Microvascular disease and anastomotic dehiscence in the colon

Defunctioning cannula ileostomy after lower anterior resection of rectal cancer

BACKGROUND AND OBJECTIVE

Most surgeons suggest the use of fecal diversion in patients undergoing low anterior resections of rectal tumors at high risk for anastomotic leakage. We describe an exploratory study to evaluate the efficacy and safety of a new diversion method called a spontaneously closing cannula ileostomy, which was designed to protect rectal anastomoses in patients at high risk for anastomotic leakage. The outcomes of patients treated with cannula ileostomy were compared to those of patients treated with loop ileostomy.

MAIN OUTCOME MEASURES

Outcomes included the rates of anastomotic leakage, reoperation and other complications, as well as length of hospital stay and cost.

DESIGN AND PATIENTS

From January 2011 to December 2012, 294 patients undergoing low colorectal or coloanal anastomosis were treated with ileum diversion using cannula ileostomy or traditional loop ileostomy. Demographics, clinical features, and operational data were recorded.

RESULTS

The anastomotic leakage rates were 8.1% (12/149) in the cannula ileostomy group and 8.3% (12/145) in the loop ileostomy group (p = 1.0). The reoperation rate was 3% (4/149) in patients treated with a cannula ileostomy and 3.4% (5/145) in those who underwent a loop ileostomy (p = 0.75). The median length of the hospital stay was 8.6 days in the cannula ileostomy group and 17.1 days (p < 0.01) in the loop ileostomy group, including time for the initial and reversal operations. In the cannula ileostomy group, the median time to defecation from the anus was 16.5 days after the operation. During the follow-up period, 13 patients in the loop ileostomy group retained their stoma, as compared to 2 in the cannula ileostomy group (p < 0.01).

LIMITATIONS

This study was a nonrandomized design and lacked contrast enema data to identify anastomotic leaks.

CONCLUSIONS

Cannula ileostomy is a safe and effective diverting technique that protects low colorectal and coloanal anastomoses. Patients receiving a cannula ileostomy had shorter hospital stays and lower rates of permanent stoma than those receiving a loop ileostomy.

Use of cannula ileostomy to protect a low colorectal anastomosis in patients having preoperative neoadjuvant chemoradiotherapy

AIM

This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy.

METHOD

Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy (n = 28) or conventional loop ileostomy (n = 22). Demographics, clinical features and operation data were recorded.

RESULTS

Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy.

CONCLUSION

Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma.

Protection of intestinal anastomosis with biological glues: an experimental randomized controlled trial

BACKGROUND

The aim of the study was to compare the degree of healing and air tightness of hand-sewn colonic anastomoses provided by different biological glues.

METHODS

Thirty colonic anastomoses were fashioned in ten rabbits, at 5, 10, 15 cm from the ileocecal valve, with 4/0 PDS running sutures. Each suture was randomized to treatment with fibrin sealant (Tissucol®), a synthetic glue (Coseal®), or nothing (control). After 15 days, the rabbits were killed and the anastomoses examined for their integrity and resistance to bursting. The van der Hamm scale was used to evaluate postoperative adhesions. A blind histological evaluation of the newly formed tissue was made (Ehrlich-Hunt scale).

RESULTS

Two rabbits developed an intraabdominal abscess, one in the control anastomosis group without glue. Postoperative adhesions were present in all animals. Median anastomosis bursting pressures were 0.9 atm in all three groups: Tissucol, Coseal, and control. Pressure values were 0.9, 1.0, and 0.9 atm in the three different proximodistal sites, respectively. A trend toward an increased resistance was observed in the glued anastomosis, although this was not significant. Lymphocyte infiltration, fibroblast activity, blood vessel density, and collagen deposition were lower in controls. Anastomoses treated with Tissucol had the highest lymphocyte infiltration level. The Coseal group developed the highest rates of fibroblast activity, collagen deposition, and blood vessel neogenesis.

CONCLUSION

The use of biological glues did not result in a statistically significantly increased bursting resistance. Histological evaluation demonstrated more intense tissue neoformation in the glue groups, particularly in the Coseal group. The role of biological glues in decreasing the leakage rate of intestinal anastomoses is uncertain, and larger trials using different protective agents are warranted.

Use of intracolonic bypass secured by a biodegradable anastomotic ring to protect the low rectal anastomosis

PURPOSE

Because of the relatively high morbidity and mortality of anastomotic leakage in patients with low rectal cancer who receive an anterior resection, many fecal diverting methods have been introduced. This study was designed to assess the efficacy and safety of the Valtrac-secured intracolonic bypass in protecting low rectal anastomosis and to compare the efficacy and complications of Valtrac-secured intracolonic bypass with those of loop ileostomy.

