RESULTS

Of the seven tissue adhesives, GRF and Bioglue showed the highest rates of bowel wall destruction and ileus and the most severe immunohistopathological tissue reactions at 7 and 28 days. Cyanoacrylates (Histoacryl Flex, Omnex, Glubran 2) showed high mechanical strength and mild immunohistopathological reactions at 7 and 28 days. Duraseal Xact and Tissucol were the most inert tissue adhesives, but exhibited low mechanical strength. At 28 days, mechanical strength was significantly correlated to CD8, CD68, and Ki67 cell counts.

CONCLUSION

Based on the clinical and immunohistopathological outcomes, GRF and Bioglue were found to be the least suitable tissue adhesives for colonic use. Duraseal Xact and Tissucol were inert but also showed low mechanical strength. Cyanoacrylates exhibited mild clinical and immunohistopathological effects while maintaining high strength, which makes them promising as colonic sealants. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 846-854, 2017.

Aziz SH, Zakaria AD. Effect of Tualang honey on the anastomotic wound healing in large bowel anastomosis in rats-A randomized controlled trial

Background

Honey has long been used for the treatment of number of ailments and diseases including surgical wounds. Current study evaluates the effectiveness of Tualang honey (TH) for large bowel anastomotic healing in Wistar rats.

Methods

Thirty male Wistar rats were given a 3 centimeter infra-umbilical laparotomy wound, in`flicted on their abdomen. The colonic transection was performed at 5 cm distal to caecum, with end to end anastomosis of colon segment. They were divided into two groups. Group I was fed with standard rat chow and water. Meanwhile, Group II apart from standard feed, was also given TH 1.0 g/kg every morning until day seven post operatively. Afterwards, anastomotic bursting pressures were measured and histopathological examination on the anastomosis line was performed with light microscopes. The data from two groups were analyzed by Independent paired t test for continuous variables.

Results

It was found that the tensile strength of colon anastomosis (95 % CI; p = <0.001) and the histopathological study including fibroblast count (p = <0.001) and inflammatory cells (p = 0.002) showed statistically significant difference in the favor of TH-treated group. Meanwhile, neovascularization formation was not statistically significant (p = 0.807); however, the overall count in the TH group was high.

Conclusion

Oral treatment with TH enhances anastomotic wound healing by increasing the number of fibroblasts and by decreasing inflammatory cells leading towards increased wound strength.

Strong poly(ethylene oxide) based gel adhesives via oxime cross-linking

There is a demand for materials to replace or augment the use of sutures and staples in surgical procedures. Currently available commercial surgical adhesives provide either high bond strength with biological toxicity or polymer and protein-based products that are biologically acceptable (though with potential sensitizing potential) but have much reduced bond strength. It is desirable to provide novel biocompatible and biodegradable surgical adhesives/sealants capable of high strength with minimal immune or inflammatory response. In this work, we report the end group derivatization of 8-arm star PEOs with aldehyde and amine end groups. Gels were prepared employing the Schiff-base chemistry between the aldehydes and the amines. Gel setting times, swelling behavior and rheological characterization were carried out for these gels. The mechanical-viscoelastic properties were found to be directly proportional to the crosslinking density of the gels, the 10K PEO gel was stiffer in comparison to the 20K PEO gel. The adhesive properties of these gels were tested using porcine skin and showed excellent adhesion properties. Cytotoxicity studies were carried out for the individual gel components using two different methods: (a) Crystal Violet Staining assay (CVS assay) and (b) impedance and cell index measurement by the xCELLigence system at concentrations >5%. Gels prepared by mixing 20% w/w solutions were also tested for cytotoxicity. The results revealed that the individual gel components as well as the prepared gels and their leachables were non-cytotoxic at these concentrations.

STATEMENT OF SIGNIFICANCE

This work presents a new type of glue that is aimed at surgery applications using a water soluble star shaped polymer. It show excellent adhesion to skin and is tough and easy to use. We show that it is very biocompatible based on tests on live human cells, and could therefore in principle be used for internal surgery. Comparison with other reported and commercial glues shows that it is stronger than most, and does not swell in water to the same degree as many other water based bioadhesives.

