Prospective study of hand-sutured anastomosis after colorectal resection

Surgical approaches to colonic and rectal anastomosis: systematic review and meta-analysis

PURPOSE

Postoperative complications after a colonic and rectal surgery are of significant concern to the surgical community. Although there are different techniques to perform anastomosis (i.e., handsewn, stapled, or compression), there is still no consensus on which technique provides the least number of postoperative problems. The objective of this study is to compare the different anastomotic techniques regarding the occurrence or duration of postoperative outcomes such as anastomotic dehiscence, mortality, reoperation, bleeding and stricture (as primary outcomes), and wound infection, intra-abdominal abscess, duration of surgery, and hospital stay (as secondary outcomes).

METHODS

Clinical trials published between January 1, 2010, and December 31, 2021, reporting anastomotic complications with any of the anastomotic technique were identified using the MEDLINE database. Only articles that clearly defined the anastomotic technique used, and report at least two of the outcomes defined were included.

RESULTS

This meta-analysis included 16 studies whose differences were related to the need of reoperation (p < 0.01) and the duration of surgery (p = 0.02), while for the anastomotic dehiscence, mortality, bleeding, stricture, wound infection, intra-abdominal abscess, and hospital stay, no significant differences were found. Compression anastomosis reported the lowest reoperation rate (3.64%) and the handsewn anastomosis the highest (9.49%). Despite this, more time to perform the surgery was required in compression anastomosis (183.47 min), with the handsewn being the fastest technique (139.92 min).

CONCLUSIONS

The evidence found was not sufficient to demonstrate which technique is most suitable to perform colonic and rectal anastomosis, since the postoperative complications were similar between the handsewn, stapled, or compression techniques.

Systematic Review and Meta-Analysis on Colorectal Anastomotic Techniques

Purpose

Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery.

Methods

A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK).

Results

All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques' current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions.

Conclusion

Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons' levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body's natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions.

Article Commentary: Evolving Colon Injury Management: A Review

The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges

Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.

Mid-term absorbable monofilament is safe and effective for gastrointestinal anastomosis - PROMEGAT - A single-arm prospective observational study

Introduction

Various suture materials and suture techniques are used to perform gastrointestinal anastomosis after tumour resection, but the best combination is still a matter of debate.

Methods

This multi-centre, international, single-arm, prospective observational study aimed at demonstrating the non-inferiority of a mid-term absorbable monofilament in comparison to braided sutures in gastrointestinal anastomosis. Monosyn suture was used to create the gastrointestinal anastomosis and the frequency of anastomotic leakage until day of discharge was chosen as the primary parameter. The outcome was compared to the results published for braided sutures in the literature. Secondary parameters were the time to perform the anastomosis, length of hospital stay, costs, and postoperative complications.

Results

The anastomosis leakage rate was 2.91%, indicating that Monosyn suture was not inferior to braided sutures used in gastrointestinal anastomosis. Of the reported anastomotic suture techniques, the single layer continuous method was the fastest and most economical technique in the present observational study.

Conclusion

Monosyn suture is safe and effective in gastrointestinal anastomosis and represents a good alternative to other sutures used for gastrointestinal anastomosis. With regard to safety, time and cost-efficiency, the single-layer continuous technique should be considered a preferred method. The transfer of results from clinical studies into daily practice with regard to surgical techniques for gastrointestinal anastomosis should be further evaluated in larger studies or in nationwide registries.

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Monosyn suture material is safe and efficient for anastomosis performed in the gastrointestinal tract in daily routine.

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Monofilament mid-term absorbable suture (Monosyn) represents a good alternative to other sutures used for gastrointestinal anastomosis.

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Regarding safety and cost-efficiency, the single layer continuous technique should be considered as a preferred method.

Mechanical bowel preparation versus no preparation before colorectal surgery: A randomized prospective trial in a tertiary care institute

Background:

In the first half of 20^th century; mortality from colorectal surgery often exceeded 20%, mainly due to sepsis. Modern surgical techniques and improved perioperative care have significantly lowered the mortality rate. Mechanical bowel preparation (MBP) is aimed at cleansing the large bowel of fecal content thus reducing morbidity and mortality related to colorectal surgery. We carried out a study aimed to investigate the outcomes of colorectal surgery with and without MBPs, to avoid unpleasant side-effects of MBP and also to design a protocol for preparation of a patient for colorectal surgery.

Materials and Methods:

This was a prospective study over a period of March 2008-May 2010 carried out at Department of General Surgery of our institution. A total of 63 patients were included in this study; among those 32 patients were operated with MBPs and 31 without it; admitted in in-patient department undergoing resection of left colon and rectum for benign and malignant conditions in both emergency and elective conditions.

Results:

Anastomotic leakage, intra-abdominal collections was detected clinically and radiologically in 2 and 4 patients in each group respectively. P > 0.5 in both situations, indicating statistically no difference between results of two groups. Wound infections were detected in 12 (37.5%) patients with MBP group and 11 (35.48%) patients without MBP.

Conclusion:

The present results suggest that the omission of MBP does not impair healing of colonic anastomosis; neither increases the risk of leakage.

The use of collagen content as determined by spectral domain polarization-sensitive optical coherence tomography to assess colon anastomosis healing in a rat model

BACKGROUND/PURPOSE

Many studies have been undertaken to prevent anastomosis leakage of the colon, and several methods have been used to assess anastomosis healing, such as measurement of bursting pressure or hydroxyproline (a marker of collagen) content at the anastomosis site. However, these methods are inappropriate for comparing anastomosis healing at two time points in the same animals. In the present study, we measured the collagen level by spectral domain polarization-sensitive optical coherence tomography (SD-PS-OCT) to assess anastomosis healing.

METHODS

Sprague-Dawley rats were divided into groups C (saline-administered controls; study group) and M [a 5-fluorouracil (5-FU)-administered experimental group]. Immediately after end-to-end anastomosis of the colon, SD-PS-OCT images of anastomoses were taken (baseline). Animals were administered saline or 5-FU for 7 days. On the 7th postoperative day, SD-PS-OCT images were acquired, a histopathologic exam was performed, and hydroxyproline levels as well as mRNA expressions of collagen-1 and collagen-3 were measured at the anastomosis site.

