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

A new colorectal/coloanal anastomotic technique in sphincter-preserving operation for lower rectal carcinoma using transanal pull-through combined with single stapling technique

PURPOSE

This study aims to introduce a new anastomotic technique-transanal pull-through combined with single stapling technique (PT-SST), and evaluate the value in the sphincter-preserving operation for lower rectal carcinoma.

METHODS

Between January 2004 and September 2011, 131 consecutive patients had sphincter-preserving operations using PT-SST and double stapling technique (DST) for low colorectal anastomosis. The data was prospectively collected.

RESULTS

There are 45 patients (male 26, median = 55 years) in PT-SST group and 86 (male 46, median = 55 years) in the DST group. Anastomotic leakage took place in three patients in DST group, while no anastomotic leakage happened in PT-SST group. There are recurrences in pelvic cavity for one patient (2.2 %), in anastomotic stoma for no patient, and hepatic metastasis for four patients (8.9 %) in PT-SST group; while there are recurrences in pelvic cavity for three patients (3.5 %), in anastomotic stoma for two patients (2.3 %), and hepatic metastasis for seven patients (8.1 %) in DST group. No significant difference was indicated in the terms of the recurrence and hepatic metastasis between the two groups. Patients were satisfied with functional results.

CONCLUSIONS

This new technique can solve some technique problems of DST and has at least comparable outcomes compared with DST. It is a safe and feasible procedure for performing low anastomosis with high rate of sphincter preservation. It can be used especially for patients with small pelvis.

Growth factors and gastrointestinal anastomotic healing

BACKGROUND

Failure of anastomotic healing in the gastrointestinal tract is a major source of surgery-related morbidity, repeated surgical procedures, and impaired quality of life. Growth factors have been shown to be involved in healing processes in various tissues including the gastrointestinal tract. This opens the perspective to use growth factors therapeutically to support impaired anastomotic healing. The aim of the present study was to review the particular role of several growth factors in different phases of anastomotic healing, experimental approaches of growth factor application, and to discuss possibilities and limitations of growth factor-directed interventions in gastrointestinal surgery.

MATERIALS AND METHODS

A PubMed search was performed to examine the potential role of fibroblast growth factor, epidermal growth factor, heparin binding EGF-like growth factor, transforming growth factor β, insulin-like growth factor I, vascular endothelial growth factor, and platelet-derived growth factor during anastomotic healing.

RESULTS

Growth factors show beneficial effects on a broad range of cell types and regulate various processes during all phases of tissue healing. Despite extensive research in the field of growth factors, additional evidence is needed before translating into a clinical setting.

CONCLUSIONS

Future research should focus on adequate sustained but limited drug delivery. Undesired side effects, such as formation of strictures, development of peritoneal adhesions, and potential induction of malignancies, have to be reflected. Although growth factor application is currently far from clinical routine in gastrointestinal surgery, it might find application in selected patients at risk for impaired anastomotic healing, such as patients with long-time steroid therapy, immunosuppressives, inflammatory disorders, sepsis, hemodynamic shock, malnutrition, or neoadjuvant radiochemotherapy.

Do we really know why colorectal anastomoses leak?

INTRODUCTION

Colorectal anastomotic leak, a feared complication, results in significantly increased patient morbidity, mortality, and hospital resource utilization. The overall incidence of colorectal anastomotic leak is approximately 11% with increasing rate the closer the anastomosis is to the anal verge. Because surgeons are unable to reliably predict which anastomosis would fail, most will construct a diverting ileostomy for low colorectal anastomosis to circumvent the devastating complications of anastomotic failure. Despite extensive investigations on technical considerations of anastomosis construction, anastomotic leaks continue to occur at an unacceptably high rate.

DISCUSSION

In this review, we examine the major known risk factors and technical considerations that have been implicated as factors in leakage. Although surgical technique has evolved over the past several decades with the advent of newer surgical staplers, laparoscopy, and robotics, we have not witnessed a decrease in the incidence of colorectal anastomotic leaks suggesting that the fundamental pathogenesis of anastomotic leak remains unknown. Among the factors contributing to anastomotic healing, intestinal bacteria remains largely overlooked even though compelling evidence exist that intraluminal microbes could play a major role in pathogenesis of anastomotic leak. Further investigation focusing on intestinal microbes could be one such avenue for uncovering the elusive cause of colorectal anastomotic leak.

Diclofenac causes more leakage than naproxen in anastomoses in the small intestine of the rat

BACKGROUND

Non-steroid anti-inflammatory drugs such as the cyclooxygenase isoenzyme inhibitors diclofenac and naproxen are increasingly used for perioperative pain relief, while their potential effects on wound healing are scarcely investigated.

METHODS

In 104 male Wistar rats, an anastomosis was constructed in both colon and ileum. The rats were divided into groups who received diclofenac (4 mg kg(-1) day(-1)) or naproxen (10 mg kg(-1) day(-1)) daily from the day of surgery or from day 3 after surgery. Animals were killed on day 3 or 7 and analysed for signs of anastomotic dehiscence and wound strength of anastomoses and abdominal fascia.

RESULTS

Anastomotic leakage in the ileum (p < 0.0001) and mortality rates (p = 0.001) were significantly increased in the diclofenac group. On day 7, the anastomotic bursting pressure in the ileum remained below that of the controls in the diclofenac- and naproxen-treated rats. When administration of diclofenac was postponed to day 3 after surgery, anastomotic dehiscence was almost absent. The colonic anastomosis and abdominal wall always remained unaffected.

