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Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine. Eur J Anaesthesiol 2015; 32:88-105. [DOI: 10.1097/eja.0000000000000118] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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252
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Diverting ileostomy in colorectal surgery: when is it necessary? Langenbecks Arch Surg 2015; 400:145-52. [PMID: 25633276 DOI: 10.1007/s00423-015-1275-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice. METHODS Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion. RESULTS Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion. CONCLUSIONS Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.
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Li R, Liu N, Li B, Wang Y, Wu G, Ma J. Synthesis and properties of temperature-sensitive and chemically crosslinkable poly(ether-urethane) hydrogel. Polym Chem 2015. [DOI: 10.1039/c5py00181a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The PEU-MA solutions can gelate at physiological temperature, and be further crosslinked by UV light.
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Affiliation(s)
- Ruizhi Li
- Key Laboratory of Functional Polymer Materials of MOE
- Institute of Polymers
- Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
- Nankai University
- Tianjin 300071
| | - Na Liu
- Key Laboratory of Functional Polymer Materials of MOE
- Institute of Polymers
- Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
- Nankai University
- Tianjin 300071
| | - Bingqiang Li
- Key Laboratory of Functional Polymer Materials of MOE
- Institute of Polymers
- Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
- Nankai University
- Tianjin 300071
| | - Yinong Wang
- Key Laboratory of Functional Polymer Materials of MOE
- Institute of Polymers
- Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
- Nankai University
- Tianjin 300071
| | - Guolin Wu
- Key Laboratory of Functional Polymer Materials of MOE
- Institute of Polymers
- Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
- Nankai University
- Tianjin 300071
| | - Jianbiao Ma
- School of Chemistry and Chemical Engineering
- Tianjin University of Technology
- Tianjin 300191
- PR China
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Colorectal cancer with intestinal perforation - a retrospective analysis of treatment outcomes. Contemp Oncol (Pozn) 2014; 18:414-8. [PMID: 25784840 PMCID: PMC4355655 DOI: 10.5114/wo.2014.46362] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 08/29/2014] [Accepted: 09/05/2014] [Indexed: 12/18/2022] Open
Abstract
Aim of the study Colorectal cancer (CRC) is one of the leading cause of death in European population. It progresses without any symptoms in the early stages or those clinical symptoms are very discrete. The aim of this study was a retrospective analysis of treatment outcomes in patients with colorectal cancer complicated with intestinal perforation. Material and methods A retrospective analysis of patients urgently operated upon in our Division of General Surgery, because of large intestine perforation, from February 1993 to February 2013 has been made. Results were compared with a group of patients undergoing the elective surgery for colorectal cancer in the same time and Division. Results Intestinal perforation occurred more often in males (6.52% vs. 6.03%), patients with mucous component in histopathological examination (9.09% vs. 6.01%) and with clinicaly advanced CRC. Patients treated because of perforation had a five-fold higher 30 day mortality rate (9.09% vs. 1.83%), however long-term survival did not differ significantly in both groups. After resectional surgery in 874 patients an intestinal anastomosis was made. Anastomotic leakage was present in 23 (2.6%) patients. This complication occurred six-fold more frequently in a group of patients operated upon because of intestinal perforation (12.20% vs. 2.16%). Conclusions In patients with CRC complicated with perforation of the colon in a 30-day observation significantly higher rate of complications and mortality was shown, whereas there was no difference in distant survival rates.
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255
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Wu SW, Ma CC, Yang Y. Role of protective stoma in low anterior resection for rectal cancer: A meta-analysis. World J Gastroenterol 2014; 20:18031-18037. [PMID: 25548503 PMCID: PMC4273155 DOI: 10.3748/wjg.v20.i47.18031] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/25/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection (LAR) for rectal cancer.
METHODS: The PubMed, EMBASE, and MEDLINE databases were searched for studies and relevant literature published between 2007 and 2014 regarding the construction of a protective stoma during LAR. A pooled risk ratio (RR) with 95% confidence intervals (CIs) was used to assess the outcomes of the studies, including the rate of postoperative anastomotic leakage and reoperations related to leakage. Funnel plots and Egger’s tests were used to evaluate the publication biases of the studies. P values < 0.05 were considered statistically significant.
RESULTS: A total of 11 studies were included in the meta-analysis. In total, 5612 patients were examined, 2868 of whom had a protective stoma and 2744 of whom did not. The sample size of the studies varied from 34 to 1912 patients. All studies reported the number of patients who developed an anastomotic leakage and required a reoperation related to leakage. A random effects model was used to calculate the pooled RR with the corresponding 95%CI because obvious heterogeneity was observed among the 11 studies (I2 = 77%). The results indicated that the creation of a protective stoma during LAR significantly reduces the rate of anastomotic leakage and the number of reoperations related to leakage, with pooled RRs of 0.38 (95%CI: 0.30-0.48, P < 0.00001) and 0.37 (95%CI: 0.29-0.48, P < 0.00001), respectively. The shape of the funnel plot did not reveal any evidence of obvious asymmetry.
CONCLUSION: The presence of a protective stoma effectively decreased the incidences of anastomotic leakage and reoperation and is recommended in patients undergoing low rectal anterior resections for rectal cancer.
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Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program. World J Surg 2014; 38:985-91. [PMID: 24305917 DOI: 10.1007/s00268-013-2340-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. METHODS This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. RESULTS Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. CONCLUSIONS Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.
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257
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Whistance RN, Forsythe RO, McNair AGK, Brookes ST, Avery KNL, Pullyblank AM, Sylvester PA, Jayne DG, Jones JE, Brown J, Coleman MG, Dutton SJ, Hackett R, Huxtable R, Kennedy RH, Morton D, Oliver A, Russell A, Thomas MG, Blazeby JM. A systematic review of outcome reporting in colorectal cancer surgery. Colorectal Dis 2014; 15:e548-60. [PMID: 23926896 DOI: 10.1111/codi.12378] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/01/2013] [Indexed: 02/08/2023]
Abstract
AIM Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered. METHOD Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies. RESULTS Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617). CONCLUSION Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.
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Affiliation(s)
- R N Whistance
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK; Division of Surgery Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Gervaz P, Platon A, Buchs NC, Rocher T, Perneger T, Poletti PA. CT scan-based modelling of anastomotic leak risk after colorectal surgery. Colorectal Dis 2014; 15:1295-300. [PMID: 23710555 DOI: 10.1111/codi.12305] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/08/2013] [Indexed: 02/08/2023]
Abstract
AIM Prolonged ileus, low-grade fever and abdominal discomfort are common during the first week after colonic resection. Undiagnosed anastomotic leak carries a poor outcome and computed tomography (CT) scan is the best imaging tool for assessing postoperative abdominal complications. We used a CT scan-based model to quantify the risk of anastomotic leak after colorectal surgery. METHOD A case-control analysis of 74 patients who underwent clinico-radiological evaluation after colorectal surgery for suspicion of anastomotic leak was undertaken and a multivariable analysis of risk factors for leak was performed. A logistic regression model was used to identify determinant variables and construct a predictive score. RESULTS Out of 74 patients with a clinical suspicion of anastomotic leak, 17 (23%) had this complication confirmed following repeat laparotomy. In multivariate analysis, three variables were associated with anastomotic leak: (1) white blood cells count > 9 × 10(9) /l (OR = 14.8); (2) presence of ≥ 500 cm(3) of intra- abdominal fluid (OR = 13.4); and (3) pneumoperitoneum at the site of anastomosis (OR = 9.9). Each of these three parameters contributed one point to the risk score. The observed risk of leak was 0, 6, 31 and 100%, respectively, for patients with scores of 0, 1, 2 and 3. The area under the receiver operating characteristic curve for the score was 0.83 (0.72-0.94). CONCLUSION This CT scan-based model seems clinically promising for objective quantification of the risk of a leak after colorectal surgery.