RESULTS

Fibroblast proliferation and inflammatory cell infiltration were greater in group C than in group M. The mRNA expressions of collagen-1 and collagen-3 were substantially higher in group C. Hydroxyproline levels were higher in group M than in group C. Though collagen levels measured by SD-PS-OCT at 7 days were elevated compared with baseline in group C, no such changes were observed for group M.

CONCLUSION

Collagen levels at the colon anastomosis site, measured with SD-PS-OCT, were not increased at 7 days postoperatively versus baseline when 5-FU was injected, but were increased in saline-treated controls. The measurement of collagen content by SD-PS-OCT was found to provide a good means of assessing anastomosis healing, because it allows in situ assessment of collagen contents at baseline and during the postoperative period.

American Society of Anesthesiologists class and Charlson's comorbidity index as predictors of postoperative colorectal anastomotic leak: a single-institution experience

BACKGROUND

The American Society of Anesthesiologists (ASA) physical status classification and Charlson comorbidity index (CCI) was adopted to assess patients' physical condition before surgery. Studies suggest that ASA score and CCI might be a prognostic criterion (indicator) for patient outcome. The aim of this study is to determine if ASA classification and CCI can determine the risk of anastomotic leaks (AL) in patients who underwent colorectal surgery.

METHODS

A retrospective analysis of 505 consecutive colorectal resections with primary anastomoses between 2008 and 2012 was performed at a university hospital. ASA score, CCI, surgical procedure, length of stay, age, body mass index (BMI), comorbidities, and postoperative outcomes were analyzed.

RESULTS

Two hundred sixty-five patients had an ASA score of I and II, 227 patients had an ASA score of III, and 13 patients had an ASA score of IV. A total of 19 patients had an anastomotic leak (ASA I-II: 5 patients, 1.9%; ASA III: 12 patients, 5.58%; ASA IV: 2 patients, 18.18%). A higher ASA score was significantly associated with AL on further analysis (OR: 2.99, 95% CI: 1.345-6.670, P = 0.007). When matched for age, BMI, and CCI on logistic regression analysis, increased ASA level was independently related to an increased likelihood of leak (OR(steroids) = 14.35, P < 0.01; OR(ASA_III v I-II) = 2.02, P = 0.18; OR(ASA_IVvI-II) = 8.45, P = 0.03). There were no statistically significant differences in means between the leak and no-leak patients with respect to age (60.69 versus 65.43, P = 0.17), BMI (28.03 versus 28.96, P = 0.46), and CCI (6.19 versus 7.58, P = 0.09).

CONCLUSIONS

ASA score, but not CCI, is independently associated with anastomotic leak. Patients with a high ASA class should be closely followed postoperatively for AL after colorectal operations.

Effects of Intraperitoneal Bevacizumab Administration on Colonic Anastomosis and Early Postoperative Adhesion Formation

Aim. The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. Materials and Methods. A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. Results. The mean adhesion grade was 2.63 ± 0.92, and 1 ± 0.93 and 0.75 ± 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications ( P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue ( P = .001), whereas there was no significant difference in the blood and the IP fluid ( P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups ( P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. Conclusion. IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.

Local delivery of growth factors using coated suture material

The optimization of healing processes in a wide range of tissues represents a central point for surgical research. One approach is to stimulate healing processes with growth factors. These substances have a short half-life and therefore it seems useful to administer these substances locally rather than systemically. One possible method of local delivery is to incorporate growth factors into a bioabsorbable poly (D, L-lactide) suspension (PDLLA) and coat suture material. The aim of the present study was to establish a procedure for the local delivery of growth factors using coated suture material. Sutures coated with growth factors were tested in an animal model. Anastomoses of the colon were created in a rat model using monofilament sutures. These were either untreated or coated with PDLLA coating alone or coated with PDLLA incorporating insulin—like growth factor-I (IGF-I). The anastomoses were subjected to biomechanical, histological, and immunohistochemical examination. After 3 days the treated groups showed a significantly greater capacity to withstand biomechanical stress than the control groups. This finding was supported by the results of the histomorphometric. The results of the study indicate that it is possible to deliver bioactive growth factors locally using PDLLA coated suture material. Healing processes can thus be stimulated locally without subjecting the whole organism to potentially damaging high systemic doses.

Stapled versus handsewn methods for colorectal anastomosis surgery

BACKGROUND

Previous systematic reviews comparing stapled and handsewn colorectal anastomosis that are available in the medical literature have not shown either technique to be superior. An update of this systematic review was performed to find out if there are any data that properly answer this question.

OBJECTIVES

To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis surgery. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications.

SEARCH METHODS

A computerized search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE according to the strategies of the Colorectal Cancer Group of The Cochrane Collaboration. There were no limits upon language, date or other criteria. A revised search strategy was performed for this updated version of the review May 2011.

SELECTION CRITERIA

All randomised controlled trials (RCTs) in which stapled and handsewn colorectal anastomosis techniques were compared. Participants were adult patients undergoing elective colorectal anastomosis surgery. The interventions were endoluminal circular stapler and handsewn colorectal anastomosis surgery. Outcomes considered were a) mortality; b) overall anastomotic dehiscence; c) clinical anastomotic dehiscence; d) radiological anastomotic dehiscence; e) stricture; f) anastomotic haemorrhage; g) reoperation; h) wound infection; i) anastomosis duration; and j) hospital stay.

DATA COLLECTION AND ANALYSIS

Data were independently analysed by the two review authors (CBN, SASL) and cross-checked. The methodological quality of each trial was assessed by the same two authors. After searching the literature for this update, no study was added to those in the previous version of this review. Details of randomizations (generation and concealment), blinding, whether an intention-to-treat analysis was done or not, and the number of patients lost to follow-up were recorded. The analysis of the risk of bias was updated according to the software Review Manager 5.1. The results of each RCT were summarized on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by the characteristics of the participants, interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The risk difference (RD) method (random-effects model) and number needed to treat (NNT) for dichotomous outcome measures and weighted mean differences (WMD) for continuous outcomes measures, with the corresponding 95% confidence intervals (CI), were presented in this review. Statistical heterogeneity was evaluated using a funnel plot and the Chi(2) test.