CONCLUSIONS

This study implies that immediate postoperative administration of diclofenac and, to a far lesser extent, naproxen can affect healing in the ileal anastomosis in the rat. This negative effect can be prevented by a short postoperative delay in administration. On steroid anti-inflammatory drugs such as the cyclooxygenase isoenzyme inhibitors diclofenac and naproxen are increasingly used for perioperative pain relief, while their potential effects on wound healing are scarcely investigated.

Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?

AIM: To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.

METHODS: The data of patients who received trans-anal reinforcing sutures were compared with those of patients who did not receive them after low anterior resection. Patients who underwent laparoscopic low anterior resection and the double-stapled anastomosis technique for primary rectal cancer between January 2008 and December 2011 were included in this study. Patients with no anastomosis, a hand-sewn anastomosis, high anterior resection, or preoperative chemoradiation were excluded. The primary outcomes measured were the incidence of postoperative anastomotic complications and placement of a diverting ileostomy.

RESULTS: Among 110 patients, the rate of placement of a diverting ileostomy was significantly lower in the suture group (SG) compared with the non-suture control group (CG) [SG, n = 6 (12.8%); CG, n = 19 (30.2%), P = 0.031]. No significant difference was observed in the rate of anastomotic leakage [SG, n = 3 (6.4%); CG, n = 5 (7.9%)].

CONCLUSION: Trans-anal reinforcing sutures may reduce the need for diverting ileostomy. A randomized prospective study with a larger population should be performed in the future to demonstrate the efficacy of trans-anal reinforcing sutures.

Comparison of clinical outcomes after conservative and surgical treatment of isolated anastomotic leaks after esophagectomy for esophageal cancer

The clinical course and outcome of isolated anastomotic leaks (IALs) after esophagectomy are significantly different from those of necrotic leaks. The purpose of this study was to investigate the clinical features, diagnosis, treatment, and long-term outcome in patients with IALs after esophagectomy with reconstruction for esophageal cancer. A total of 663 patients underwent esophagectomy with esophageal reconstruction because of esophageal cancer between 2000 and 2010 at the Seoul Asan Medical Center. IALs occurred in 23 patients (3.5%). All patients with IAL were male, with a median age of 61 years. Patients with IAL were divided into three groups based on their clinical course. group A comprised patients who had definite clinical symptoms and/or signs indicating mediastinal contamination or leak before routine contrast esophagography was performed. Groups B and C comprised patients who had no definite clinical symptoms and/or signs of leaks before the routine contrast examination. Furthermore, group B contained those patients who resumed oral intake because no leak was found in the routine contrast examination and was diagnosed some days after resuming oral intake. Group C contained those patients who kept fasting because the leak was found in the routine contrast examination. The median follow-up period was 30 months. The mean time to closure of the IAL was 70.1 ± 96.0 days (range 4-364). There was a 72.7% overall closure rate within 60 days. By univariate analysis, the mean time to closure of the IAL was found to be significantly longer for group A patients or in cases where the patients had an uncontained leak, leukocytosis, or empyema. However, there was no statistically significant differences in age, neoadjuvant treatment, site of anastomosis (cervical vs. thoracic), fever, or treatment of the leak. By multivariate analysis, group A was found to be an independent predictive factor for the time to closure of the IAL. Repeat contrast studies revealed no anastomotic leaks in 18 patients and the formation of contained fistula in four cases (excluding one patient who died in hospital). The four patients with a contained fistula showed no clinical symptoms or signs, and tolerated resumed oral intake. IALs were resolved in most cases with low leak-related mortality, and resolution of the leaks occurred within 2 months in the majority of patients.

Little consensus in either definition or diagnosis of a lower gastro-intestinal anastomotic leak amongst colorectal surgeons

PURPOSE

The purposes of this study were to assess the working definition of a colorectal anastomotic leak among colorectal surgeons and to survey the current approach to investigation and management of a patient with a suspected anastomotic leak.

METHODS

Online survey consisting of nine questions regarding the definition, assessment and investigation of anastomotic leaks was conducted. Of the 738 eligible ACP members contacted, 210 responded (28.4%).

RESULTS

Results demonstrated that 94.2% of surgeons agreed 'extravasation of contrast on enema' and 91.8% agreed 'faecal material seen in drains/from the wound' constituted a clinical leak. Only 69.2% agreed that a leak was 'intra-abdominal sepsis requiring a laparotomy', and about half agreed that radiological collections constituted a leak when either treated with antibiotics (46.6%) or with percutaneous drainage (51.4%). Serial clinical examination was the perceived most sensitive clinical feature for a leak, with 75% of surgeons ranking this in their top three choices. Surgeons radiologically confirm a leak on average in 80.2% of cases. A CT with rectal contrast for a left-sided leak was selected by 42.9% of respondents. For a right-sided/small bowel anastomosis, 44.5% selected a CT with oral contrast and 43.4% a CT with IV contrast.

CONCLUSIONS

There is still significant heterogeneity between surgeons in what they define as an anastomotic leak. Most surgeons valued clinical examination as the most sensitive initial tool for leak detection; however, radiology has a major role in the confirmation of clinical leaks in colorectal patients. There is an increasing need to be able to classify and grade anastomotic leaks, both to improve the care of patients and for audit purposes.

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

AIM

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events.

METHOD

Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality.

RESULTS

In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016).