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Affiliation(s)
- P Gervaz
- Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
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Asari SAL, Cho MS, Kim NK. Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center. Eur J Surg Oncol 2014; 41:175-85. [PMID: 25468455 DOI: 10.1016/j.ejso.2014.10.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 09/25/2014] [Accepted: 10/17/2014] [Indexed: 02/09/2023] Open
Abstract
Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.
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Affiliation(s)
- S A L Asari
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea
| | - M S Cho
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea
| | - N K Kim
- Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, 250 Seongsan-ro, Seodaemun-gu, Seoul 120-527, South Korea.
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260
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Does somatostatin-14 have an impact on gastric fistula after laparoscopic sleeve gastrectomy? Obes Surg 2014; 25:377-80. [PMID: 25381116 DOI: 10.1007/s11695-014-1483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The main complications following laparoscopic sleeve gastrectomy (LSG) is gastric fistula (GF). Gastric fistula is a rare but serious complication (affecting 2 % of LSGs). Somatostatin-14 and its analogs are mainly used in the prevention and curative treatment of digestive fistulas. These compounds inhibit secretions in the pancreas, stomach, and small intestine. Treatment with somatostatin-14 increases the spontaneous closure rate and reduces the closure time of postoperative digestive fistulas. However, the impact of somatostatin-14 on GF after LSG has not been studied. We report on a prospective, non-randomized, single-center, case-matched study of patients receiving somatostatin-14 after a post-LSG GF was discovered. Our results suggest that use of somatostatin-14 is associated with a shorter length of hospital stay and (perhaps) a shorter treatment period.
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261
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Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks. J Am Coll Surg 2014; 220:195-206. [PMID: 25592468 DOI: 10.1016/j.jamcollsurg.2014.11.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/16/2014] [Accepted: 11/04/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center. STUDY DESIGN We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact. RESULTS Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs. 28.4%; p < 0.0001), length of stay (13 vs. 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs. 2.5%; p < 0.0001), long-term mortality (36.4% vs. 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6-381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0-20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6-8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1-5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2-0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06-0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6-75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6-46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3-46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8-26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5-17.7; p = 0.009). CONCLUSIONS Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.
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262
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Alonso S, Pascual M, Salvans S, Mayol X, Mojal S, Gil MJ, Grande L, Pera M. Postoperative intra-abdominal infection and colorectal cancer recurrence: a prospective matched cohort study of inflammatory and angiogenic responses as mechanisms involved in this association. Eur J Surg Oncol 2014; 41:208-14. [PMID: 25468742 DOI: 10.1016/j.ejso.2014.10.052] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 09/16/2014] [Accepted: 10/21/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications. METHODS Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid. RESULTS Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6-1473.2] versus control: 0.6 [0.6-17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4-1574.0] versus control: 90.3 [35.2.6-106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3-10000.0] versus control: 438.3 [214.1-677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0-10000.0] versus control: 477.8 [313.5-814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001). CONCLUSIONS Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.
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Affiliation(s)
- S Alonso
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain; Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Surgery, Universidad Autónoma de Barcelona, Bellaterra, Spain
| | - M Pascual
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain; Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Surgery, Universidad Autónoma de Barcelona, Bellaterra, Spain
| | - S Salvans
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain; Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - X Mayol
- Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - S Mojal
- Consulting Service on Methodology for Biomedical Research, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - M J Gil
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain
| | - L Grande
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain; Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Surgery, Universidad Autónoma de Barcelona, Bellaterra, Spain
| | - M Pera
- Section of Colon and Rectal Surgery, Hospital del Mar, Barcelona, Spain; Colorectal Cancer Research Group, Cancer Program, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Surgery, Universidad Autónoma de Barcelona, Bellaterra, Spain.
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263
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Vermeer T, Orsini R, Daams F, Nieuwenhuijzen G, Rutten H. Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment. Eur J Surg Oncol 2014; 40:1502-9. [DOI: 10.1016/j.ejso.2014.03.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 03/04/2014] [Accepted: 03/18/2014] [Indexed: 12/13/2022] Open
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Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler. Dis Colon Rectum 2014; 57:1195-201. [PMID: 25203376 DOI: 10.1097/dcr.0000000000000207] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic complications, including leaks, stenoses, and bleeding, cause considerable mortality and morbidity after colorectal surgery. OBJETIVE The purpose of this work was to evaluate the effectiveness of bioabsorbable staple line reinforcement in reducing colorectal anastomotic complications. DESIGN This was a prospective randomized clinical study. SETTINGS This study was conducted at a university hospital within a specialized colorectal unit. PATIENTS Patients undergoing left colon resection for a benign or malignant condition were eligible. A total of 302 patients participated, including 154 control subjects and 148 with reinforcement. INTERVENTION Patients were prospectively randomly assigned to reinforcement of circular stapled anastomosis with a bioabsorbable device versus stapled circular anastomosis without reinforcement. MAIN OUTCOME MEASURES The primary end point was the rate of pooled incidences of anastomotic complications (leakage, bleeding, or stenosis). Secondary outcomes were the rate of reoperations and the length of hospital stay. RESULTS Baseline characteristics were similar between both groups. Intention-to-treat analysis revealed that there were no significant differences in the pooled incidences of anastomotic complications (p = 0.821). Regarding individual complications, we did not observe statistical differences between groups, including leakage (6.6% vs 4.8%; p = 0.518), hemorrhage (1.4% vs 1.3%; p = 0.431), or stenosis (2.9% vs 6.8%; p = 0.128). Again, no significant differences were observed in length of stay (7 days; p = 0.242) or rate of reoperation (7.3% vs 9.6%; p = 0.490). A patient (0.3%) in the control group died. LIMITATIONS Sample size calculation was performed including all 3 of the complications, which may render it underpowered to detect differences regarding a specific complication. Anastomoses located within 5 cm from the anal verge were excluded from the study. CONCLUSIONS The results obtained show that bioabsorbable staple line reinforcement in a colorectal anastomosis >5 cm from the anal verge does not reduce the rate of pooled anastomotic complications (ie, leaks, bleeding, or stenosis).