To drain or not to drain in colorectal anastomosis: a meta-analysis

BACKGROUND

Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.

OBJECTIVE

To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.

METHODS

We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms "colorectal" or "colon/colonic" or "rectum/rectal" and "anastomo*" and "drain or drainage." Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.

RESULTS

Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR) = 1.14, 95 % confidence interval (CI) 0.80-1.62, P = 0.47), (2) clinical anastomotic leakage (RR = 1.39, 95 % CI 0.80-2.39, P = 0.24), (3) radiologic anastomotic leakage (RR = 0.92, 95 % CI 0.56-1.51, P = 0.74), (4) mortality (RR = 0.94, 95 % CI 0.57-1.55, P = 0.81), (5) wound infection (RR = 1.19, 95 % CI 0.84-1.69, P = 0.34), (6) re-operation (RR = 1.18, 95 % CI 0.75-1.85, P = 0.47), and (7) respiratory complications (RR = 0.82, 95 % CI 0.55-1.23, P = 0.34).

CONCLUSIONS

Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.

Partial esophagogastrostomy with esophagogastric anastomosis below the aortic arch in cardiac carcinoma: characteristics and treatment of postoperative anastomotic leakage

BACKGROUND

Anastomotic leakage is a severe and common complication for surgeries of cardiac cancer. Here we explore the clinical features, diagnosis, and treatment strategies of anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis.

METHODS

From January 2009 to December 2013, 1,196 patients with cardiac carcinoma underwent esophagectomy and esophagogastric anastomosis in Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences. Of them, 25 patients developed symptomatic anastomotic leakage. Their clinical data were retrospectively reviewed.

RESULTS

Among these 25 patients with anastomotic leakage, three died after active treatment and fifteen healed with thoracic drainage time 18-115 days. The left seven patients who did not heal until discharge developed chronic infection sinus of anastomotic leakage. Without infection symptoms, they were discharged 30-100 days after surgery with nasoenteral tube and thoracic drainage.

CONCLUSIONS

Anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis can be classified into five subtypes: occult type, left thoracic type, right thoracic type, mediastinal type, and mixd type. Subtyping of anastomotic leakage is useful and convenient for diagnosis and treatment.

Gastric leaks after sleeve gastrectomy: no impact on weight loss, co-morbidities, and satisfaction rates

BACKGROUND

No data are available concerning the results on weight loss, correction of co-morbidities, and satisfaction rates in patients with healed gastric leak (GL) after sleeve gastrectomy (SG).

OBJECTIVE

Evaluate weight loss, correction of co-morbidities, and satisfaction rate of patients with healed GL after SG.

SETTING

University hospital, France, public practice.

METHODS

Between March 2004 and October 2012, all patients managed for GL after SG with a minimum of 1 year follow-up were included. These patients (GL group) were matched in terms of preoperative data and type of surgical procedure (first- or second-line SG) on a 1:2 basis with 74 patients without GL (control group) selected from a population of 899 SGs. Primary endpoint was the weight change over a 1-year period after performing SG. Secondary endpoints were GL data, co-morbidities data, and satisfaction rates 1 year after SG.

RESULTS

The GL group consisted of 37 patients (27 first-line SG [73%]). The mean EWL in the GL group was 52.2% and 68.8% at 6 and 12 months, whereas the mean EWL in the control group was 58.9% and 72.2%, respectively (P = .12; P = .46). No significant difference was observed between the 2 groups in terms of correction of co-morbidities. At 12 months follow-up, mean BAROS score was 6.02 in the GL group and 7.14 in the control group (P = .08). No significant difference was observed between the 2 groups in terms of the SF-36 questionnaire.

CONCLUSION

Despite the morbidity associated with GL, the results on weight loss, correction of co-morbidities, and satisfaction rates were similar in patients with healed GL and in patients without GL.