CONCLUSION

The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Anastomotic leakage as an outcome measure for quality of colorectal cancer surgery

INTRODUCTION

When comparing mortality rates between hospitals to explore hospital performance, there is an important role for adjustment for differences in case-mix. Identifying outcome measures that are less influenced by differences in case-mix may be valuable. The main goal of this study was to explore whether hospital differences in anastomotic leakage (AL) and postoperative mortality are due to differences in case-mix or to differences in treatment factors.

METHODS

Data of the Dutch Surgical Colorectal Audit were used. Case-mix factors and treatment-related factors were identified from the literature and their association with AL and mortality were analysed with logistic regression. Hospital differences in observed AL and mortality rates, and adjusted rates based on the logistic regression models were shown. The reduction in hospital variance after adjustment was analysed with Levene's test for equality of variances.

RESULTS

17 of 22 case-mix factors and 4 of 11 treatment factors related to AL derived from the literature were available in the database. Variation in observed AL rates between hospitals was large with a maximum rate of 17%. This variation could not be attributed to differences in case-mix but more to differences in treatment factors. Hospital variation in observed mortality rates was significantly reduced after adjustment for differences in case-mix.

CONCLUSIONS

Hospital variation in AL is relatively independent of differences in case-mix. In contrast to 'postoperative mortality' the observed AL rates of hospitals evaluated in our study were only slightly affected after adjustment for case-mix factors. Therefore, AL rates may be suitable as an outcome indicator for measurement of surgical quality of care.

Late anastomotic leakage in colorectal surgery: a significant problem

AIM

Reported incidence rates of colorectal anastomotic leakage (AL) vary between 2.5 and 20%. There is little information on late anastomotic leakage (LAL). The aim of this study was to determine the incidence of LAL after colorectal resection.

METHOD

All patients undergoing colorectal resection with primary anastomosis between January 2004 and October 2009 at the University Medical Center Groningen were included. LAL was defined as anastomotic leakage diagnosed more than 30 days after surgery.

RESULTS

One hundred and forty-one patients were analysed. Indications for surgery included both benign and malignant conditions. The incidence of early anastomotic leakage (EAL) within 30 days after surgery was 13%. The LAL rate was 6%. Eighty-nine per cent of patients with EAL underwent relaparotomy compared with 44% for LAL (P = 0.02).

CONCLUSION

One-third of all anastomotic leakages were diagnosed more than 30 days after surgery. Of these, 44% underwent relaparotomy. Patients with leakage diagnosed within 30 days after surgery were more likely to undergo relaparotomy. LAL is a significant problem after colorectal surgery.

Comparison of anastomotic leak rate after colorectal surgery using different databases

BACKGROUND

Anastomotic leaks are one of the most important clinical outcomes after colorectal anastomosis. Because of the lack of measurement of this outcome in databases, research has been limited by the need to perform chart review.

OBJECTIVE

The aim of this study was to evaluate the ability of 2 sources, an administrative database and a clinical registry, to identify anastomotic leaks.

DESIGN AND SETTING

A retrospective cohort study of patients undergoing colorectal procedures at an academic medical center over a 1-year period was performed.

PATIENTS

International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to identify patients, and chart review of all patient records was performed. Risk factors for anastomotic leak were recorded along with the presence or absence of anastomotic leak.

MAIN OUTCOME MEASURES

Patients were identified as having a leak in the University HealthSystem Consortium (administrative database) by procedure codes and in the National Surgical Quality Improvement Program (clinical registry) if they had a postoperative organ space surgical site infection. The administrative and clinical data sources were compared with the use of sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for anatomotic leak.

RESULTS

We identified 424 patients; 66 that did not have an anastomosis and 6 that lacked outpatient follow-up were excluded. Anastomotic leak was identified by chart review in 24 patients (6.8%). The clinical registry had the highest specificity (97%) and sensitivity (8%).

LIMITATIONS

Because of the lack of a definition for anastomotic leak in either the administrative database or clinical registry, logical proxies were used.

CONCLUSIONS

Although the clinical registry had higher sensitivity and specificity for anastomotic leak, both databases had low sensitivity. Future research on anastomotic leaks would benefit greatly from a uniform definition and recording of this outcome in national databases.

Systematic review on the value of CT scanning in the diagnosis of anastomotic leakage after colorectal surgery

BACKGROUND

Timely diagnosis of anastomotic leakage after colorectal surgery and adequate treatment is important to reduce morbidity and mortality. Abdominal computed tomography (CT) scanning is the diagnostic tool of preference, but its value may be questionable in the early postoperative period. The accuracy of CT scanning for the detection of anastomotic leakage and its role in timing of intervention was evaluated.

METHODS

A systematic literature search was performed. Relevant publications were identified from four electronic databases between 1990 and 2011. Inclusion criteria were human studies, studies published in English or Dutch, colorectal surgery with primary anastomosis, and abdominal CT scan with reported outcome for the detection of anastomotic leakage. Exclusion criteria were cohort of fewer than five patients, other gastrointestinal surgery, no anastomosis, and radiological imaging other than CT.

RESULTS

Eight studies, including 221 abdominal CT scans, fulfilled the inclusion criteria. Overall, the methodological quality of the studies was poor. The overall sensitivity of CT scanning to diagnose leakage was 0.68 (95 % confidence interval 0.59-0.75) for colonic resection. Data on the sequelae of false-negative CT scanning was not available.

CONCLUSION

There is limited good-quality evidence to determine the value of CT scans in the detection of anastomotic leakage. To prevent delay in diagnosis and appropriate treatment of anastomotic leakage, the relatively low sensitivity of CT scanning must be taken into account.