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265
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What is the risk of clinical anastomotic leak in the diverted colorectal anastomosis? J Gastrointest Surg 2014; 18:1812-6. [PMID: 25022256 DOI: 10.1007/s11605-014-2588-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/27/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study was to identify clinical leak in diverted colorectal anastomoses. DESIGN Cohort analysis. SETTING The study was conducted in a subspecialty practice at a tertiary care facility. PATIENTS Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012. INTERVENTIONS No intervention was applied. MAIN OUTCOME MEASURES Clinical anastomotic leak. RESULTS Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14%) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5%) patients within 30 days of surgery (early leaks) and in 21 (9%) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing. CONCLUSIONS In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.
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Evaluation of long-term anorectal function after low anterior resection: a 5-year follow-up of a randomized multicenter trial. Dis Colon Rectum 2014; 57:1162-8. [PMID: 25203371 DOI: 10.1097/dcr.0000000000000197] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anorectal function after rectal surgery with low anastomosis is often impaired. Outcome of long-term anorectal function is poorly understood but may improve over time. OBJECTIVE We evaluated anorectal function 5 years after low anterior resection for cancer with regard to whether patients had a temporary stoma at initial resection. The objective of this study was to assess changes in anorectal function over time by comparing the results with anorectal function 1 year after rectal resection. DESIGN This study was a secondary end point of a randomized, multicenter controlled trial. SETTINGS The study was conducted at 21 Swedish hospitals performing rectal cancer surgery from 1999 to 2005. PATIENTS Patients included were those operated on with low anterior resection. INTERVENTIONS Patients were randomly assigned to receive or not receive a defunctioning stoma. MAIN OUTCOME MEASURES We evaluated anorectal function in patients who were initially randomly assigned to the defunctioning stoma or no stoma group, who had been free of stoma for 5 years, by means of using a standardized patient questionnaire. Questions addressed stool frequency, urgency, fragmentation of bowel movements, evacuation difficulties, incontinence, lifestyle alterations, and patient preference regarding permanent stoma formation. Results were compared with the same patient cohort at 1-year follow-up. RESULTS A total of 123 patients answered the bowel function questionnaire (65 in the no-stoma group and 58 in the stoma group). No differences were found between groups regarding the number of passed stools, need for medication to open the bowel, evacuation difficulties, incontinence, and urgency. General well-being was significantly better in the no-stoma group (p = 0.033). Comparison with anorectal function at 1 year showed no further changes over time. LIMITATIONS The study was based on a limited sample size (n = 123) and formed a secondary end point of a randomized trial. CONCLUSIONS Anorectal function was impaired for many patients, but the temporary presence of a defunctioning stoma after rectal resection did not affect long-term outcome. Anorectal function did not change between 1-year and 5-year follow-up.
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Shogan BD, An GC, Schardey HM, Matthews JB, Umanskiy K, Fleshman JW, Hoeppner J, Fry DE, Garcia-Granereo E, Jeekel H, van Goor H, Dellinger EP, Konda V, Gilbert JA, Auner GW, Alverdy JC. Proceedings of the first international summit on intestinal anastomotic leak, Chicago, Illinois, October 4-5, 2012. Surg Infect (Larchmt) 2014; 15:479-89. [PMID: 25215465 DOI: 10.1089/sur.2013.114] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The first international summit on anastomotic leak was held in Chicago in October, 2012 to assess current knowledge in the field and develop novel lines of inquiry. The following report is a summary of the proceedings with commentaries and future prospects for clinical trials and laboratory investigations. BACKGROUND Anastomotic leakage remains a devastating problem for the patient, and a continuing challenge to the surgeon operating on high-risk areas of the gastrointestinal tract such as the esophagus and rectum. Despite the traditional wisdom that anastomotic leak is because of technique, evidence to support this is weak-to-non-existent. Outcome data continue to demonstrate that expert high-volume surgeons working in high-volume centers continue to experience anastomotic leaks and that surgeons cannot predict reliably which patients will leak. METHODS A one and one-half day summit was held and a small working group assembled to review current practices, opinions, scientific evidence, and potential paths forward to understand and decrease the incidence of anastomotic leak. RESULTS RESULTS of a survey of the opinions of the group demonstrated that the majority of participants believe that anastomotic leak is a complicated biologic problem whose pathogenesis remains ill-defined. The group opined that anastomotic leak is underreported clinically, it is not because of technique except when there is gross inattention to it, and that results from animal models are mostly irrelevant to the human condition. CONCLUSIONS A fresh and unbiased examination of the causes and strategies for prevention of anastomotic leak needs to be addressed by a continuous working group of surgeons, basic scientists, and clinical trialists to realize a real and significant reduction in its incidence and morbidity. Such a path forward is discussed.
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269
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Iatrogenic esophageal injuries: evidence-based management for diagnosis and timing of contrast studies after repair. Int Surg 2014; 97:1-5. [PMID: 23101993 DOI: 10.9738/cc73.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Leakage from gastroesophageal repair is considered a major complication and is often associated with increased hospital stay, morbidity, and mortality. Management of these patients is variable among surgeons. Cases managed by the thoracic surgical service from March 1, 2010 to March 1, 2011 were retrospectively reviewed. Eight patients met criteria for inclusion: 4 were repaired primarily, 2 by debridement with diversion, and 2 by Ivor-Lewis resection and reconstruction. Esophograms were completed between 1 and 7 days postoperatively. Of the 8 patients treated, there was 1 mortality (12%) due to fungal mediastinitis. Soluble contrast imaging revealed 2 leaks (25%), 1 contained and 1 diffuse, which was the only mortality. Changes in clinical status, even minor, require contrast imaging of the esophagus to assess repair integrity. Timing of contrast study is variable in the literature, averaging 5 to 14 days. A conservative time frame is 7 days, unless any clinical suspicion of an esophageal leak exists.
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270
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Reporting of Adverse Events in Surgical Trials: Critical Appraisal of Current Practice. World J Surg 2014; 39:80-7. [DOI: 10.1007/s00268-014-2776-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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271
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The determination of bile leakage in complex hepatectomy based on the guidelines of the International Study Group of Liver Surgery. World J Surg 2014; 38:168-76. [PMID: 24146194 DOI: 10.1007/s00268-013-2252-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The International Study Group of Liver Surgery (ISGLS) has defined bile leakage as a drain fluid-to-serum total bilirubin concentration (TBC) ratio (the bilirubin ratio) ≥ 3.0. The aim of the present study was to determine the clinical significance of this definition, and to outline characteristics of bile leakage in complex hepatectomy. METHODS The TBCs of the serum and drain fluid were measured on postoperative days (POD) 1, 3, and 7 in 241 patients who had undergone hepatobiliary resection. The validation of the bilirubin ratio and predictors of bile leakage were retrospectively assessed. RESULTS Grade A, B, or C bile leakage was found in 23 (9.5 %), 66 (27.4 %), and 0 patients, respectively. The median duration of drainage was 27 days in grade B bile leakage. The sensitivity and specificity of the bilirubin ratio for detecting grade B bile leakage were 59 and 87 %, respectively. The area under the receiver operating characteristics curve of the drain fluid TBC on POD 3 had the highest predictive value: 68 % sensitivity and 76 % specificity for a drain fluid TBC of 3.7 mg/dL. The multivariate analysis demonstrated that operative time, left trisectionectomy, bilirubin ratio, and TBC of the drain fluid on POD 3 were independent predictors of grade B bile leakage. CONCLUSIONS In complex hepatectomy, bile leakage develops most frequently after left trisectionectomy and often results in a refractory clinical course. The ISGLS biochemical definition is valid, and a combination of bilirubin ratio and drain fluid TBC may enhance risk prediction for grade B bile leakage.