Core Outcomes and Common Data Elements in Chronic Subdural Hematoma: A Systematic Review of the Literature Focusing on Reported Outcomes

The plethora of studies in chronic subdural hematoma (CSDH) has not resulted in the development of an evidence-based treatment strategy, largely due to heterogeneous outcome measures that preclude cross-study comparisons and guideline development. This study aimed to identify and quantify the heterogeneity of outcome measures reported in the CSDH literature and to build a case for the development of a consensus-based core outcome set. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered with the PROSPERO international prospective register of systematic reviews (CRD42014007266). All full-text English language studies with >10 patients (prospective) or >100 patients (retrospective) published after 1990 examining clinical outcomes in CSDH were eligible for inclusion. One hundred two eligible studies were found. There were 14 (13.7%) randomized controlled trials, one single arm trial (1.0%), 25 (24.5%) cohort comparison studies, and 62 (60.8%) prospective or retrospective cohort studies. Outcome domains reported by the studies included mortality (63.8% of included studies), recurrence (94.1%), complications (48.0%), functional outcomes (40.2%), and radiological (38.2%) outcomes. There was significant heterogeneity in the definitions of the outcome measures, as evidenced by the seven different definitions of the term “recurrence,” with no definition given in 19 studies. The time-points of assessment for all the outcome domains varied greatly from inpatient/hospital discharge to 18 months. This study establishes and quantifies the heterogeneity of outcome measure reporting in CSDH and builds the case for the development of a robust consensus-based core outcome set for future studies to adhere to as part of the Core Outcomes and Common Data Elements in CSDH (CODE-CSDH) project.

Longterm -ostomy as a quality marker: Comparison of outcomes from a six year series of laparoscopic surgery in MRI defined low rectal cancer

AIM

We propose long-term -ostomy rate following laparoscopic rectal cancer resection must be included as an overall quality indicator of treatment in conjunction with frequently reported and readily available end points.

METHOD

A database was collated prospectively of consecutive rectal cancer resections over a 6-year period. Recorded data included pre-operative MRI (tumour stage and height from the anal-verge), as well as demographics, treatment, local recurrence rate, survival and -ostomy rate as the primary outcome measure.

RESULTS

65 patients were identified and classified as low-rectal cancer if the tumour on MRI was < 6 cm from the anal verge or middle/upper-rectal cancer if between 6 and 15 cm from the anal-verge and below the peritoneal reflection. Permanent stoma rates including colostomies and non-reversed ileostomies were 31.7% for middle/upper rectal cancer; 62.5% for low-rectal cancer and an overall rate of 42.1% for all rectal cancers. For upper-rectal cancer the rates of local recurrence, predicted mortality, R0 resection and conversion were: 0%, 1.9%, 97.6% and 0% respectively. Corresponding figures for low-rectal cancer were: 4.2%, 2.7%, 95.8% and 0%. There were no significant differences for age, sex, predicted morbidity/mortality, survival, recurrence or leak rates between the groups.

CONCLUSION

Laparoscopic rectal cancer surgery has a comparable permanent -ostomy rate to open rectal cancer surgery. We benchmark 31.7% as the permanent -ostomy rate for upper-rectal cancer and 62.5% for low-rectal cancer following laparoscopic resection, in the context of 96.9% R0 resection and 0% conversion rate in a consecutive series of patients.

Assessment by Using a Water-Soluble Contrast Enema Study of Radiologic Leakage in Lower Rectal Cancer Patients With Sphincter-Saving Surgery

Purpose

This study evaluated the efficacy of a water-soluble contrast enema (WCE) in predicting anastomotic healing after a low anterior resection (LAR).

Methods

Between January 2000 and March 2012, 682 consecutive patients underwent a LAR or an ultra-low anterior resection (uLAR) and were followed up for leakage. Clinical leakage was established by using physical and laboratory findings. Radiologic leakage was identified by using retrograde WCE imaging. Abnormal radiologic features on WCE were categorized into four types based on morphology: namely, dendritic, horny, saccular, and serpentine.

Results

Of the 126 patients who received a concurrent diverting stoma, only two (1.6%) suffered clinical leakage due to pelvic abscess. However, 37 patients (6.7%) in the other group suffered clinical leakage following fecal diversion (P = 0.027). Among the 163 patients who received a fecal diversion, 20 showed radiologic leakage on the first WCE (eight with and 12 without a concurrent diversion); 16 had abnormal features continuously until the final WCE while four patients healed spontaneously. Eleven of the 16 patients (69%), by their surgeon's decision, underwent a stoma restoration based on clinical findings (2/3 dendritic, 3/4 horny, 5/7 saccular, 1/2 serpentine). After stoma reversal, only 2 of the 11 (19%) complained of complications related to the rectal anastomosis.