Definition and classification of complications of gastrectomy for gastric cancer based on the accordion severity grading system

BACKGROUND

Postoperative complications still comprise the marker used most frequently to assess the quality of gastrectomy. However, the definition and grading of morbidity is not standardized, hampering meaningful comparisons over time and among centers. This study proposes specific definitions and a reproducible classification of complications following gastrectomy using standardized grading tools.

METHODS

We defined each complication based on the literature, and adopted the Accordion Severity Grading System to stratify morbidity. The classification was applied to 890 patients with gastric cancer seen between January 2010 and April 2011. The correlation between the complication grades and the length of hospital stay (LOS) was analyzed, and risk factors for complications were examined with special reference to severity grade.

RESULTS

The overall morbidity rate was 18.1 %. Mild complications occurred in 31 patients (3.5 %), moderate in 77 patients (8.7 %), severe--invasive procedure/no general anesthesia (GA) in 27 patients (3.0 %), severe--invasive procedures/GA in 18 patients (2.0 %), and severe--organ failure in 3 patients (0.3 %). Five patients (0.6 %) died postoperatively. The grade of complications had a significant effect on the LOS (p < 0.001). Operating time and cardiovascular and pulmonary co-morbidities were independent risk factors for severe complications [odds ratio (OR) 1.001, p = 0.016; OR 2.226, p = 0.006; OR = 2.896, p = 0.003, respectively].

CONCLUSIONS

The complications after gastrectomy could be classified into different severity grades that had distinct clinical outcomes. The use of this classification provides more reliable, practical outcome data. Consequently, complications should be reported using a standardized classification tool such as the Accordion Severity Grading System, which requires consensus on the definition of specific complications.

Treatment of colorectal anastomotic leakage: results of a questionnaire amongst members of the Dutch Society of Gastrointestinal Surgery

Anastomotic leakage after colorectal surgery is correlated with considerable morbidity and mortality. Although many studies focus on risk factors and detection, studies on the treatment strategy for colorectal anastomotic leakage are scarce. A national questionnaire amongst 350 members of the Dutch Society for Gastrointestinal Surgery was undertaken on the current treatment of colorectal anastomotic leakage. The response was 40% after two anonymous rounds. 27% of the respondents state that a leaking anastomosis above the level of the promontory should be salvaged in ASA 1-2 patients <80 years of age, for ASA 3 and/or >80 years of age this percentage is 7.3%. For an anastomosis under the promontory, 50% of the respondents choose preserving the anastomosis for ASA 1-2 compared to 17% for ASA 3 and/or >80 years of age. In ASA 1-2 patients with a local abscess after a rectum resection without protective ileostomy, 31% of the respondents will create an protective ileostomy, 40% break down the anastomosis to create a definite colostomy, in ASA 3 and/or >80 years of age 14% of the respondents create a protective ileostomy and 63% a definitive colostomy. In ASA 1-2 patients with peritonitis after a rectum resection with deviating ileostomy, 31% prefer a laparotomy for lavage and repair of the anastomosis, 25% for lavage without repair and 36% of the respondents prefer to break down the anastomosis. When the patient is ASA 3 and/or >80 years of age, 13% prefer repair, 9% a lavage and 74% breaking down the anastomosis. This questionnaire shows that in contrast to older people, more surgeons make an effort to preserve the anastomosis in younger people.

Early and late symptomatic anastomotic leakage following low anterior resection of the rectum for cancer: are they different entities?

AIM

The aim of the study was to compare patients with symptomatic anastomotic leakage following low anterior resection of the rectum (LAR) for cancer diagnosed during the initial hospital stay with those in whom leakage was diagnosed after hospital discharge.

METHOD

Forty-five patients undergoing LAR (n = 234) entered into a randomized multicentre trial (NCT 00636948), who developed symptomatic anastomotic leakage, were identified. A comparison was made between patients diagnosed during the initial hospital stay on median postoperative day 8 (early leakage, EL; n = 27) and patients diagnosed after hospital discharge at median postoperative day 22 (late leakage, LL; n = 18). Patient characteristics, operative details, postoperative course and anatomical localization of the leakage were analysed.

RESULTS

Leakage from the circular stapler line of an end-to-end anastomosis was more common in EL, while leakage from the stapler line of the efferent limb of the J-pouch or side-to-end anastomosis tended to be more frequent in LL (P = 0.057). Intra-operative blood loss (P = 0.006) and operation time (P = 0.071) were increased in EL compared with LL. On postoperative day 5, EL performed worse than LL with regard to temperature (P = 0.021), oral intake (P = 0.006) and recovery of bowel activity (P = 0.054). Anastomotic leakage was diagnosed most often by a rectal contrast study in EL and by CT scan in LL. The median initial hospital stay was 28 days for EL and 10 days for LL (P < 0.001).

CONCLUSION

The present study has demonstrated that symptomatic anastomotic leakage can present before and after hospital discharge and raises the question of whether early and late leakage after LAR may be different entities.

Tissue adhesives in gastrointestinal anastomosis: a systematic review

BACKGROUND

Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives.

METHODS

We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence.

RESULTS

We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans.

CONCLUSIONS

Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.

Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic review and meta-analysis of randomized, controlled trials

BACKGROUND

Nonsteroidal anti-inflammatory drugs are a key component of contemporary perioperative analgesia. Recent experimental and observational clinical data suggest an associated increased incidence of anastomotic dehiscence in bowel surgery.

OBJECTIVE

The aim of this study was to conduct a systematic review and meta-analysis of anastomotic dehiscence in randomized, controlled trials of perioperative nonsteroidal anti-inflammatory drugs.