MAIN RESULTS

Of the 1233 patients enrolled in nine identified trials, 622 were treated with staples and 611 with manual suture. The following main results were obtained. a) Mortality, result based on 901 patients: RD -0.6%, 95% CI -2.8% to +1.6%. b) Overall dehiscence, result based on 1233 patients: RD 0.2%, 95% CI -5.0% to +5.3%. c) Clinical anastomotic dehiscence, result based on 1233 patients: RD -1.4%, 95% CI -5.2 to +2.3%. d) Radiological anastomotic dehiscence, result based on 825 patients: RD 1.2%, 95% CI -4.8% to +7.3%. e) Stricture, result based on 1042 patients: RD 4.6%, 95% CI 1.2% to 8.1%; NNT 17, 95% CI 12 to 31. f) Anastomotic haemorrhage, result based on 662 patients: RD 2.7%, 95% CI -0.1% to +5.5%. g) Reoperation, result based on 544 patients: RD 3.9%, 95% CI 0.3% to 7.4%. h) Wound infection, result based on 567 patients: RD 1.0%, 95% CI -2.2% to +4.3%. i) Anastomosis duration, result based on one study (159 patients): WMD -7.6 minutes, 95% CI -12.9 to -2.2 minutes. j) Hospital stay, result based on one study (159 patients): WMD 2.0 days, 95% CI -3.27 to +7.2 days.

AUTHORS' CONCLUSIONS

The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis surgery, regardless of the level of anastomosis. There were no randomised clinical trials comparing these two types of anastomosis in elective conditions in the last decade. The relevance of this research question has possibly lost its strength where elective surgery is concerned. However, in risk situations, such as emergency surgery, trauma and inflammatory bowel disease, new clinical trials are needed.

Stapled versus handsewn methods for ileocolic anastomoses

BACKGROUND

Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007.

OBJECTIVES

To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications.

SEARCH STRATEGY

MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology.

SELECTION CRITERIA

Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults.

DATA COLLECTION AND ANALYSIS

Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed.

MAIN RESULTS

After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference.

AUTHORS' CONCLUSIONS

Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

[Intestinal anastomoses and techniques in the lower gastrointestinal tract]

Surgery of the lower gastrointestinal tract includes segmental resections for benign colorectal diseases and radical resections for treating colorectal cancer performed under elective and emergency conditions. The most important part of the surgical procedure is the reconstruction of the physiological intestinal continuity by anastomosis. At present laparoscopic surgery has widened the array of different suturing and stapling techniques. The effectiveness of manual and stapled anastomoses depends on the expertise of the surgeon. However, skillful preparation of the hand-sutured technique is essential.

Management and outcome of anastomotic leakage after colonic surgery

AIM

Anastomotic leakage remains a key factor for morbidity after colonic surgery. The aim of the study was to analyse the outcome of different therapeutical approaches.

METHOD

Of 1731 consecutive patients undergoing colonic resection between 1998 and 2005 at our institution, 67 patients with anastomotic leakage were identified from a prospective database. A logistic regression model was used to determine factors which influenced the therapeutic approach and outcome.

RESULTS

The overall anastomotic leakage rate was 3.5%. All patients were re-operated. The anastomosis was resected without restoration of continuity in 31 but preserved in 36 patients. An ileostomy was constructed in 27 of 36 patients with anastomotic leakage after repair or revision of the anastomosis, the remaining nine cases were treated without ileostomy. Five of these latter nine vs three of the 27 patients with ileostomy experienced re-leakage (P = 0.05). The overall mortality was 25%. The Mannheim Peritonitis Index was 17.44 for survivors vs 25.64 for nonsurvivors (P < 0.001). Restoration of intestinal continuity was performed in 95% of the patients with ileostomy and in 88% after Hartmann's procedure. Multivariate analysis identified multi organ failure as the only factor predictive of a fatal outcome (P < 0.001). An ASA-score of more than 2 (P = 0.02) and peritonitis (P = 0.002) were reasons for not preserving the anastomosis.

CONCLUSION

Repair or redo of the anastomosis without a protective ileostomy frequently results in failure of the procedure. After Hartmann's operation or split stoma creation a majority of patients undergo restoration of intestinal continuity.

Influence of anastomotic leakage on oncological outcome in patients with rectal cancer

INTRODUCTION

Anastomotic leakages are one of the most serious complications of postoperative recovery among patients that undergo rectal cancer resection. Some investigators have suggested that anastomotic leakages have an impact on the oncological outcome; however, this is currently controversial.

PROCEDURE

Considering the increase of sphincter-preserving procedures for rectal cancer, anastomotic leakage, and its impact on oncological outcomes has become an important issue.

OUTCOME

The rates of anastomotic leakage are reported to range between 0.6% and 17.4%, depending on the definitions used. Here, we review the available information on anastomotic leakage and its association with oncological outcome.

The integrity of colonic anastomoses following the intraperitoneal administration of oxaliplatin

INTRODUCTION

The purpose of this experimental study was to determine the effect of oxaliplatin on the integrity of colonic anastomoses which were under oxaliplatin administration.

MATERIALS AND METHODS

Thirty rats were randomized to two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control group were injected with 3 ml of 0.9% sodium chloride solution and in the oxaliplatin group with 2.4 mg/kg of oxaliplatin intraperitoneally immediately after surgery and for seven postoperative days. All rats were sacrificed on the tenth postoperative day, and the anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels.

RESULTS

The body weight changes were significantly greater in the oxaliplatin group (p = 0.005). Anastomotic dehiscence occurred only in the oxaliplatin group. The adhesion formation was significantly increased in the group of oxaliplatin compared to the control group (p = 0.001). The colonic bursting pressure was significantly lower in the oxaliplatin group compared to the control group (p < 0.001). The mean inflammatory cell infiltration was significantly lower in the oxaliplatin group (1.00 vs. 2.33, p < 0.001). The mean neoagiogenesis was significantly lower in the oxaliplatin group (0.80 vs. 2.20, p < 0.001). The mean collagen deposition was significantly lower in the oxaliplatin group and the mean fibroblast activity was significantly lower in the oxaliplatin group (1.27 vs. 2.53, p < 0.001). Hydroxyproline concentration was significantly lower in the oxaliplatin group (p < 0.001).