METHODS

From January 2002 to April 2006, 83 patients with rectal cancer who underwent elective low anterior resection received intracolonic bypass or ileostomy. Demographics, clinical features, and operative data were recorded.

RESULTS

Forty-four patients (53 percent) received a Valtrac-secured intracolonic bypass and 39 patients (47 percent) a loop ileostomy. The demographics and clinical features of the groups were similar. None of the patients developed clinical anastomotic leakage. Longer overall postoperative hospital stay (21.3 +/- 5.8 days) and higher costs incurred (3.1 +/- 0.9 x $1,000 U.S. dollars) were observed in the ileostomy group than in the intracolonic bypass group (12.5 +/- 6.3 days, 4.4 +/- 1.2 x $1,000 U.S. dollars; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (12.8 percent), bleeding (2.6 percent), and intestinal obstruction after stoma closure (5.1 percent). No complications were observed in the intracolonic bypass group except for the Valtrac ring discharging en bloc, which compromised fecal evacuation in two cases (4.5 percent).

CONCLUSIONS

The Valtrac-secured intracolonic bypass procedure is a safe, effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis. Valtrac-secured intracolonic bypass, in contrast to loop ileostomy, avoids stoma-related complications or readmission for closure and is associated with decreased hospital time and cost.

Early prediction of anastomotic leak in colorectal cancer surgery by intramucosal pH

PURPOSE

Adequate oxygenation is necessary for anastomotic healing, and ischemia has been found to be one of the most important factors in anastomotic leakage. This study was designed to assess the value of early postoperative intramucosal pH measurements for the prediction of anastomotic leakage in patients with colorectal anastomosis.

METHODS

A prospective study of 90 patients with rectal or sigmoid cancer with primary anastomosis was conducted. In all patients intramucosal pH was determined by using tonometry at the anastomotic and gastric levels during the first 24 and 48 hours postoperatively. Seven other variables also were tested by univariate and multivariate analysis for any association with anastomotic leakage.

RESULTS

The rate of clinical anastomotic leakage was 6.6 percent. Multivariate analysis showed that only the intramucosal pH at the anastomosis was an independent factor for the development of anastomotic leakage. The risk of leakage was 22 times higher in patients with an anastomotic intramucosal pH < 7.28 in the first 24 hours after surgery.

CONCLUSIONS

Measurement of anastomotic intramucosal pH in the early postoperative period can more accurately predict the risk of anastomotic leakage and benefit those patients who would need additional measures to improve the viability of the anastomosis.

Systemic coagulation activation and anastomotic leakage after colorectal cancer surgery

PURPOSE

The aim of the present study was to study whether patients developing anastomotic leakage after colorectal resections for colorectal cancer have laboratory signs of an altered hemostatic balance in the systemic circulation, preoperatively and postoperatively, causing an impaired healing process.

METHODS

Patients operated on for colorectal cancer were studied. Seventeen consecutive patients with anastomotic leakage and 17 patients without anastomotic leakage were matched according to age, gender, tumor stage, and localization of tumor. Hemostatic balance was estimated preoperatively and at one, two, and seven days and at three months after surgery by plasma levels of sensitive markers of coagulation activation and fibrinolysis, i.e., prothrombin fragment 1 + 2, thrombin-antithrombin complexes, soluble fibrin, tissue-type plasminogen activator activity, and plasminogen activator inhibitor Type 1.

RESULTS

Preoperatively, the hemostatic balance was comparable in patients with and without anastomotic leakage. In the early postoperative period, patients developing anastomotic leakage exhibited signs of systemic coagulation activation, i.e., elevated plasma levels of prothrombin fragment 1 + 2, thrombin-antithrombin complexes, soluble fibrin, and plasminogen activator inhibitor Type 1. The observed coagulation activation appeared before the anastomotic leakage became clinically evident. More patients with anastomotic leakage received perioperative blood transfusions than patients without leakage, despite the fact that duration of surgery and intraoperative blood loss were comparable in the two groups.

CONCLUSIONS

Enhanced coagulation activity was observed postoperatively in patients developing anastomotic leakage after colorectal resections for colorectal cancer. Such a hypercoagulable state may contribute to the development of anastomotic leakage by facilitating formation of microthromboses in the perianastomotic area.