DATA SOURCES

Published and unpublished trials in any language reported 1990 or later were identified by searching electronic databases, bibliographies, and relevant conference proceedings.

STUDY SELECTION

Trials of adults undergoing bowel surgery randomly assigned to perioperative nonsteroidal anti-inflammatory drugs or control were included. The number of patients with a bowel anastomosis and the incidence of anastomotic dehiscence had to be reported or be available from authors for the study to be included.

INTERVENTION

At least 1 dose of a nonsteroidal anti-inflammatory drug was given perioperatively within 48 hours of surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was 30-day incidence of anastomotic dehiscence as defined by authors.

RESULTS

Six trials comprising 480 patients having a bowel anastomosis met inclusion criteria. In 4 studies, anastomotic dehiscence rates were higher in the intervention groups. Overall rates were 14/272 participants (5.1%) in intervention arms vs 5/208 (2.4%) in control arms. Peto OR was 2.16 (95% CI 0.85, 5.53; p = 0.11), and there was no heterogeneity between studies (I statistic 0%).

LIMITATIONS

Sizes of available trials were small, preventing firm conclusions and subset analysis of drugs of different cyclooxygenase specificity. A precise and consistent definition of anastomotic dehiscence was not used across trials.

CONCLUSIONS

A statistically significant difference in incidence of anastomotic dehiscence was not demonstrated. However, the Peto OR of 2.16 (0.85, 5.53) and lack of heterogeneity between trials suggest that this finding may be due to a lack of power of the available data rather than a lack of effect.

[Cervical anastomotic leak after esophagectomy: diagnosis and management]

INTRODUCTION

Cervical anastomotic leaks after esophagectomy are still a frequent and severe complication that needs an early diagnosis and an appropriate treatment. The aim of this study was to describe our experience with the management of this complication.

PATIENTS AND METHODS

Retrospective study (2003-2011) of a consecutive series of 77 patients with a cervical esophagogastric anastomosis, 18 of them (23.3%) presenting a leak. Fistulae were classified into 4 groups depending on clinical presentation, radiology (esophagogram or CT), surgical findings (in case of re-operation) and, since 2010, endoscopic examination. Type I leaks were an asymptomatic or radiographic leak, type II had local signs limited to the neck, type III was associated with respiratory symptoms due to a pleural or mediastinal collection, and type IV with a systemic disorder secondary to gastric necrosis.

RESULTS

Four patients (22.2%) were classified as type I, 8 (44.4%) as type II, 3 (16.6%) as type III, and 3 (16.6%) as type IV. Eight patients were managed conservatively; in 9 a self-expanding stent was used, 5 required a thoracotomy, and one of them (type IV) died. Leaks were related to a higher associated morbidity (61 versus 30%; P=.019) and a longer hospital stay (median of 28.5 vs 14 days; P=.009).

CONCLUSIONS

Almost one quarter of cervical esophagogastric anastomoses present some kind of anastomotic leak. Although most of them can be treated conservatively or by endoscopy, they are associated with an increase in morbidity and mortality.

Intracorporeal versus extracorporeal anastomosis during laparoscopic right hemicolectomy - systematic review and meta-analysis

BACKGROUND

Since 2005, after an initial scanty spreading, the vast majority of surgeons advice against the intracorporeal ileocolic anastomosis following right hemicolectomies. In the subsequent years, greater interest was re-discovered for the intracorporeal ileocolic anastomosis formed after video-assisted right hemicolectomies

OBJECTIVE

The aim of this systematic review is to compare the intra-abdominal versus extra-abdominal anastomosis after right laparoscopic colectomy.

DATA SOURCES

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central and the Science Citation Index.

STUDY SELECTION

A total of 191 publications were identified; seven non-randomized studies published between 2004 and 2012 with a total of 945 patients, who underwent laparoscopic right colectomy for malignant and benign disease, were included in this systematic review.

INTERVENTION

Intra-abdominal versus extra-abdominal confectioning of ileo-coloc anastomosis after right laparoscopic colectomy.

MAIN OUTCOME MEASURES

Anastomotic leak, overall post-operative morbidity and overall 30-days post-operative mortality.

RESULTS

Anastomotic leak rate resulted similar in IA (1.13%) and EA (1.84%) group (P=0.81, OR of 0.90, 95% CI 0.24-3.10) (Chi(2)=3.90, P=0.42, I(2)=0%). The mortality rate was lower in the IA group (0.34% versus 1.32%), although no statistically difference was demonstrated between the two groups (P = 0.48, OR of 0.52 95% CI 0.09-3.10). It was not possible to conduct a meta-analysis of post-operative morbidity as the data reported in the included studies were too heterogeneous.

LIMITATIONS

The weakness in our results was due to the lack of evidence in current published literature.

CONCLUSIONS

The present systematic review of literature and meta-analysis failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right hemicolectomy. Future randomized, controlled trials are needed to further evaluate different surgical anastomosis after laparoscopic right hemicolectomy.

Early surgical outcomes of NiTi endoluminal compression anastomotic clip (NiTi CAC 30) use in patients with gastrointestinal malignancy

BACKGROUND

The NiTi endoluminal Compression Anastomotic Clip (CAC™) 30 (NiTi CAC 30) (NiTi Alloys Technologies, Ltd., Netanya, Israel) is a new device with shape-memory characteristics. We aimed to investigate the safety and early surgical outcomes of NiTi CAC 30 for intestinal anastomosis in patients with gastrointestinal malignancy.