CONCLUSION

Intra- and postoperative intraperitoneal administration of oxaliplatin definitely impairs healing of colonic anastomoses in rats.

After-hours colorectal surgery: a risk factor for anastomotic leakage

PURPOSE

This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center.

METHODS

All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis.

RESULTS

In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m(2) (p = 0.006; OR 2.6 CI 1.3-5.2) and "after hours" construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1-4.5) to be independent risk factors.

CONCLUSION

BMI greater than 30 kg/m(2) and "after hours" construction of an anastomosis were independent risk factors for colorectal anastomotic leakage.

Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer

AIMS

Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival.

PATIENTS AND METHODS

Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans.

RESULTS

The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p<0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p<0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p=0.02).

CONCLUSION

Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.

Healing of colonic anastomoses after immediate postoperative intraperitoneal administration of oxaliplatin

AIM

The aim of this experimental study was to investigate the effect of intraperitoneal administration of oxaliplatin on the healing of colonic anastomoses when injected immediately after colon resection.

MATERIALS AND METHODS

Thirty male Wistar rats were used. During the operation, the rats were randomized to two groups of 15 rats each. Immediately after colonic anastomoses were performed, the rats were injected intraperitoneally with either 3 ml of 0.9% NaCl solution or oxaliplatin (2.4 mg/kg body weight) depending on their group. All rats were killed on the eighth postoperative day. The anastomoses were examined macroscopically. The anastomotic bursting pressures were recorded, the anastomoses graded histologically, and the hydroxyproline tissue contents determined.

RESULTS

Anastomotic leakage was noted in four rats (26.7%) of the oxaliplatin group, whereas no anastomotic dehiscence was detected among rats of the control group (p = 0.016). The adhesion formation at the anastomotic sites and the inflammatory cell infiltration were significantly higher in the oxaliplatin group than in the control group (p = 0.001). The bursting pressures (p = 0.001), the hydroxyproline tissue content (p = 0.001), the neoangiogenesis (p = 0.033), the fibroblast activity (p = 0.001), and the collagen deposition (p = 0.001) were significantly lower in the oxaliplatin group in comparison to the control group.

CONCLUSION

The immediate postoperative intraperitoneal administration of oxaliplatin seems to impair healing of colonic anastomoses in rats.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery

BACKGROUND

The risk factors and incidence of anastomotic leak following colorectal surgery are well reported in the literature. However, the management of the multiple clinical scenarios that may be encountered has not been standardized.

METHODS

The medical literature from 1973 to 2007 was reviewed using PubMed for papers relating to anastomotic leaks and abdominal abscess, with a specific emphasis on predisposing factors, prevention strategies, and treatment approaches. A six-round modified Delphi research method was utilized to find consensus among a group of expert colorectal surgeons and interventional radiologists regarding standardized management algorithms for anastomotic leaks.

RESULTS

Management scenarios were divided into those for intraperitoneal anastomoses, extraperitoneal (low pelvic) anastomoses, and anastomoses with proximal diverting stomas. Management options were then based on the clinical presentation and radiographic findings and organized into three interconnected algorithms.

CONCLUSIONS

This process was a useful first step toward establishing guidelines for the management of anastomotic leak.

Outcomes of colorectal anastomoses during pelvic exenteration for gynaecological malignancy

BACKGROUND

Although pelvic exenteration is frequently indicated during surgery for gynaecological malignancy, performing a colorectal anastomosis remains contentious because of concern about leakage. This study evaluated the safety of performing a low colorectal anastomosis during pelvic exenteration for gynaecological malignancy.

METHODS

Between April 2001 and December 2006, 145 consecutive patients underwent low colorectal anastomosis without (122) or with (23) a stoma after pelvic exenteration for advanced primary or recurrent gynaecological malignancy. Subjects were assessed in terms of five patient-, four disease- and two surgery-related variables. The proportion of patients with each risk factor for leakage was found, and the rate of symptomatic anastomotic leakage was determined.

RESULTS

The mean age of the patients was 53.5 (range 10-77) years and the most common diagnosis was ovarian cancer (77.9 per cent). The mean operating time was 453 (range 145-845) min and the mean blood loss was 1080 (range 110-10 500) ml; 95 patients (65.5 per cent) required a blood transfusion. Of the 145 patients, 81 (55.9 per cent) had patient-related, 94 (64.8 per cent) had disease-related and 67 (46.2 per cent) had surgery-related variables associated with a risk of leakage. Symptomatic anastomotic leakage developed in three patients (2.1 per cent).

CONCLUSION

Although patients with gynaecological malignancy carry considerable risks associated with anastomotic leakage, carefully executed low colorectal anastomosis during pelvic exenteration was found to be safe.

Factors affecting anastomotic complications following anterior resection in rectal cancer

OBJECTIVE

Anastomotic complications following sphincter saving rectal surgery remains a significant clinical problem in rectal cancer surgery. Preoperative combined modality therapy followed by anterior resection with total mesorectal excision (TME) has become the preferred treatment paradigm for locally advanced rectal cancer. However, its impact on anastomotic complications has not been adequately evaluated. This study aimed to assess the relationship between the response of the primary tumour to neo-adjuvant therapy with anastomotic complications and to evaluate the effect of other clinico-pathological factors previously implicated, in this patient cohort.

METHOD

A total of 119 consecutive patients with primary rectal cancer were assessed of which there were 87 anterior resections. A prospectively collected database was queried to determine the incidence of anastomotic complications, association with response to neo-adjuvant therapy and other clinico-pathological factors. Data were analysed with SPSS 14.0.

RESULTS

Anterior resection was performed in 87/111 (78.4%) patients of which 46/84 (56%) were low resections, with an abdominoperineal excision of rectum rate of 11/111 (9.9%). Anastomotic complications were seen as clinical leaks in 10/87 (11.5%) and late colo-visceral fistulae in 2/87 (2.2%) patients. Subclinical/ radiological 'leaks' were quantified as 4/87 (4.5%). A good pathological response to neo-adjuvant therapy was found to be strongly associated with anastomotic complications (P = 0.006). Presence of a perioperative cardiac event was the only other clinical factor associated with anastomotic complications (P = 0.004) in our study.