Conclusion

WCE is helpful for detecting radiologic leakage before stoma restoration, especially in patients suffering clinical leakage after an uLAR. However, surgeons appear to opt for stoma restoration despite the persistent existence of radiologic leakage in cases with particular features on the WCE.

The PRECious trial PREdiction of Complications, a step-up approach, CRP first followed by CT-scan imaging to ensure quality control after major abdominal surgery: study protocol for a stepped-wedge trial

Background

After major abdominal surgery (MAS), 20 % of patients endure major complications, which require invasive treatment and are associated with increased morbidity and mortality. A quality control algorithm after major abdominal surgery aimed at early identification of patients at risk of developing major complications can decrease associated morbidity and mortality. Literature studies show promising results for C-reactive protein (CRP) as an early marker for postoperative complications, however clinical significance has yet to be determined.

Methods

A multicenter, stepped wedge, prospective clinical trial including all adult patients planned to undergo elective MAS. The first period consists of standard postoperative monitoring, which entails on demand additional examinations. This is followed by a period with implementation of postoperative control according to the PRECious protocol, which implicates standardized measurement of CRP levels. If CRP levels exceed 140 mg/L on postoperative day 3,4 or 5, an enhanced CT-scan is performed.

Primary outcome in this study is a combined primary outcome, entailing all morbidity and mortality due to postoperative complications. Complications are graded according to the Clavien-Dindo classification. Secondary outcomes are hospital length of stay, patients reported outcome measures (PROMs) and cost-effectiveness. Data will be collected during admission, three months and one year postoperatively. Approval by the medical ethics committee of the VU University Medical Center was obtained (ID 2015.114).

Discussion

the PRECious trial is a stepped-wedge, multicenter, open label, prospective clinical trial to determine the effect of a standardized postoperative quality control algorithm on postoperative morbidity and mortality, and cost-effectiveness.

Trial registration

www.ClinicalTrials.gov, NCT02102217. Registered 5 February 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0903-y) contains supplementary material, which is available to authorized users.

Diagnostic value of drain amylase for detecting intrathoracic leakage after esophagectomy

AIM: To investigate the value of elevated drain amylase concentrations for detecting anastomotic leakage (AL) after minimally invasive Ivor-Lewis esophagectomy (MI-ILE).

METHODS: This was a retrospective analysis of prospectively collected data in two hospitals in the Netherlands. Consecutive patients undergoing MI-ILE were included. A Jackson-Pratt drain next to the dorsal side of the anastomosis and bilateral chest drains were placed at the end of the thoracoscopic procedure. Amylase levels in drain fluid were determined in all patients during at least the first four postoperative days. Contrast computed tomography scans and/or endoscopic imaging were performed in cases of a clinically suspected AL. Anastomotic leakage was defined as any sign of leakage of the esophago-gastric anastomosis on endoscopy, re-operation, radiographic investigations, post mortal examination or when gastro-intestinal contents were found in drain fluid. Receiver operator characteristic curves were used to determine the cut-off values. Sensitivity, specificity, positive predictive value, negative predictive value, risk ratio and overall test accuracy were calculated for elevated drain amylase concentrations.

RESULTS: A total of 89 patients were included between March 2013 and August 2014. No differences in group characteristics were observed between patients with and without AL, except for age. Patients with AL were older than were patients without AL (P = 0.01). One patient (1.1%) without AL died within 30 d after surgery due to pneumonia and acute respiratory distress syndrome. Anastomotic leakage that required any intervention occurred in 15 patients (16.9%). Patients with proven anastomotic leakage had higher drain amylase levels than patients without anastomotic leakage [median 384 IU/L (IQR 34-6263) vs median 37 IU/L (IQR 26-66), P = 0.003]. Optimal cut-off values on postoperative days 1, 2, and 3 were 350 IU/L, 200 IU/L and 160 IU/L, respectively. An elevated amylase level was found in 9 of the 15 patients with AL. Five of these 9 patients had early elevations of their amylase levels, with a median of 2 d (IQR 2-5) before signs and symptoms occurred.