SUBJECTS AND METHODS

Fifty patients operated on with NiTi CAC 30 were matched for sex, age, body mass index, operation type (open versus laparoscopy), operation name, and anastomosis type with patients in a control group operated on with a stapling device between November 2009 and May 2010. Early clinical outcomes were investigated.

RESULTS

One misfired case of NiTi CAC 30 was excluded. Between the two groups, no significant differences were observed in demographics except for previous abdominal operation history. The results of early clinical outcomes were investigated, including operation time, estimated blood loss, time to first flatus, first defecation, and discharge, and complications. No differences were noted. Postoperatively, migration started in 1 patient between 3 and 5 days, 11 patients between 6 to 7 days, and 37 patients after 8 days. The expulsion of 31 cases occurred between 2 and 3 weeks, postoperatively. The NiTi CAC 30 was expulsed within 1 week in 4 patients and between 1 to 2 weeks in 8 patients. An expulsion occurred in 1 case at over 4 weeks. No problems related to early migration and expulsion were observed, and no anastomotic leakage and bleeding occurred.

CONCLUSIONS

Intestinal anastomosis with the NiTi CAC 30 was safe and feasible without anastomotic leakage and reoperation compared with the stapling technique.

Anesthesia and perioperative management of colorectal surgical patients - specific issues (part 2)

Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.

Identification of risk factors for esophagojejunal anastomotic leakage after gastric surgery

BACKGROUND

Despite the development of the surgical technique and improvements in perioperative management, anastomotic leakage still occurs at esophagojejunal anastomoses after total or proximal gastrectomy. Anastomotic leakage is one of the major complications of concern, chiefly because it can lead to death. The objective of the present study was to identify the risk factors for esophagojejunal anastomotic leakage.

METHODS

The study was based on retrospective analysis of the data of a total of 1,640 consecutive patients who underwent total, proximal, or completion gastrectomy, including esophagojejunal anastomosis, between 1999 and 2008.

RESULTS

Thirty-five patients (2.1 %) developed anastomotic leakage. Univariate analysis revealed patient age, pulmonary insufficiency, lymph node dissection, combined resection of other organs, omental resection, operative time, blood loss, intraoperative blood transfusion, and postoperative creatinine level were the significant factors influencing anastomotic leakage. Multivariate analysis identified pulmonary insufficiency and the duration of the operation as the predictors of anastomotic leakage.

CONCLUSIONS

To avoid leakage, surgeons should take care in creating the anastomosis in gastrectomy patients, particularly in cases of poor pulmonary function or when the procedure requires a longer operation.

Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality

BACKGROUND

Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer.

METHODS

A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed.

RESULTS

Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes.

CONCLUSION

We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.

Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) represents the evolution of surgery towards less invasive procedures. The feasibility of NOTES transrectal approach has increased its clinical applicability. This report describes a first series of minilaparoscopy-assisted transrectal low anterior resection with double purse-string end-to-end circular stapler anastomoses.

METHODS

Between March and April 2012 three selected patients underwent transrectal minilaparoscopy-assisted natural orifice surgery total mesorectal excision for rectal cancer. All the oncologic principles of open/laparoscopic low anterior resection for rectal cancer were strictly fulfilled. Two patients underwent neoadjuvant treatment. Laparoscopic visualization and assistance was provided through one 10-mm umbilical port and two ports, one of which was used as stoma site (5 mm) and the other as a drain site (2 mm needle port). The specimen was transected transanally followed by the confection of double purse-string lateral/end-to-end anastomoses. There were no intraoperative complications.

RESULTS

Mean operative time was 143 min. Oral intake was initiated on the second postoperative day. Patients were discharged home by day 5. The pathology unit confirmed that distal and circumferential margins were free of tumor invasion, and quality of mesorectum resection was reported satisfactory. One patient had to be readmitted because of severe dehydration due to increased ileostomy output. The patient was discharged at the third day after the readmission without renal failure.

CONCLUSIONS

In this preliminary report, transrectal minilaparoscopy-assisted low anterior resection was feasible and safe. Lateral/end-to-end anastomoses can be considered an interesting alternative to the double-stapling technique. However, it is necessary to further study and develop these procedures, along with careful patient selection, before transrectal low anterior resection may be considered for routine clinical use.

Reporting of short-term clinical outcomes after esophagectomy: a systematic review

OBJECTIVE

This review summarizes reporting of complications of esophageal cancer surgery.

BACKGROUND

Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects.

METHODS

Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken.

RESULTS

Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity.

CONCLUSIONS

Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a "core outcome set" is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.

Routine leak testing in colorectal surgery in the Surgical Care and Outcomes Assessment Program

OBJECTIVE

To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined.

DESIGN

Observational, prospectively designed cohort study.

SETTING

Data from Washington state's Surgical Care and Outcomes Assessment Program (SCOAP).

PATIENTS

Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009.

INTERVENTIONS

Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥ 90% use) in a given calendar quarter.

MAIN OUTCOME MEASURE

Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals.

RESULTS

Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99).

CONCLUSION

Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

Bilirubin level in the drainage fluid is an early and independent predictor of clinically relevant bile leakage after hepatic resection

BACKGROUND

Variations in the definition of bile leakage after hepatic resection have prevented the identification of risk factors for early diagnosis and efficient management. The International Study Group of Liver Surgery (ISGLS) definition standardizes reporting of this complication. It was our aim in the present study to prospectively validate the ISGLS definition of bile leakage after hepatic resection. Furthermore, we sought to identify early predictors of clinically relevant bile leakage.