CONCLUSION

Rectal cancer treated with neo-adjuvant therapy and radical resection with TME for better local control may be associated with greater anastomotic complications particularly when a good pathological response is seen.

Hyperthermic intraperitoneal chemoperfusion (HIPEC) decrease wound strength of colonic anastomosis in a rat model

BACKGROUND AND AIMS

There is controversy about the effect of the influence of hyperthermia and chemotherapeutic agents on the healing of intestinal anastomosis. The effects of hyperthermic intraperitoneal chemoperfusion (HIPEC) of wound healing after colonic anastomosis were investigated in a rat model.

MATERIALS AND METHODS

Thirty-six Wag/Rija rats were randomized into three groups of 12 animals each: group I: control (only colonic anastomosis was performed) (n = 12); group II: HIPEC (mitomycin C in a concentration of 20 mg/m(2) (n = 12) colonic anastomosis was performed before HIPEC; group III: HIPEC (mitomycin C in a concentration of 20 mg/m(2) (n = 12) colonic anastomosis was performed after HIPEC. Bursting pressure and bursting sites were recorded 4 and 10 days after intervention. Collagen deposits, inflammation and foreign body reactions were evaluated.

RESULTS

Lower bursting pressure and lost of collagen were found in both HIPEC groups and compared with the control group. There was almost no difference between both HIPEC groups. They were noted overwhelmingly at the anastomosis in the HIPEC group. The degree of collagen accumulation was well-correlated with bursting pressure.

CONCLUSION

These results have shown that hyperthermic intraperitoneal chemoperfusion (HIPEC) impairs wound healing in colonic anastomosis in rats.

Effect of IGF-I on healing of colonic anastomoses in rats under 5-FU treatment

BACKGROUND

The aim of this experimental study was to investigate whether insulin-like growth factor I (IGF-I) can protect the colonic healing from the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU).

MATERIALS AND METHODS

Eighty male Wistar rats were randomized into four groups of 20 rats each. Immediately after anastomoses were performed, rats in the control group were injected with 1 mL/100 gr of intraperitoneal saline solution, which was repeated daily until killed. Rats in the 5-FU and IGF-I +5-FU groups received 5-FU in a dose of 20 mg/kg body weight intraperitoneally, from the day of operation until killed. Rats in the IGF-I and IGF-I +5-FU groups received IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on 2nd, 4th, and 6th postoperative day. Rats were sacrificed on the 7th postoperative day.

RESULTS

The dehiscence rate in the 5-FU group was 30% and it was significantly higher compared with the control and the IGF-I group (P = 0.020 for both comparisons). However, in the IGF-I +5-FU group, the dehiscence rate decreased to 10%. The administration of IGF-I resulted in a significant rise of bursting pressure in the IGF-I +5-FU group compared with the 5-FU group (P < 0.001). There was no statistical difference in bursting pressure between the IGF-I +5-FU and control groups (P = 1.000). The hydroxyproline levels were higher in the IGF-I and the IGF-I +5-FU groups as a result of the stimulating act of IGF-I.

CONCLUSION

IGF-I, when given intraperitoneally, seems to mediate some of the adverse effects of 5-FU on the colonic healing in rats.

Stapled versus handsewn methods for ileocolic anastomoses

BACKGROUND

Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. To our knowledge, this is the first systematic review specifically investigating ileocolic anastomosis.

OBJECTIVES

To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications.

SEARCH STRATEGY

MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005. Abstracts presented to the following society meetings between 1970 and 2002 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology.

SELECTION CRITERIA

Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults.

DATA COLLECTION AND ANALYSIS

Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 4.2 Analysis version 1.0.5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer and inflammatory bowel disease as indication for ileocolic anastomoses were performed.

MAIN RESULTS

After obtaining individual data from authors for studies that include other anastomoses, six trials (including one unpublished) with 955 ileocolic participants (357 stapled, 598 handsewn) were included. The three largest trials had adequate allocation concealment. Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=5/357, HS=36/598, OR 0.34 [0.14, 0.82] p=0.02). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significant fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). There were too few Crohn's disease patients to perform sub-group analysis. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference.

AUTHORS' CONCLUSIONS

Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

Effect of Ginkgo biloba Extract (EGb 761) on the Healing of Left Colonic Anastomoses in Rat

BACKGROUND

The aim of this study was to assess the effect of Ginkgo biloba extract (EGb 761) on healing of experimental colonic anastomoses in a rat model.

METHODS

Rats were divided into four groups: postoperative day (POD) 3 untreated control group, POD 3 EGb 761 group, POD 7 untreated control group, and POD 7 EGb 761 group. In the oral EGb 761 groups, the agent was given at 9.6 mg daily per orogastric route using a 4-F fine feeding catheter. We measured bursting pressures and hydroxyproline content and histologically examined the resected anastomoses on POD 3 and POD 7.

RESULTS

The bursting pressures increased more in the EGb 761 group than in the untreated control group on POD 3, but this difference was not statistically significant. Hydroxyproline content was higher in the EGb 761 group than in the untreated control group on POD 3, and this difference was statistically significant. Anastomosis bursting pressure values and hydroxyproline contents were significantly higher in the EGb 761 group than in the untreated control group on POD 7. Histological examination showed greater fibroblastic activity in the EGb 761 group than in the untreated control group on POD 3. There was no significant difference in anastomotic polimorphonuclear leukocyte, mononuclear cells and blood vessel neodevelopment between the POD 3 groups, but there was significant difference in fibroblastic activity and blood vessel neodevelopment between the POD 7 groups.

CONCLUSIONS

These results showed us that EGb 761 administration resulted in enhanced stability of colonic anastomoses during the first postoperative week.