CONCLUSION: Measurement of drain amylase levels is an inexpensive and easy tool that may be used to screen for anastomotic leakage soon after MI-ILE. However, clinical validation of this marker is necessary.

The impact of anastomotic leak and its treatment on cancer recurrence and survival following elective colorectal cancer resection

AIM

Anastomotic leakage is a serious complication in restorative colorectal surgery. Anastomotic leakage and its subsequent management may have long-term impact on survival. This study aims to assess the impact of colorectal anastomotic leak (AL) on overall survival (OS) and disease-free survival (DFS).

METHODS

A prospective database of 1,048 patients undergoing restorative colorectal cancer resections at St Mark's hospital between October 2004 and October 2013 was examined.

RESULTS

The overall leak rate was 99/1,048 (9.4%). 43 ALs were managed conservatively with antibiotics or radiological drainage and 56 with reoperations. OS was significantly reduced in the AL group treated with a reoperation (HR 2.74, 95% CI 1.67-4.52, p < 0.001). AL was not significantly associated with worse DFS [conservatively managed AL's vs. no AL-HR 2.07 (95% CI 1.05-4.10); reoperated AL's vs. no AL-HR 1.56 (95% CI 0.81-2.99), overall p value = 0.058].

CONCLUSION

Patients who suffer anastomotic leaks requiring reoperations have worse OS compared to patients who do not leak, but there were no significant differences in DFS between patients who leaked and those who did not.

Morbidity after intracranial tumor surgery: sensitivity and specificity of retrospective review of medical records compared with patient-reported outcomes at 30 days

OBJECT

Published outcome reports in neurosurgical literature frequently rely on data from retrospective review of hospital records at discharge, but the sensitivity and specificity of retrospective assessments of surgical morbidity is not known. The aim of this study was to elucidate the sensitivity and specificity of retrospective assessment of morbidity after intracranial tumor surgery by comparing it to patient-reported outcomes at 30 days.

METHODS

In 191 patients who underwent surgery for the treatment of intracranial tumors, we evaluated newly acquired neurological deficits within the motor, language, and cognitive domains. Traditional retrospective discharge data were collected by review of hospital records. Patient-reported data were obtained by structured phone interviews at 30 days after surgery. Data on perioperative medical and surgical complications were obtained from both hospital records and patient interviews conducted 30 days postoperatively.

RESULTS

Sensitivity values for retrospective review of hospital records as compared with patient-reported outcomes were 0.52 for motor deficits, 0.4 for language deficits, and 0.07 for cognitive deficits. According to medical records, 158 patients were discharged with no new or worsened deficits, but only 117 (74%) of these patients confirmed this at 30 days after surgery. Specificity values were high (0.97-0.99), indicating that new deficits were unlikely to be found by retrospective review of hospital records at discharge when the patients did not report any at 30 days. Major perioperative complications were all identified through retrospective review of hospital records.

CONCLUSIONS

Retrospective assessment of medical records at discharge from hospital may greatly underestimate the incidence of new neurological deficits after brain tumor surgery when compared with patient-reported outcomes after 30 days.

Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies

BACKGROUND

Enhanced recovery programs following colorectal resection recommend the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia. The present study aimed to assess whether postoperative NSAID use increased the risk of anastomotic leak.

METHODS

A systematic review of published literature was performed for studies comparing anastomotic leak following NSAID administration versus control. Meta-analysis was conducted for studies in human patients and experimental animal models. The primary endpoint was anastomotic leak.

RESULTS

The final analysis included 8 studies in humans and 12 experimental animal studies. Use of NSAIDs was significantly associated with anastomotic leak in humans (8 studies, 4,464 patients, odds ratio [OR] 2.14; p < 0.001). This effect was seen with nonselective NSAIDs (6 studies, 3,074 patients, OR 2.37; p < 0.001), but not with selective NSAIDs (4 studies, 1,223 patients, OR 2.32; p = 0.170). There was strong evidence of selection bias from all clinical studies, with additional inconsistent definitions and outcomes assessment. From experimental animal models, anastomotic leak was more likely with NSAID use (ten studies, 575 animals, OR 9.51; p < 0.001). Bursting pressures at day 7 were significantly lower in NSAID versus controls (7 studies, 168 animals, weighted mean difference -35.7 mmHg; p < 0.001).