METHODS

A total of 265 patients who underwent elective hepatic resection were enrolled prospectively. Bilirubin concentrations were determined in the serum and drainage fluid until postoperative day 5. Risk factors of Grade B/C bile leakage were assessed by the use of univariate and multivariate analyses.

RESULTS

Grade A, B, and C bile leakage was diagnosed in 23 (8.7%), 38 (14.3%), and 11 (4.1%) patients, respectively. The definition as well as severity grading of bile leakage correlated with the duration of drainage and intensive care unit and hospital stay. Perioperative mortality was 0% for Grade A, 5.2% for Grade B, and 45.4% for Grade C bile leakage (P < .0001). Multivariate analysis confirmed bilirubin concentration in the drainage fluid ≥2.4 mg/dL on postoperative day 2 (odds ratio 11.88; 95% confidence interval 5.33-26.49; P < .0001) and anatomic resection (odds ratio 3.59; 95% CI 1.08-11.97; P = .04) as independent predictors of clinically relevant bile leakage.

CONCLUSION

The ISGLS definition and severity grading of bile leakage after hepatic resection is clinically meaningful. Bilirubin concentration in the drainage fluid on postoperative day 2 is a strong predictor of clinically relevant bile leakage.

Efficacy of the over-the-scope clip (OTSC) for treatment of colorectal postsurgical leaks and fistulas

BACKGROUND

Colorectal postsurgical leaks and fistulas are severe complications that dramatically increase morbidity and mortality. The aim of this study was to evaluate the clinical impact of over-the-scope clip (OTSC) closure to seal the visceral wall in the management of acute and chronic colorectal postsurgical leaks and fistulas.

METHODS

We reviewed our prospective series of acute and chronic colorectal postsurgical leaks and fistulas observed between April 2008 and September 2011 and treated by OTSC. Indications were all cases with an orifice <15 mm in maximum diameter with no extraluminal abscess and luminal stenosis.

RESULTS

Endoscopic OTSC closure was performed in 14 consecutive patients (mean defect = 9.1 mm in diameter) by means of 10.5- or 12-mm clips, depending on the wall defect diameter. In eight cases, the indication was an acute leak and in six cases a chronic leak, mainly after anterior rectal resection; two cases were complicated by a rectovaginal fistula and in two other cases by a colocutaneous fistula. OTSC treatment was used to complete endoscopic vacuum-assisted closure of a large defect in three cases. The overall success rate was 86 % (12/14): 87 % (7/8) in acute and 83 % (5/6) in chronic cases. No OTSC-related complications occurred. Further surgery was required in one case.

CONCLUSION

Endoscopic OTSC closure of colorectal postsurgical leaks and fistulas is a safe technique, with a high success rate in both acute and chronic cases, including rectovaginal and colocutaneous fistulas.

Risk factors for anastomotic leakage after colectomy

BACKGROUND

Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication.

OBJECTIVE

The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis.

DESIGN

The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed.

SETTING

This study was performed at academic and community medical centers in the state of Michigan.

PATIENTS

Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010.

MAIN OUTCOME MEASURES

Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage.

RESULTS

Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003.

LIMITATIONS

The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review.

CONCLUSION

Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

Colorectal cancer surgery 2000-2008: evaluation of a prospective database

BACKGROUND

  Colorectal cancer is a common cause of cancer death in Australia and is primarily managed operatively. Surgical databases are valuable in monitoring performance in cancer treatment and detecting problems and trends.

METHODS

  Diagnostic and treatment variables and short-term outcomes were gathered prospectively for patients undergoing resection for colorectal cancer over a 9-year period. Survival data were obtained by linkage to state and interstate death indices.

RESULTS

  Eight hundred and five patients underwent resection for colorectal cancer during the study period. Overall 5-year survival was 61%. Five-year cancer-specific survival was 73%. Five-year cancer-specific survival for Australian Clinico-Pathological Staging (ACPS) stages A, B, C and D was 96, 80, 61 and 19%, respectively (P < 0.0001). Emergency presentations showed diminished survival (59% versus 75%, P < 0.0001) after controlling for age and stage (hazard ratio (HR) 1.78, P= 0.005), as did transfusion recipients (63% versus 74%, P= 0.0014; HR 1.78, P= 0.004). Anastomotic leak did not affect survival in multivariable analysis. Non-cancer causes accounted for 26% deaths, primarily comprising cardiovascular deaths in the elderly.

DISCUSSION

  High case ascertainment, data completeness and accuracy can be obtained with prospective, independently gathered data linked electronically to national death records. Survival for colorectal cancer in South Australia continues to improve. Close follow-up for disease recurrence is warranted for transfusion recipients, emergencies and advanced disease. Locally managed databases with linkage to state registries and other institutions are powerful methods to improve data quality and surgical care at a national level.

Perioperative pain relief by a COX-2 inhibitor affects ileal repair and provides a model for anastomotic leakage in the intestine

The authors examined the potential of the cyclooxygenase 2 (COX-2) inhibitor carprofen to reproducibly induce anastomotic leakage. In experiment 1, an anastomosis was constructed in both ileum and colon of 20 rats, and they were given carprofen (5 mg/kg subcutaneously every 24 hours) or buprenorphine (0.02 mg/kg subcutaneously every 12 hours). In another 20 rats an anastomosis was constructed in either ileum or colon, and all received carprofen (experiment 2). Animals were sacrificed after 3 days. In experiment 1, the ileal dehiscence rate was 60% in the carprofen group and 0% in the buprenorphine group (P = .0108). Colonic anastomoses in both groups remained patent. In experiment 2, the anastomotic leakage rate was 80% in ileum and 0% in colon. Thus, COX-2 inhibitors can severely interfere with intestinal healing, particularly in the ileum. Perioperative administration of carprofen yields a unique model for anastomotic leakage, which allows translational research on the effectiveness of perisuture line reinforcement.