Contribution of insulin-like growth factor I to the healing of colonic anastomoses in rats

The aim of this experimental study was to investigate the contribution of insulin-like growth factor I (IGF)-I in the colonic healing process when injected intraperitoneally after colon resection. Forty male Wistar rats were used. Rats in the control group were injected with 3 mL of a solution of 0.9% NaCl intraperitoneally after the operation and on postoperative day 2, 4, and 6. Rats in the IGF-I group received recombinant human IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on postoperative day 2, 4, and 6. All rats were killed on postoperative day 7. The hydroxyproline tissue content was significantly higher in the IGF-1 group than in the control group. The bursting pressures were also significantly higher in IGF-1 group than in the control group. The weight change between the groups differed significantly; in the control group the average weight decreased about 5% postoperatively, while in the IGF-1 group the average weight increased about 6%. The average inflammatory cell infiltration score was significantly higher in the control group. Neoagiogenesis did not differ significantly between the two groups. The fibroblast activity differed significantly between the two groups, as the control group had significantly less fibroblasts compared to the IGF-1 group. In conclusion, IGF-I when given intraperitoneally stimulates the healing of colonic anastomoses in the rats. Further studies are required in order to determine whether this effect is dose related.

Effects of Simultaneous Hepatic Resection on Healing of Left-Sided Colonic Anastomoses: An Experimental Study in Rats

BACKGROUND

A combined colorectal and hepatic resection is considered too risky by many surgeons owing to the high risk of postoperative septic complications. The aim of the present study was to investigate the effects of hepatic resection on the healing of left-sided colonic anastomoses in rats on postoperative day 7.

MATERIAL AND METHODS

Fifty-four Sprague-Dawley rats were block-randomized into three groups. In each group, 1 cm of the left side of the colon was resected and anastomosed. Additionally, 40 or 70% of the liver was resected in group 2 and 3, respectively. Rats were killed on postoperative day 7. The abdominal cavity was inspected for the presence of complications. The bursting pressure and hydroxyproline content of the anastomoses were measured.

RESULTS

The total number of complications was significantly higher in group 3 than in group 2. Anastomotic bursting pressure and hydroxyproline content did not differ significantly among the groups.

CONCLUSIONS

Increasing the extent of simultaneous hepatic resection did not significantly affect the healing of left-sided colonic anastomoses in rats on postoperative day 7, although there was a tendency towards lower bursting pressure paralleling the extent of liver resection. Excessive hepatic resection with colectomy may increase postoperative complications.

Anastomotic disruption after large bowel resection

Anastomotic disruption is a feared and serious complication of colon surgery. Decades of research have identified factors favoring successful healing of anastomoses as well as risk factors for anastomotic disruption. However, some factors, such as the role of mechanical bowel preparation, remain controversial. Despite proper caution and excellent surgical technique, some anastomotic leaks are inevitable. The rapid identification of anastomotic leaks and the timely treatment in these cases are paramount.

Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery

PURPOSE

Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted.

METHODS

During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak.

RESULTS

In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11).

CONCLUSION

In the present study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.

Positive effects of phenytoin on experimental colonic anastomoses

BACKGROUND AND AIMS

Anastomotic dehiscence following colorectal surgery is a significant cause of morbidity and mortality. Phenytoin has wound-healing promoting and collagenase inhibitory effects. This study assessed these effects on healing of experimental colonic anastomoses in a rat model.

MATERIALS AND METHODS

Ninety Wistar rats weighing 240-290 g were divided into six groups: 3rd-day control group (n=15), 3rd-day oral administration of phenytoin (n=15), 3rd-day rectal administration of phenytoin (n=15), 7th-day control group (n=15), 7th-day oral administration of phenytoin (n=15), and 7th-day rectal administration of phenytoin (n=15). In oral phenytoin groups the agent was given at 10 mg/kg daily per orogastric route by 4-F fine feeding catheter; in rectal phenytoin RAP groups the agent was administered at 10 mg/0.5 cc daily to the anastomoses transrectally via a fine anal catheter.

RESULTS

There were significantly higher anastomosis bursting pressure values and hydroxyproline contents in phenytoin groups than in controls. In histopathological examination it was seen that phenytoin treatment caused greater collagen deposition, fibroblast, and blood vessel ingrowth than in controls. Immunohistochemical analysis showed the stimulatory effect of phenytoin in expression of vascular endothelial growth factor and basic fibroblast growth factor. Anastomosis bursting pressure, histopathological analysis, hydroxyproline content, and immunohistochemical results were better in the groups with rectal administration than in those with oral administration.

CONCLUSION

These results had showed us that phenytoin administration resulted in enhanced stability of colonic anastomoses during the first postoperative week and rectal administration showed better results than oral administration.

Effects of trapidil on the healing of colonic anastomoses in an experimental rat model

BACKGROUND

Trapidil has various properties including vasodilatation, inhibition of lipid peroxidation and platelet aggregation as well as, and reduction of, the inflammatory response to injury. The aim of the present study was to investigate the effects of trapidil on dexamethasone-impaired colonic anastomotic healing in an experimental rat model.

METHODS

Twenty-four Wistar rats underwent colonic transsection and primary anastomosis. Rats were divided into four groups of six: group 1 (G1), control; group 2 (G2) trapidil, 8 mg/kg per day intravenously; group 3 (G3) dexamethasone, 0.1 mg/kg per day intramuscularly; and group 4 (G4) dexamethasone 0.1 mg/kg intramuscularly and trapidil 8 mg/kg intravenously per day, for 1 week. Anastomotic bursting pressure, hydroxyproline level, histopathological grading, malondialdehyde and nitrite/nitrate levels were determined.

RESULTS

Dexamethasone-impaired anastomotic healing was found to be improved by trapidil administration in terms of anastomotic bursting pressure and hydroxyproline content (P = 0.026, and P = 0.017). In addition, histopathological examination revealed an increase in fibroblast proliferation and collagen deposition (P = 0.004, and P = 0.015) and a decrease in leucocyte infiltration (P = 0.004). Moreover, serum nitrite/nitrate and malondialdehyde levels decreased when G3 was compared to G4 (P < 0.001, P = 0.38).

CONCLUSIONS

Trapidil may improve the dexamethasone-impaired anastomotic healing due to its preventive effects on inflammatory response and lipid peroxidation in rats.