CONCLUSIONS

Emerging data strongly suggest that postoperative NSAIDs are linked to anastomotic leak, although most studies are flawed and may be describing pre-existing selection bias. However, when combined with experimental data, these increasing concerns suggest caution is needed when prescribing NSAIDs to patients with pre-existing risk factors for leak, until more definitive evidence emerges.

Outcome reporting in randomised controlled trials and meta-analyses of appendicitis treatments in children: a systematic review

Background

Acute appendicitis is the most common surgical emergency in children. Despite this, there is no core outcome set (COS) described for randomised controlled trials (RCTs) in children with appendicitis and hence no consensus regarding outcome selection, definition and reporting. We aimed to identify outcomes currently reported in studies of paediatric appendicitis.

Methods

Using a defined, sensitive search strategy, we identified RCTs and systematic reviews (SRs) of treatment interventions in children with appendicitis. Included studies were all in English and investigated the effect of one or more treatment interventions in children with acute appendicitis or undergoing appendicectomy for presumed acute appendicitis. Studies were reviewed and data extracted by two reviewers. Primary (if defined) and all other outcomes were recorded and assigned to the core areas ‘Death’, ‘Pathophysiological Manifestations’, ‘Life Impact’, ‘Resource Use’ and ‘Adverse Events’, using OMERACT Filter 2.0.

Results

A total of 63 studies met the inclusion criteria reporting outcomes from 51 RCTs and nine SRs. Only 25 RCTs and four SRs defined a primary outcome. A total of 115 unique and different outcomes were identified. RCTs reported a median of nine outcomes each (range 1 to 14). The most frequently reported outcomes were wound infection (43 RCTs, nine SRs), intra-peritoneal abscess (41 RCTs, seven SRs) and length of stay (35 RCTs, six SRs) yet all three were reported in just 25 RCTs and five SRs. Common outcomes had multiple different definitions or were frequently not defined. Although outcomes were reported within all core areas, just one RCT and no SR reported outcomes for all core areas. Outcomes assigned to the ‘Death’ and ‘Life Impact’ core areas were reported least frequently (in six and 15 RCTs respectively).

Conclusions

There is a wide heterogeneity in the selection and definition of outcomes in paediatric appendicitis, and little overlap in outcomes used across studies. A paucity of studies report patient relevant outcomes within the ‘Life Impact’ core area. These factors preclude meaningful evidence synthesis, and pose challenges to designing prospective clinical trials and cohort studies. The development of a COS for paediatric appendicitis is warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0783-1) contains supplementary material, which is available to authorized users.

Treatment of Esophagojejunal Anastomosis Leakage: A Systematic Review from the Last Two Decades

Esophagojejunal anastomosis leakage is one of the major complications after total gastrectomy for gastric cancer and is an independent predictor of survival. Our aim is to systematically review the literature and discuss the reported therapeutic approaches to identify the best therapeutic approach. Pubmed, EMbase, Cochrane Library, CILEA Archive, BMJ Clinical Evidence, and Up ToDate databases were screened limiting the research to articles written in English from January 1992 through December 2013. This way a total of 474 manuscripts were retrieved for furthermore evaluation. Eleven manuscripts were considered eligible and the study is focused on those works. We analyzed a total of 3,893 patients and 114 cases of esophagojejunal anastomosis leakage. Different treatments were grouped into three main categories: conservative approach (66 cases), endoscopic approach (21 cases), and surgical approach (27 cases). The overall mortality rate is 26.32 per cent and surgical approach showed the higher rate. According to the reported data, a complete resolution of the leakage can be achieved in an interval ranging from 7 to 28 days in the group treated conservatively. Conservative approach should always be considered as the treatment of choice. Reoperation may be necessary in case of wide dehiscence or when other treatments fail; therefore, the high mortality rate related to this procedure is due to the comorbidities of patients undergoing relaparotomy. Finally, endoscopic approach with endoclips seems promising but needs furthermore studies.