Gastric leak after sleeve gastrectomy: analysis of its management

BACKGROUND

Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening.

METHODS

The focus of the study is nine patients who underwent a SG and developed a gastric leak after surgery. Our data were obtained from the clinical charts of the patients and through interviews with the surgeon who performed the index surgery.

RESULTS

Eight patients underwent SG at outside institutions while one was operated at Clinica Alemana. Three patients developed symptoms within 5 days after surgery, while the rest were diagnosed after 10 days from the surgery. A CT scan was the method used to confirm the diagnosis in all patients. The three patients who had a leak detected during the immediate postoperative period underwent laparoscopic reoperation. Among the rest of the patients, percutaneous drainage was employed in one patient as the primary procedure while the other underwent surgical drainage. An esophageal endoluminal stent was employed in four patients. The leak closed in all patients with the healing time ranging from 21 to 240 days.

CONCLUSIONS

Diagnosis of a leak after a SG required a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Evolution is characterized by longer periods of time that are necessary in order to wait until the leak closes. Management must be tailored to each patient.

Missed Inadvertent Gastrointestinal Injuries during Abdominal Operations: Characteristics, Diagnosis, and Treatment

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations’ characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21–87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1–13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.

The effect of fibrin glue on the early healing phase of intestinal anastomoses in the rat

PURPOSE

Protecting the anastomotic integrity using suture or staple line reinforcement remains an important goal for ongoing research. The present comprehensive study aims to establish the effects of fibrin glue on the early phase of anastomotic healing in the rat intestine.

METHODS

One hundred and eight young adult male Wistar rats underwent resection and anastomosis of both the ileum and colon. In half, fibrin glue was applied around the anastomoses. Parameters for repair included wound strength, both bursting pressure and breaking strength at days 1, 3, and 5 after operation; hydroxyproline content; and histology, the latter also after 7 days.

RESULTS

A transient colonic ileus was observed in the experimental group. Anastomotic breaking strength was always similar in both the control and fibrin glue groups. Anastomotic bursting pressures remained low at days 1 and 3, without any differences between the groups. In both groups, the bursting pressure increased sharply (p < 0.001) between days 3 and 5. At day 5, the bursting pressure in the fibrin glue group remained below than that in the controls, although only significantly (p = 0.0138) so in the ileum. At day 5, but not at day 7, the wounds in the fibrin glue group contained less collagen. Other aspects of microscopic wound architecture appeared to be the same.

CONCLUSIONS

There is no justification for using fibrin glue on patent anastomoses constructed under low-risk conditions. Its potential benefit under conditions where chances for anastomotic leakage are enhanced needs further investigation.

Evaluation of Bioabsorbable Seamguard for Staple Line Reinforcement in Stapled Rectal Anastomoses

Introduction. The concept of staple line reinforcement is a growing area of interest. This study evaluated the feasibility and effect of using bioabsorbable Seamguard (BSG) to bolster end-to-end stapled rectal anastomoses in a porcine model. Methods. Eleven female 45-kg Yucatan domestic pigs were used. Each animal served as its own control by creating a BSG and nonreinforced anastomosis using a 29-mm end-to-end anastomotic stapling device. Reinforced anastomoses were randomized to proximal and distal positions along the rectum. Each staple line reinforcement agent consisted of adding BSG to the stapling device according to the manufacturer’s instructions. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured and underwent pathologic review. Results. Bolstered anastomoses offered no strength advantage as burst pressures were no different as compared with unbolstered anastomoses. There was also no difference in anastomotic internal or external diameters. Only 1 stapled anastomosis burst during testing and none in the bolstered group. On histological analysis, there was a significant increase in inflammatory infiltrate in the bolstered group as compared with the stapled group ( P = .041), with a higher incidence of lymphocytes ( P = .047) and giant cells ( P = .037). There was no difference in mucosal loss at the anastomotic site, neovascularization, fibroblast presence, extent of fibrosis, muscle layer disruption, percentage of anastomosis replaced by collagen, and elastin deposition. Conclusions. The routine use of BSG bolsters in stapled rectal anastomoses is safe and results in equivalent anastomotic strength as traditional stapled anastomoses.

Laparoscopic total colectomy: Does the indication influence the outcome?

AIM: To assess and compare outcomes of laparoscopic total colectomy performed for a variety of indications.

METHODS: Sixty six patients underwent laparoscopic total colectomy for inflammatory bowel disease (IBD) (13) and other diseases (53). Data on demographics, pre- and post-operative outcomes were collected prospectively.

RESULTS: Mean operative time was 4.5 h. Conversion rate was 13.6%. Total colectomy performed for IBD was associated with a significantly higher anastomotic leak rate (23.1% vs 1.9%, P < 0.05). On univariate analysis, hand sewn anastomosis and treatment with more than 20 mg of prednisolone for at least 3 mo was associated with a higher anastomotic leak rate (P < 0.05). No significant difference was found in return of gut function and overall morbidity between disease groups.

CONCLUSION: Laparoscopic total colectomy is feasible and outcomes are equivalent whatever the indication, except for anastomotic leak rate which is higher for patients with IBD.