Colo-rectal anastomotic leakage often masquerades as a cardiac complication

OBJECTIVE

The aim of this study was to identify the mode of presentation of patients with clinical anastomotic leaks following restorative colorectal resection for carcinoma.

PATIENTS AND METHODS

Prospective information was collected on all patients having restorative resection of colorectal cancer. These data were reviewed for a five-year period (1994-1998) to identify all patients who had suffered a clinical anastomotic leak and their notes were retrieved and reviewed.

RESULTS

Three hundred and seventy-nine patients underwent restorative resection for colorectal cancer during the study period (178 female, 201 male), mean age 70 years (range 36-94). There were 22 (6%) clinical anastomotic leaks. Seven (32%) patients presented with obvious abdominal peritonitis. The remaining 15 (68%) were initially misdiagnosed. Thirteen (59%) patients were treated for cardiac symptoms, 1 (5%) patient for obstruction and 1 (5%) for ascites. The delay in diagnosis ranged from 0 to 11 days (mean 4 days). For the whole series of 379 there were 30 patients who suffered cardiac symptoms (8%) 13(43%) of whom had an anastomotic leak.

CONCLUSION

Patients who develop cardiac symptoms following restorative colorectal resection for carcinoma should have a water soluble enema as there is a 40% chance that they will have an anastomotic leak.

Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence

BACKGROUND

The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence.

METHODS

The study included all patients who had a potentially curative anterior resection with anastomosis for adenocarcinoma of the rectum between 1971 and 1991 at Concord Hospital. The data were collected prospectively, with complete follow-up for at least 5 years. The Kaplan-Meier method was used to compare time to recurrence between strata of categorical variables. Proportional hazards regression was used in multivariate modelling.

RESULTS

There were 403 patients in the study. After adjustment for lymph node metastases, the distal resection margin of resection, non-total anatomical dissection of the rectum and the level of anastomosis, multivariate analysis identified a significant association between anastomotic leakage and local recurrence (hazard ratio 3.8, 95 per cent confidence interval 1.8 to 7.9).

CONCLUSION

Leakage following a colorectal anastomosis after potentially curative resection for adenocarcinoma of the rectum is an independent predictor of local recurrence.

Stapled versus handsewn methods for colorectal anastomosis surgery: a systematic review of randomized controlled trials

CONTEXT

The interest in the results from comparisons between handsewing and stapling in colorectal anastomoses has been reflected in the progressive increase in the number of clinical trials. These studies, however, do not permit conclusions to be drawn, given the lack of statistical power of the samples analyzed.

OBJECTIVE

To compare stapling and handsewing in colorectal anastomosis, testing the hypothesis that in colorectal anastomosis the technique of stapling is superior to that of handsewing.

DESIGN

A systematic review of randomized controlled trials. SURVEY STRATEGY: Systematic revision of the literature and meta-analysis were used, without restrictions on language, dates or other considerations. The sources of information used were Embase, Lilacs, Medline, Cochrane Controlled Clinical Trials Database, and letters to authors and industrial producers of staples and thread.

SELECTION CRITERIA

Studies were included in accordance with randomization criteria. The external validity of the studies was investigated via the characteristics of the participants, the interventions and the variables analyzed. An independent selection of clinical studies focusing on analysis of adult patients attended to on an elective basis was made by two reviewers.

DATA COLLECTION AND ANALYSIS

The methodological quality of the studies was assessed by the same reviewers. In addition to the randomization criteria, the masking, treatment intention, losses and exclusions were also analyzed. The meta-analysis was performed using risk difference and weighted average difference, with their respective 95% confidence intervals. The variables studied were mortality, clinical and radiological anastomotic dehiscence, anastomotic stricture, hemorrhage, reoperation, wound infection, time taken to perform the anastomosis and hospital stay.

RESULTS

Nine clinical trials were selected. After verifying that it was possible to perform one of the two techniques being compared, 1,233 patients were included, of whom 622 underwent stapling and 611 the handsewing technique. No statistical difference was found between the variables, except for stenosis, which was more frequent in stapling (p < 0.05), and the time taken to perform the anastomosis, which was greater in handsewing (p < 0.05).

CONCLUSION

The evidence found was insufficient to demonstrate superiority of the stapling method over handsewing, independent of the level of colorectal anastomosis.

Complications after colorectal surgery without mechanical bowel preparation

BACKGROUND

The current practice of mechanical bowel preparation (MBP) before colorectal surgery is questionable. Mechanical bowel preparation is unpleasant for the patient, often distressful, and potentially harmful. The results are often less than desired, increasing the risk of contamination. Cleansing the colon and rectum before surgery has never been shown in clinical trials to benefit patients. In animal experiments MBP has a detrimental effect on colonic healing.

STUDY DESIGN

To investigate the outcomes of colorectal surgery without MBP, we prospectively evaluated a consecutive series of patients who underwent resection and primary anastomosis of the colon and upper rectum, including emergency operations. One surgeon performed all operations. Endpoints were wound infection, anastomotic failure, and death. Late signs and symptoms that might be secondary to leakage of the anastomosis were considered as an anastomotic failure as well, during a followup of 1 year.

RESULTS

Two hundred fifty operations were performed, of which 199 (79.6%) were elective. Colectomies were left-sided in 65.6%. Anastomoses were ileocolic in 32%, colocolic in 20.8%, colorectal intraperitoneal in 34.4%, and extraperitoneal in 12.8%. No patient suffered from fecal impaction. Followup was complete in 97.2%. Eight patients (3.3%; 95% confidence interval [CI]: 1.4-6.4) developed superficial wound infections. In three patients there was leakage from an extraperitoneal colorectal anastomosis, in two of them after hospital discharge. The overall anastomotic failure rate was 1.2% (95% CI: 0.3-3.6). The in-hospital mortality rate was 0.8% (95% CI: 0.1-2.9) and was not related to abdominal or septic complications.

CONCLUSION

Mechanical bowel preparation is not a sine qua non for safe colorectal surgery.

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

BACKGROUND

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.

METHODS

A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.

RESULTS

Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.

CONCLUSION

There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.