A scoring system to predict the risk of postoperative complications after laparoscopic gastrectomy for gastric cancer based on a large-scale retrospective study

To investigate the risk factors for postoperative complications following laparoscopic gastrectomy (LG) for gastric cancer and to use the risk factors to develop a predictive scoring system.Few studies have been designed to develop scoring systems to predict complications after LG for gastric cancer.We analyzed records of 2170 patients who underwent a LG for gastric cancer. A logistic regression model was used to identify the determinant variables and develop a predictive score.There were 2170 patients, of whom 299 (13.8%) developed overall complications and 78 (3.6%) developed major complications. A multivariate analysis showed the following adverse risk factors for overall complications: age ≥65 years, body mass index (BMI) ≥ 28 kg/m, tumor with pyloric obstruction, tumor with bleeding, and intraoperative blood loss ≥75 mL; age ≥65 years, a Charlson comorbidity score ≥3, tumor with bleeding and intraoperative blood loss ≥75 mL were identified as independent risk factors for major complications. Based on these factors, the authors developed the following predictive score: low risk (no risk factors), intermediate risk (1 risk factor), and high risk (≥2 risk factors). The overall complication rates were 8.3%, 15.6%, and 29.9% for the low-, intermediate-, and high-risk categories, respectively (P < 0.001); the major complication rates in the 3 respective groups were 1.2%, 4.7%, and 10.0% (P < 0.001).This simple scoring system could accurately predict the risk of postoperative complications after LG for gastric cancer. The score might be helpful in the selection of risk-adapted interventions to improve surgical safety.

Comparing colon cancer outcomes: The impact of low hospital case volume and case-mix adjustment

OBJECTIVE

When comparing performance across hospitals it is essential to consider the noise caused by low hospital case volume and to perform adequate case-mix adjustment. We aimed to quantify the role of noise and case-mix adjustment on standardized postoperative mortality and anastomotic leakage (AL) rates.

METHODS

We studied 13,120 patients who underwent colon cancer resection in 85 Dutch hospitals. We addressed differences between hospitals in postoperative mortality and AL, using fixed (ignoring noise) and random effects (incorporating noise) logistic regression models with general and additional, disease specific, case-mix adjustment.

RESULTS

Adding disease specific variables improved the performance of the case-mix adjustment models for postoperative mortality (c-statistic increased from 0.77 to 0.81). The overall variation in standardized mortality ratios was similar, but some individual hospitals changed considerably. For the standardized AL rates the performance of the adjustment models was poor (c-statistic 0.59 and 0.60) and overall variation was small. Most of the observed variation between hospitals was actually noise.

CONCLUSION

Noise had a larger effect on hospital performance than extended case-mix adjustment, although some individual hospital outcome rates were affected by more detailed case-mix adjustment. To compare outcomes between hospitals it is crucial to consider noise due to low hospital case volume with a random effects model.

Risk factors and consequences of anastomotic leak after colectomy: a national analysis

BACKGROUND

Previous research has identified a number of patient and operative factors associated with anastomotic leak after colectomy; however, a study that examines these factors on a national level with direct coding for anastomotic leak is lacking.

OBJECTIVE

The purpose of this work was to identify risk factors associated with anastomotic leak on a national level and quantify the additional morbidity and mortality experienced by these patients.

DESIGN

We performed a retrospective analysis of patients who underwent segmental colectomy with anastomosis from the 2012 American College of Surgeons National Surgical Quality Improvement Program colectomy procedure-targeted database. Anastomotic leak was defined as minor leak requiring percutaneous intervention or major leak requiring laparotomy. Multivariate logistic regression was used to determine predictors of anastomotic leak and its impact on postoperative outcomes.

SETTINGS

This study was conducted at a tertiary university department.

PATIENTS

This study includes 13,684 patients who underwent segmental colectomy with anastomosis at American College of Surgeons National Surgical Quality Improvement Program-affiliated hospitals in 2012.

MAIN OUTCOME MEASURES

The primary outcome studied was anastomotic leak.