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272
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Tan WP, Hong EY, Phillips B, Isenberg GA, Goldstein SD. Anastomotic Leaks after Colorectal Anastomosis Occurring More than 30 Days Postoperatively: A Single-institution Evaluation. Am Surg 2014. [DOI: 10.1177/000313481408000919] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
National hospital registries only report colorectal anastomotic leaks (ALs) within 30 days post-operatively. The aim of our study was to determine the incidence and significance of ALs that occur beyond 30 days postoperatively. We performed a retrospective review of our prospective database from June 2008 to August 2012. A total of 504 patients were included. These patients were operated on by two surgeons. Any clinical or radiographic abnormalities were considered to be an anastomotic imperfection. A total of 504 patients were reviewed with a total of 18 (3.6%) anastomotic leaks. Six leaks (31.6% of leaks) were diagnosed more than 30 days postoperatively ( P < 0.001). Of the 18 leaks, interventional radiology drainage was performed for four cases and 14 patients required reoperation. All six delayed leaks required reoperation. There was one leak that occurred under 30 days, which was discovered on autopsy. The median follow-up was 12 months (range, 1 to 4 months). All the delayed leak patients presented with fistulas, whereas 58 per cent of typical leak patients presented with the triad of leukocytosis, fever, and abdominal pain. Colorectal anastomotic leaks can occur after the 30-day postoperative period. In patients with vague and atypical abdominal findings, anastomotic leak must be suspected. More systematic, prospective studies are required to help us further understand the risk factors and natural history of anastomotic failures in elective colorectal surgery.
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Affiliation(s)
- Wei Phin Tan
- From the Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - En Yaw Hong
- From the Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Benjamin Phillips
- From the Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gerald A. Isenberg
- From the Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Scott D. Goldstein
- From the Division of Colorectal Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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274
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Bhangu A, Singh P, Pinkney T, Blazeby JM. A detailed analysis of outcome reporting from randomised controlled trials and meta-analyses of inguinal hernia repair. Hernia 2014; 19:65-75. [DOI: 10.1007/s10029-014-1299-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
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275
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Lee CM, Huh JW, Yun SH, Kim HC, Lee WY, Park YA, Cho YB, Chun HK. Laparoscopic versus open reintervention for anastomotic leakage following minimally invasive colorectal surgery. Surg Endosc 2014; 29:931-6. [PMID: 25060688 DOI: 10.1007/s00464-014-3755-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/10/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this study is to evaluate the safety and feasibility of laparoscopic reintervention compared with open surgery in patients with anastomotic leakage after minimally invasive colorectal surgery. METHODS Between January 2008 and December 2012, 77 patients who required surgical reintervention for anastomotic leakage following minimally invasive colorectal surgery were included in this study. Data on the patients' demographics, operative management, morbidity, hospital stay, and mortality were analyzed for differences based on whether they received laparoscopic or open surgery. RESULTS Sixteen patients underwent open surgery following laparoscopy, and 61 patients received laparoscopic reintervention following laparoscopy. The conversion rate was 8.2 % (5/61). The median total hospital stay following reintervention was significantly shorter for laparoscopic surgery (16.0 days, range 9-117 days) than for open surgery (35.5 days, range 10-135 days, p < 0.001). The postoperative 30-day morbidity rate, including wound dehiscence (25.0 vs 3.3 %, p = 0.015) and intra-abdominal infection (31.3 vs 6.6 %, p = 0.016), was lower in the laparoscopic surgery group than in the open surgery group. The rate of stoma closure was lower in the open surgery group than in the laparoscopic surgery group (43.8 vs 80.5 %, p < 0.001). There was one in-hospital mortality in the open surgery group. CONCLUSIONS Laparoscopic reintervention for anastomotic leakage following minimally invasive colorectal surgery is associated with a shorter hospital stay, fewer postoperative complications, and a higher stoma closure rate than open surgery. Laparoscopic reintervention for anastomotic leakage is feasible and safe.
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Affiliation(s)
- Chul Min Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Korea
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Lolis ED, Theodoridou E, Vogiatzis N, Neonaki D, Markakis C, Daskalakis K. The safety of primary repair or anastomosis in high-risk trauma patients. Surg Today 2014; 45:730-9. [PMID: 25030128 DOI: 10.1007/s00595-014-0982-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/02/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries. METHOD In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded. RESULTS Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation. CONCLUSION Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.
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Affiliation(s)
- Evangelos D Lolis
- Surgical Department, General Hospital of Rethymno, Trantalidou 17, 74100, Rethymno, Greece,
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Chen KN. Managing complications I: leaks, strictures, emptying, reflux, chylothorax. J Thorac Dis 2014; 6 Suppl 3:S355-63. [PMID: 24876942 DOI: 10.3978/j.issn.2072-1439.2014.03.36] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/28/2014] [Indexed: 12/15/2022]
Abstract
Esophagectomy can be used to treat several esophageal diseases; it is most commonly used for treatment of esophageal cancer. Esophagectomy is a major procedure that may result in various complications. This article reviews only the important complications resulting from esophageal resection, which are anastomotic complications after esophageal reconstruction (leakage and stricture), delayed emptying or dumping syndrome, reflux, and chylothorax.
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Affiliation(s)
- Ke-Neng Chen
- Key laboratory of Carcinogenesis and Translational Research (Ministry of Education), The First Department of Thoracic Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
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279
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Wahby M, Salama AF, Elezaby AF, Belgrami F, Abd Ellatif ME, El-Kaffas HF, Al-Katary M. Is routine postoperative gastrografin study needed after laparoscopic sleeve gastrectomy? Experience of 712 cases. Obes Surg 2014; 23:1711-7. [PMID: 23828033 DOI: 10.1007/s11695-013-1013-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The current standard of care is to perform a postoperative gastrografin study following laparoscopic sleeve gastrectomy (LSG) to detect leakage or obstruction. This study evaluated the usefulness of this routine procedure. METHODS A retrospective chart review was performed in December 2012. All patients had routine intraoperative methylene blue testing to check for possible leakage from the staple line, and any leaking points were oversewn. We also performed postoperative contrast study (gastrografin) routinely in the first 24-48 h for all patients. RESULTS From June 2007 to December 2012, 712 cases underwent LSG during the study period. Patients included in this study were 556 women (78.1%) and 156 men (21.9%). The mean age was 35 years. The mean BMI was 48 kg/m2. The operative time was 107 ± 29 min, and there were no conversions to open surgery. Intraoperative methylene blue test detected leakage in 28 cases (3.93%). Postoperative contrast study (gastrografin) was negative for leakage in all cases. Computed tomography (CT) scan with oral contrast study detected leakage in 1.4% (ten cases); none of these cases were detected by regular contrast study. CONCLUSIONS Our study showed that intraoperative methylene blue test for leakage is a very sensitive and effective method for detecting leakage during sleeve gastrectomy and should be done routinely in all cases. Routine postoperative contrast study is not needed to detect leakage unless clinically indicated in selected cases, and in such cases contrast-enhanced CT scans are the modality of choice.