RESULTS

The overall leak rate was 3.8%. Male sex, steroid use, smoking, open approach, operative time, and preoperative chemotherapy were associated with increased anastomotic leaks and diverting ileostomy with decreased incidence of leaks on multivariate analysis. Increased length of stay (13 vs 5 days; p < 0.001) and increased 30-day mortality (6.8% vs 1.6%; p < 0.001) were also seen in patients who experienced leaks. These patients also experienced increased readmission rates (43.5% vs 8.3%; p < 0.001) and were 37 times more likely to require reoperation as a complication of their primary procedure (p < 0.001).

LIMITATIONS

The main limitations of this study include its retrospective nature and the limited 30-day outcomes recorded in the American College of Surgeons National Surgical Quality Improvement Program database.

CONCLUSIONS

This study identified patient and operative risk factors for anastomotic leak on a national scale. It also demonstrates that these patients have increased morbidity and 30-day mortality rates, experience multiple readmissions to the hospital, and have a higher likelihood of requiring further operative intervention.

Water soluble contrast enema examination of the integrity of the rectal anastomosis prior to loop ileostomy reversal may be superfluous

PURPOSE

Defunctioning loop ileostomy in low anterior resection (LAR) is routinely used to reduce consequences of anastomotic leakage. The purpose of this study was to analyze which examination technique is optimal for evaluating the integrity of the anastomosis prior to loop ileostomy reversal.

METHODS

Retrospective analysis of 95 patients who had been subjected to LAR at Helsingborg Hospital and Skåne University Hospital, Sweden, was undertaken between January 2007 and June 2009. The examination techniques of the rectal anastomosis prior to reversal and the clinical outcome after reversal were studied.

RESULTS

Radiologic anastomosis control using water soluble contrast enema, digital rectal examination (DRE), and rectoscopy were performed in 53 % (50/95), 98 % (93/95), and 69 % (66/95), respectively. In two patients, no control of the anastomosis was performed before reversal. Fifty-two percent (49/95) of the patients were examined using all techniques. Six patients demonstrated leakage detected before reversal of which two were only radiological leakages. These two patients underwent loop ileostomy reversal after delay without complications. They were the only ones where the three examination techniques did not prove coherence. Four patients had symptomatic leakage; these were detected with rectoscopy and DRE and verified with enema. Three patients developed anastomotic leakage after loop ileostomy reversal despite normal preoperative examinations. Two of these patients had rectovaginal fistulas (AVFs).

CONCLUSIONS

This retrospective study indicates that contrast enema does not provide additional information if rectoscopy and DRE are normal. Despite negative examinations, three of nine leakages were diagnosed after loop ileostomy reversal. Especially, AVFs seem difficult to diagnose.

CT findings suggesting anastomotic leak and predicting the recovery period following gastric surgery

OBJECTIVE

To assess diagnostic performance of routine CT for detecting anastomotic leak after gastric surgery, and analyse the relationship between recovery period and CT findings.

METHODS

We included 179 patients who underwent immediate CT and fluoroscopy after gastric surgery. Two reviewers retrospectively rated the possibility of leak on CT using a five-point scale focused on predefined CT findings. They also evaluated CT findings. Patients were categorised as: Group I, leak on fluoroscopy; Group II, possible leak on CT but negative on fluoroscopy; Group III, no leak. We analysed the relationship between recovery period and group.

RESULTS

Area under the curve for detecting leak on CT was 0.886 in R1 and 0.668 in R2 with moderate agreement (к = 0.482). Statistically common CT findings for leak included discontinuity, large amount of air-fluid and wall thickening at anastomosis site (p < 0.05). Discontinuity at anastomosis site and a large air-fluid collection were independently associated with leak (p < 0.05). The recovery period including hospitalisation and postoperative fasting period was longer in Group I than Group II or III (p < 0.05). Group II showed a longer recovery period than Group III (p < 0.05).

CONCLUSIONS

Postoperative routine CT was useful for predicting anastomotic leak using specific findings, and for predicting length of recovery period.

KEY POINTS

• Anastomotic leakage remains a significant clinical problem following gastric surgery. • Routine CT without oral contrast is useful for predicting anastomotic leaking. • Wall discontinuity at anastomosis sites was an independent predictor for leaking. • CT is also useful for predicting recovery period following gastric surgery.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks

BACKGROUND

Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

METHODS

A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

RESULTS

Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

CONCLUSION

Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.