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Affiliation(s)
- M Wahby
- Department of Surgery, Jahra Hospital, Kuwait, Kuwait
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280
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Landmann RG. Surgical management of anastomotic leak following colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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281
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Rickles AS, Fleming FJ. Non-operative treatment of anastomotic leaks: Current and investigational therapies. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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282
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Audett MC, Paquette IM. Intraoperative and postoperative diagnosis of anastomotic leak following colorectal resection. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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284
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Kári D, Korsós D, Kecskédi B, Lovay Z, Ecsedy G, Lontai P, Ender F, Vörös A. [Analysis of postoperative complications following acute surgery for colorectal cancer]. Magy Seb 2014; 67:103-12. [PMID: 24873766 DOI: 10.1556/maseb.67.2014.3.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Our aim was to improve the outcome of emergency surgeries for colorectal cancer (CRC). Authors compared two periods: 2004-2006 and 2007-2011. Targeted cases were emergency admissions, in which the diagnosis of colorectal cancer is only revealed during work-up or during surgery. No other exclusion criteria were set. Analyzed main endpoints were anastomotic leak, postoperative mortality, resecability. ASA classification and TNM stages were assessed in order to learn morbidity and general condition prior to acute surgery. Considering the experience gained in prior period, in 2007, authors have made a change in treatment strategy. In following years leakage ratio became ten times lower and mortality was reduced by 5%. There is a great chance that fast work-up and preparation for surgery may decrease complications and mortality. The aim would be for CRC patients, is to reach surgery in an early stage of disease as possible, at least before complications develop.
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Affiliation(s)
- Dániel Kári
- Jahn Ferenc Dél-pesti Kórház Sebészeti Osztály 1204 Budapest Köves út 1
| | - Diána Korsós
- Semmelweis Egyetem Általános Orvostudományi Kar Budapest
| | - Bence Kecskédi
- Jahn Ferenc Dél-pesti Kórház Sebészeti Osztály 1204 Budapest Köves út 1
| | - Zoltán Lovay
- Jahn Ferenc Dél-pesti Kórház Sebészeti Osztály 1204 Budapest Köves út 1
| | - Gábor Ecsedy
- Jahn Ferenc Dél-pesti Kórház Sebészeti Osztály 1204 Budapest Köves út 1
| | - Péter Lontai
- Jahn Ferenc Dél-pesti Kórház Sebészeti Osztály 1204 Budapest Köves út 1
| | - Ferenc Ender
- Egyesített Szent István és Szent László Kórház Sebészeti Osztály Budapest
| | - Attila Vörös
- Magyar Honvédség Egészségügyi Központ I. Sz. Sebészeti Osztály Budapest
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285
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Rebibo L, Dhahri A, Berna P, Yzet T, Verhaeghe P, Regimbeau JM. Management of gastrobronchial fistula after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014; 10:460-7. [DOI: 10.1016/j.soard.2013.08.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/23/2013] [Accepted: 08/07/2013] [Indexed: 12/19/2022]
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286
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Kelly M, Bhangu A, Singh P, Fitzgerald JEF, Tekkis PP. Systematic review and meta-analysis of trainee- versus expert surgeon-performed colorectal resection. Br J Surg 2014; 101:750-9. [PMID: 24760684 DOI: 10.1002/bjs.9472] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aim of this meta-analysis was to compare short-term and oncological outcomes following colorectal resection performed by surgical trainees and expert surgeons. METHODS Systematic literature searches were made to identify articles on colorectal resection for benign or malignant disease published until April 2013. The primary outcome was the rate of anastomotic leak. Secondary outcomes were intraoperative variables, postoperative adverse event rates, and early and late oncological outcomes. Odds ratios (ORs), weighted mean differences (WMDs) and hazard ratios (HRs) for outcomes were calculated using meta-analytical techniques. RESULTS The final analysis included 19 non-randomized, observational studies of 14,344 colorectal resections, of which 8845 (61.7 per cent) were performed by experts and 5499 (38.3 per cent) by trainees. The overall rate of anastomotic leak was 2.6 per cent. Compared with experts, trainees had a lower leak rate (3.0 versus 2.0 per cent; OR 0.72, P = 0.010), but there was no difference between experts and expert-supervised trainees (3.2 versus 2.5 per cent; OR 0.77, P = 0.080). A subgroup of expert-supervised trainees had a significantly longer operating time for laparoscopic procedures (WMD 10.00 min, P < 0.001), lower 30-day mortality (OR 0.70, P = 0.001) and lower wound infection rate (OR 0.67, P = 0.040) than experts. No difference was observed in laparoscopic conversion, R0 resection or local recurrence rates. For oncological resection, there was no significant difference in cancer-specific survival between trainees and consultants (3 studies, 533 patients; hazard ratio 0.76, P = 0.130). CONCLUSION In selected patients, it is appropriate for supervised trainees to perform colorectal resection.
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Affiliation(s)
- M Kelly
- Faculty of Medicine, Imperial College London, London, UK
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Burger RA, Brady MF, Bookman MA, Monk BJ, Walker JL, Homesley HD, Fowler J, Greer BE, Boente M, Fleming GF, Lim PC, Rubin SC, Katsumata N, Liang SX. Risk factors for GI adverse events in a phase III randomized trial of bevacizumab in first-line therapy of advanced ovarian cancer: A Gynecologic Oncology Group Study. J Clin Oncol 2014; 32:1210-7. [PMID: 24637999 PMCID: PMC3986384 DOI: 10.1200/jco.2013.53.6524] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate risk factors for GI adverse events (AEs) within a phase III trial of bevacizumab in first-line ovarian cancer therapy. PATIENTS AND METHODS Women with previously untreated advanced disease after surgery were randomly allocated to six cycles of platinum-taxane chemotherapy plus placebo cycles (C)2 to C22 (R1); chemotherapy plus bevacizumab C2 to C6 plus placebo C7 to C22 (R2); or chemotherapy plus bevacizumab C2 to C22 (R3). Patients were evaluated for history or on-study development of potential risk factors for GI AEs defined as grade ≥ 2 perforation, fistula, necrosis, or hemorrhage. RESULTS Of 1,873 patients enrolled, 1,759 (94%) were evaluable, and 2.8% (50 of 1,759) experienced a GI AE: 10 of 587 (1.7%, R1), 20 of 587 (3.4%, R2), and 20 of 585 (3.4%, R3). Univariable analyses indicated that previous treatment of inflammatory bowel disease (IBD; P = .005) and small bowel resection (SBR; P = .032) or large bowel resection (LBR; P = .012) at primary surgery were significantly associated with a GI AE. The multivariable estimated relative odds of a GI AE were 13.4 (95% CI, 3.44 to 52.3; P < .001) for IBD; 2.05 (95% CI, 1.09 to 3.88; P = .026) for LBR; 1.95 (95% CI, 0.894 to 4.25; P = .093) for SBR; and 2.15 for bevacizumab exposure (aggregated 95% CI, 1.05 to 4.40; P = .036). CONCLUSION History of treatment for IBD, and bowel resection at primary surgery, increase the odds of GI AEs in patients receiving first-line platinum-taxane chemotherapy for advanced ovarian cancer. After accounting for these risk factors, concurrent bevacizumab doubles the odds of a GI AE, but is not appreciably increased by continuation beyond chemotherapy.
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Affiliation(s)
- Robert A. Burger
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Mark F. Brady
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Michael A. Bookman
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Bradley J. Monk
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Joan L. Walker
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Howard D. Homesley
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Jeffrey Fowler
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Benjamin E. Greer
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Matthew Boente
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Gini F. Fleming
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Peter C. Lim
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Stephen C. Rubin
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Noriyuki Katsumata
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
| | - Sharon X. Liang
- Robert A. Burger, Fox Chase Cancer Center, Philadelphia, PA; Mark F. Brady, GOG Statistical and Data Center, Buffalo, NY; Michael A. Bookman, Arizona Cancer Center, Tucson, AZ; Bradley J. Monk, University of California at Irvine, Orange, CA; Joan L. Walker, University of Oklahoma, Oklahoma City, OK; Howard D. Homesley, Wake Forest University Medical Center, Winston-Salem, NC; Jeffrey Fowler, Ohio State University, Columbus, OH; Benjamin E. Greer, University of Washington Medical Center, Seattle, WA; Matthew Boente, Minnesota Oncology Hematology, Minneapolis, MN; Gini F. Fleming, University of Chicago, Chicago, IL; Peter C. Lim, Center of Hope at Renown Regional Medical Center, Reno, NV; Stephen C. Rubin, University of Pennsylvania Cancer Center, Philadelphia, PA; Noriyuki Katsumata, Saitama Medical University/International Medical Center–GOG Japan, Saitama, Japan; and Sharon X. Liang, North Shore University Hospital, Manhasset, NY
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288
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Beware of false-negative CT scan for anastomotic leakage after colonic surgery. Int J Colorectal Dis 2014; 29:445-51. [PMID: 24356897 DOI: 10.1007/s00384-013-1815-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anastomotic leakage is one of the most life-threatening complications after colonic surgery. Correct diagnosis and treatment is important to reduce morbidity and mortality. An abdominal CT scan is one of the main diagnostic tools in diagnosing anastomotic leaks. The aim of this study was to examine the accuracy of abdominal CT scanning to detect anastomotic leakage and to evaluate the consequences of a false-negative CT outcome. METHODS All consecutive patients who underwent colonic resection for malignant disease between 2009 and 2011 or for benign disease in 2010 were reviewed. Patients in whom a postoperative abdominal CT scan was performed to detect anastomotic leakage were included. RESULTS In 97 of 524 patients who underwent colonic surgery, an abdominal CT scan was performed for the suspicion of anastomotic leakage. Overall leakage rate was 10.9 % (n = 57). Mortality rate after leakage was 21.1 % (n = 12). Results from all abdominal CT scans revealed an overall sensitivity of 0.59 (95 % CI 0.43-0.73), a specificity of 0.88 (95 % CI 0.75-0.95), positive predictive value 0.82 (95 % CI 0.64-0.92), negative predictive value 0.70 (95 % CI 0.57-0.81), and an accuracy of 74 %. Delayed reintervention for anastomotic leakage due to a false-negative CT outcome resulted in death in 62.5 % (n = 5). CONCLUSION The sensitivity of abdominal CT scanning after colonic surgery is relatively low. A negative CT scan does not rule out anastomotic leakage. Even with a negative CT scan, we should remain equally alert at clinical deterioration as an argument for timely intervention.
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289
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Adams K, Papagrigoriadis S. Creation of an effective colorectal anastomotic leak early detection tool using an artificial neural network. Int J Colorectal Dis 2014; 29:437-43. [PMID: 24337715 DOI: 10.1007/s00384-013-1812-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leaks greatly increase both morbidity and mortality amongst colorectal patients. Earlier detection of leaks leads to improved patient outcomes; however, diagnosis often proves difficult due to heterogeneous presentation and varied differential diagnosis. The purpose of the study was to create an artificial neural network (ANN) capable of accurately identifying patients at risk of developing a post-operative colorectal anastomotic leak. METHODS A genetic ANN was trained and validated on a retrospective patient cohort. Two comparative groups were identified: those with anastomotic leaks confirmed at re-operation with a control group of patients with a post-operative delayed recovery, but in whom leak was excluded and no re-operation required. RESULTS Seventy-six patients were identified: 20 confirmed leaks and 56 controls. No significant difference in the baseline features between leak and control groups in terms of age (leaks 65.9 years [SD 9.29] controls 58.3 years [SD 17.0)], P = 0.054). Utilising backwards variable selection, ANN maintained 19 input variables. Internal validation of the ANN produced a sensitivity of 85.0 %, specificity of 82.1 %, and AUC of 0.89 for correct identification of clinical anastomotic leaks. Of the 20 confirmed leaks, the model correctly identified 17 and misclassified 10 control patients in the clinical leak category. External validation on 12 consecutive pilot prospective patients produced a specificity of 83.3 %. CONCLUSIONS ANNs can be created to accurately detect clinical anastomotic leaks in the early post-operative period using routinely available clinical data. Further prospective ANN testing is required to confirm generalisability. ANNs may provide useful real-world tools for improving patient safety and outcomes.
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Affiliation(s)
- Katie Adams
- Department of Colorectal Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK,
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290
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Macefield RC, Boulind CE, Blazeby JM. Selecting and measuring optimal outcomes for randomised controlled trials in surgery. Langenbecks Arch Surg 2014; 399:263-72. [PMID: 24233344 PMCID: PMC3961630 DOI: 10.1007/s00423-013-1136-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 10/25/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Randomised controlled trials (RCTs) in surgery are complex to design and conduct and face unique challenges compared to trials in other specialties. The appropriate selection, measurement and reporting of outcomes are one aspect that requires attention. Outcomes in surgical RCTs are often ill-defined, inconsistent and at high risk of bias in their assessment and historically, there has been an undue focus on short-term outcomes and adverse events meaning the value of trial results for clinical practice and decision-making is limited. PURPOSE This review addresses three key problems with surgical trial outcomes—choosing the right outcomes for the trial design and purpose, selecting relevant outcomes to measure from the range of possible outcomes, and measuring outcomes with minimal risk of bias. Each obstacle is discussed in turn, highlighting some suggested solutions and current initiatives working towards improvements in these areas. Some examples of good practice in this field are also discussed. CONCLUSIONS Many of the historical problems with surgical trial outcomes may be overcome with an increased understanding of the trial design and purpose and recognition that pragmatic trials require assessments of outcomes that are patient-centred in addition to measurement of short-term outcomes. The use of core outcome sets developed for specific surgical interventions and the application of novel methods to blind outcome assessors will also improve outcome measurement and reporting. It is recommended that surgeons work together with trial methodologists to integrate these approaches into RCTs in surgery. This will facilitate the appropriate evaluation of surgical interventions with informative outcomes so that results from trials can be useful for clinical practice.
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Affiliation(s)
- Rhiannon C. Macefield
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Caroline E. Boulind
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Jane M. Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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291
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Daams F, Wu Z, Lahaye MJ, Jeekel J, Lange JF. Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature. World J Gastrointest Surg 2014; 6:14-26. [PMID: 24600507 PMCID: PMC3942535 DOI: 10.4240/wjgs.v6.i2.14] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/30/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
Although many studies have focused on the preoperative risk factors of anastomotic leakage after colorectal surgery (CAL), postoperative delay in diagnosis is common and harmful. This review provides a systematic overview of all available literature on diagnostic tools used for CAL. A systematic search of literature was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. Articles were selected when a diagnostic or prediction tool for CAL was described and tested. Two reviewers separately assessed the eligibility and level of evidence of the papers. Sixty-nine articles were selected (clinical methods: 11, laboratory tests: 12, drain fluid analysis: 12, intraoperative techniques: 22, radiology: 16). Clinical scoring leads to early awareness of probability of CAL and reduces delay of diagnosis. C-reactive protein measurement at postoperative day 3-4 is helpful. CAL patients are characterized by elevated cytokine levels in drain fluid in the very early postoperative phase in CAL patients. Intraoperative testing using the air leak test allows intraoperative repair of the anastomosis. Routine contrast enema is not recommended. If CAL is clinically suspected, rectal contrast-computer tomography is recommended by a few studies. In many studies a “no-test” control group was lacking, furthermore no golden standard for CAL is available. These two factors contributed to a relatively low level of evidence in the majority of the papers. This paper provides a systematic overview of literature on the available tools for diagnosing CAL. The study shows that colorectal surgery patients could benefit from some diagnostic interventions that can easily be performed in daily postoperative care.
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292
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Radiologic versus endoscopic evaluation of the conduit after esophageal resection: a prospective, blinded, intraindividually controlled diagnostic study. Surg Endosc 2014; 28:2078-85. [PMID: 24519029 DOI: 10.1007/s00464-014-3435-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 01/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anastomotic leakage is a major complication in esophageal surgery. Although contrast swallow is performed by many surgical centers before reintroduction of oral intake to exclude anastomotic leakage postoperatively, endoscopy is increasingly used in this situation and may be superior. This study compares radiographic contrast study and endoscopy for the identification of local complications after subtotal esophagectomy. METHODS Between January 2006 and September 2007, a prospective, blinded, intraindividually controlled study was conducted in patients who underwent transthoracic esophagectomy due to esophageal cancer. A radiographic contrast study was performed prior to endoscopy on postoperative day 5-7. Technical feasibility, sensitivity, and specificity of the radiologic and endoscopic evaluations of the esophageal substitute were described. RESULTS Radiographic contrast study was possible in only 64% of the patients (35 of 55). The contrast study could not be performed in 20 patients due to contraindications or mechanical ventilation. Endoscopy could be performed in all patients (p < 0.001). Pathologic findings were detected in 13 patients by endoscopy but in only 1 patient by contrast swallow. Leakage of the anastomosis or the conduit was correctly detected in 7 patients by endoscopy but in only 1 patient by contrast swallow (p = 0.01). Endoscopy detected focal conduit necrosis or ischemia in six additional patients. Contrast studies showed false-positive results in two patients. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of the contrast study were only 20 and 94%. No complications resulted from postoperative endoscopy or radiologic imaging. CONCLUSIONS Endoscopic evaluation of the esophageal substitute in the early postoperative course is possible in all patients without complications. Endoscopy is superior to the contrast study in detecting pathological findings after esophageal reconstruction. Radiologic contrast swallow in the early postoperative days is often not possible, has no further relevance, and should be replaced by endoscopic evaluation.
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293
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Galanopoulos G, Raptis D, Pramateftakis MG, Mantzoros I, Kanellos I, Lazarides C. The effects of iloprost on colonic anastomotic healing in rats under obstructive ileus conditions. J Surg Res 2014; 189:22-31. [PMID: 24582070 DOI: 10.1016/j.jss.2014.01.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/07/2014] [Accepted: 01/30/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND The aim of this study was to investigate the effects of iloprost, on colonic anastomotic healing in rats, under obstructive ileus conditions. MATERIALS AND METHODS Eighty male Albino rats were randomized into four groups of 20 animals each. They underwent colonic resection followed by an inverted anastomosis. The rats of group 1 (control) and group 2 (ileus) received 3 mL of saline 0.9% intraperitoneally and those of group 3 (iloprost), and group 4 (ileus + iloprost) iloprost (2 μg/kg of body weight), immediately postoperatively and daily until the day of sacrifice. Each group was further divided into two equal subgroups, depending on the day of sacrifice. The animals of subgroup "a" were sacrificed on the fourth postoperative day, whereas those of "b" on the eighth day. Macroscopic and histologic assessment was performed, whereas anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated. RESULTS Means of bursting pressure, neoangiogenesis, fibroblast activity, and hydroxyproline concentration were significantly increased in group 4 compared with group 2. In addition, on the fourth postoperative day, the inflammatory cell infiltration and the collagenase I concentration were significantly decreased in group 4 compared with group 2. Moreover, on the eighth postoperative day, collagen deposition was significantly increased in group 4 compared with group 2. CONCLUSIONS Iloprost after intraperitoneal administration reverses the negative effect of obstructive ileus. It promotes not only the angiogenic activity but also collagen formation, resulting in increased bursting pressures on the fourth and eighth postoperative days.
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Affiliation(s)
- Georgios Galanopoulos
- 4th Surgical Department, G. Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Raptis
- 4th Surgical Department, G. Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece; Surgical Department, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany.
| | | | - Ioannis Mantzoros
- 4th Surgical Department, G. Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Kanellos
- 4th Surgical Department, G. Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalambos Lazarides
- 4th Surgical Department, G. Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece
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294
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Hirst NA, Tiernan JP, Millner PA, Jayne DG. Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. Colorectal Dis 2014; 16:95-109. [PMID: 23992097 DOI: 10.1111/codi.12411] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
AIM Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage. METHOD A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing. RESULTS Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications. CONCLUSION Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.
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Affiliation(s)
- N A Hirst
- Section of Translational Anaesthesia and Surgical Sciences, Leeds Institute of Molecular Medicine, St James's University Hospital, Leeds, UK
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295
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Risk factors for failure of percutaneous drainage and need for reoperation following symptomatic gastrointestinal anastomotic leak. Am J Surg 2014; 208:58-64. [PMID: 24476970 DOI: 10.1016/j.amjsurg.2013.08.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/17/2013] [Accepted: 08/17/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks. METHODS Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD. RESULTS Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P = .03) and cancer surgery (P = .01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD. CONCLUSIONS Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.
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296
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Feo LJ, Jrebi N, Asgeirsson T, Dujovny N, Figg R, Hoedema R, Slay H, Kim D, Luchtefeld M. Anastomotic leaks: technique and timing of detection. Am J Surg 2014; 207:371-4; discussion 374. [PMID: 24456832 DOI: 10.1016/j.amjsurg.2013.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/16/2013] [Accepted: 09/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite the proven benefits of laparoscopic colorectal surgery, the rate of anastomotic leaks has not changed. This study looks at the time of presentation of anastomotic leaks between laparoscopic and open colectomies. METHODS Retrospective chart review was performed between July 2008 and 2012. Two groups were created, laparoscopic and open. The time of presentation of significant leaks requiring reoperation were compared between the groups by index colectomies. Statistical analysis is presented as paired t test and chi-square test (P < .05). RESULTS From 1,424 segmental colectomies, the anastomotic leak rate between the two groups was not statically significant (P = .69). No difference in the time of leak detection was evident (P = .67). Mortality rate was equal between the groups. The overall complication rate of the entire cohort was statically significant (P ≤ .001). CONCLUSION The timing of anastomotic leak detection does not differ between laparoscopy and open colorectal resections.
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Affiliation(s)
- Leandro J Feo
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA.
| | - Nezar Jrebi
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Theodore Asgeirsson
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Nadav Dujovny
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Ryan Figg
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Rebecca Hoedema
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Heather Slay
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Donald Kim
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
| | - Martin Luchtefeld
- Division of Colorectal Surgery, Grand Rapids Medical Education Partners, Michigan State University, Ferguson Clinic, Grand Rapids, MI, USA
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297
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Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg 2014; 18:1176-85. [PMID: 24671472 PMCID: PMC4028541 DOI: 10.1007/s11605-014-2506-4] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the clinical and economic burden associated with anastomotic leaks following colorectal surgery. METHODS Retrospective data (January 2008 to December 2010) were analyzed from patients who had colorectal surgery with and without postoperative leaks, using the Premier Perspective™ database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM). RESULTS Of the patients, 6,174 (6.18 %) had anastomotic leaks within 30 days after colorectal surgery. Patients with leaks had 1.3 times higher 30-day re-admission rates and 0.8-1.9 times higher postoperative infection rates as compared with patients without leaks (P < 0.001 for both). Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and $24,129, respectively, only within the first hospitalization. Per 1,000 patients undergoing colorectal surgery, the economic burden associated with anastomotic leaks--including hospitalization and re-admission--was established as 9,500 days in prolonged LOS and $28.6 million in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission. CONCLUSIONS Anastomotic leaks in colorectal surgery increase the total clinical and economic burden by a factor of 0.6-1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.
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Affiliation(s)
| | - Sangtaeck Lim
- Global Health Economics and Market Access, Ethicon, Inc, Somerville, NJ 08876 USA
| | - Yin Wan
- Health Outcomes Research, Pharmerit North America LLC, Bethesda, MD 20814 USA
| | - Xin Gao
- Health Outcomes Research, Pharmerit North America LLC, Bethesda, MD 20814 USA
| | - Anuprita Patkar
- Global Health Economics and Market Access, Ethicon, Inc, Somerville, NJ 08876 USA
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298
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Fry DE. The prevention of surgical site infection in elective colon surgery. SCIENTIFICA 2013; 2013:896297. [PMID: 24455434 PMCID: PMC3881664 DOI: 10.1155/2013/896297] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/12/2013] [Indexed: 05/05/2023]
Abstract
Infections at the surgical site continue to occur in as many as 20% of elective colon resection cases. Methods to reduce these infections are inconsistently applied. Surgical site infection (SSI) is the result of multiple interactive variables including the inoculum of bacteria that contaminate the site, the virulence of the contaminating microbes, and the local environment at the surgical site. These variables that promote infection are potentially offset by the effectiveness of the host defense. Reduction in the inoculum of bacteria is achieved by appropriate surgical site preparation, systemic preventive antibiotics, and use of mechanical bowel preparation in conjunction with the oral antibiotic bowel preparation. Intraoperative reduction of hematoma, necrotic tissue, foreign bodies, and tissue dead space will reduce infections. Enhancement of the host may be achieved by perioperative supplemental oxygenation, maintenance of normothermia, and glycemic control. These methods require additional research to identify optimum application. Uniform application of currently understood methods and continued research into new methods to reduce microbial contamination and enhancement of host responsiveness can lead to better outcomes.
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Affiliation(s)
- Donald E. Fry
- Michael Pine and Associates, 1 East Wacker Drive, No. 1210, Chicago, IL 60601, USA
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299
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Barreto SG, Chaudhary A. Predictors of septic shock following gastrointestinal anastomotic leaks: Only signposts, no destination. Indian J Crit Care Med 2013; 17:273-4. [PMID: 24339637 PMCID: PMC3841488 DOI: 10.4103/0972-5229.120317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Savio G Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, Haryana, India
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300
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Kalaiselvan R, Abu Dakka M, Ammori BJ. Late perforation at the jejuno-jejunal anastomosis after laparoscopic gastric bypass for morbid obesity. Surg Obes Relat Dis 2013; 9:874-8. [PMID: 24321567 DOI: 10.1016/j.soard.2013.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 02/27/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although marginal ulceration and perforation at the gastrojejunal anastomosis is an established, albeit rare, risk after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity, little is known about the risk of late perforation at the jejuno-jejunal (J-J) anastomosis. The objective of this study was to identify the incidence of J-J perforation and describe management options and sequelae. METHODS This is a retrospective review of the database of all patients who underwent LRYGB. The results are presented as mean (range) where appropriate. RESULTS Between April 2002 and April 2012, 1652 patients underwent LRYGB (1577 primary and 75 revision procedures). The operative mortality was .18%. Three patients developed late perforation of the J-J anastomosis (.18%) at 7, 9, and 18 weeks, respectively. Two patients were managed with resection and reanastomosis of the perforation by laparotomy, and a third patient was managed laparoscopically with peritoneal lavage and transcutaneous tube jejunostomy of the perforation. All patients recovered well postoperatively. However, the third patient represented 42 days later with sepsis and died secondary to recurrent J-J ulcer perforation. CONCLUSION Perforation of the J-J anastomosis is a rare and life-threatening delayed complication after LRYGB and usually presents within 2-8 months postoperatively. It poses difficulties with diagnosis and management and should be dealt with judiciously.
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