Mycophenolate mofetil impairs healing of left-sided colon anastomoses

INTRODUCTION

Inadequate healing and consequent leakage from bowel anastomoses are a significant cause of postoperative morbidity and mortality. Immunosuppressive drugs are known to disturb healing processes and to impair the mechanical stability of bowel anastomosis. Mycophenolate mofetil (MMF) is an immunosuppressive agent that selectively inhibits the proliferation of T and B lymphocytes and has been shown to be effective in preventing allograft rejection after organ transplantation. Adverse effects are few; however, nothing is known in regard to possible adverse effects of MMF administration on the healing of bowel anastomosis. The aim of the present study was to evaluate the effect of systemic MMF administration on the healing of colon anastomoses in rats.

METHODS

Rats underwent laparotomy, division of the left colon, and sigmoidostomy. MMF (25 mg/kg) or vehicle was administered intraperitoneally in two groups (n=21 per group) 3 days before surgery and then once daily until euthanization (7 animals per group; 2, 4, and 6 days after surgery). Bursting pressure measurements, histologic evaluation, morphometric analysis, mucin and collagen staining, and BrdU immunohistochemistry of the anastomotic site were performed. Furthermore, matrix protein expression at the anastomotic site was determined by collagen I and fibronectin Western blots.

RESULTS

Administration of MMF significantly decreased anastomotic bursting pressure postoperatively. Accordingly, histology, mucin staining, and BrdU immunohistochemistry and measurements of the colonic crypt depth showed more extended inflammation, a significantly lower proliferation rate, and a significantly thinned mucosal layer in the MMF-treated groups when compared to control animals, whereas matrix synthesis at the anastomotic site was not different.

CONCLUSIONS

The administration of the immunosuppressive agent MMF significantly impairs healing and mechanical stability of colon anastomosis in rats during the early postoperative period. MMF act to disturb host reparative processes mainly by impairment of reparative colonic epithelium proliferation and less by a disturbance of matrix synthesis.

Stapled versus handsewn methods for colorectal anastomosis surgery

BACKGROUND

Randomized controlled trials comparing stapled with handsewn colorectal anastomosis have not shown either technique to be superior, perhaps because individual studies lacked statistical power. A systematic review, with pooled analysis of results, might provide a more definitive answer.

OBJECTIVES

To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications.

SEARCH STRATEGY

The RCT register of the Cochrane Review Group was searched for any trial or reference to a relevant trial (published, in-press, or in progress). All publications were sought through computerised searches of EMBASE, LILACS, MEDLINE, the Cochrane Controlled Clinical Trials Database, and through letters to industrial companies and authors. There were no limits upon language, date, or other criteria.

STUDIES

All randomized clinical trials (RCTs) in which stapled and handsewn colorectal anastomosis were compared.

PARTICIPANTS

Adult patients submitted electively to colorectal anastomosis.

INTERVENTIONS

Endoluminal circular stapler and handsewn colorectal anastomosis.

OUTCOMES

a) Mortality b) Overall Anastomotic Dehiscence c) Clinical Anastomotic Dehiscence d) Radiological Anastomotic Dehiscence e) Stricture f) Anastomotic Haemorrhage g) Reoperation h) Wound Infection i) Anastomosis Duration j) Hospital Stay.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by the two reviewers (SASL, DM) and cross-checked. The methodological quality of each trial was assessed by the same two reviewers. Details of the randomization (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up were recorded. The results of each RCT were summarised on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by characteristics of the participants, the interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The Risk Difference method (random effects model) and NNT for dichotomous outcomes measures and weighted mean difference for continuous outcomes measures, with the corresponding 95% confidence interval, were presented in this review. Statistical heterogeneity was evaluated by using funnel plot and chi-square testing.

MAIN RESULTS

Of the 1233 patients enrolled ( in 9 trials), 622 were treated with stapled, and 611 with manual, suture. The following main results were obtained: a) Mortality: result based on 901 patients; Risk Difference - 0.6% Confidence Interval -2.8% to +1.6%. b) Overall Dehiscence: result based on 1233 patients; Risk Difference 0.2%, 95% Confidence Interval -5.0% to +5.3%. c) Clinical Anastomotic Dehiscence : result based on 1233 patients; Risk Difference -1.4%, 95% Confidence Interval -5.2 to +2.3%. d) Radiological Anastomotic Dehiscence : result based on 825 patients; Risk Difference 1.2%, 95% Confidence Interval -4.8% to +7.3%. e) Stricture: result based on 1042 patients; Risk Difference 4.6%, 95% Confidence Interval 1.2% to 8.1%. Number needed to treat 17, 95% confidence interval 12 to 31. f) Anastomotic Hemorrhage: result based on 662 patients; Risk Difference 2.7%, 95% Confidence Interval - 0.1% to +5.5%. g) Reoperation: result based on 544 patients; Risk Difference 3.9%, 95% Confidence Interval 0.3% to 7.4%. h) Wound Infection: result based on 567 patients; Risk Difference 1.0%, 95% Confidence Interval -2.2% to +4.3%. i) Anastomosis duration: result based on one study (159 patients); Weighted Mean Difference -7.6 minutes, 95% Confidence Interval -12.9 to -2.2 minutes. j) Hospital Stay: result based on one study (159 patients), Weighted Mean Difference 2.0 days, 95% Confidence Interval -3.27 to +7.2 days.

REVIEWER'S CONCLUSIONS

The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis, regardless of the level of anastomosis.

Insulin-like growth factor I and truncated keratinocyte growth factor accelerate healing of left-sided colonic anastomoses

BACKGROUND

Human full-length keratinocyte growth factor (KGF) promotes healing of colon anastomoses in rats through mechanisms other than enhancement of collagen synthesis. Since insulin-like growth factor (IGF) I increases matrix synthesis, the aim of this study was to evaluate the effect of systemic truncated KGF (tKGF), IGF-I and combined tKGF-IGF-I administration on the healing of colonic anastomoses in rats.

METHODS

Rats underwent laparotomy, division of the left colon, and sigmoidosigmoidostomy. tKGF (1 mg/kg), IGF-I (1 mg/kg), tKGF-IGF-I (both 1 mg/kg) or vehicle was administered intraperitoneally in four groups (n = 18 per group) 12 h before surgical intervention, and then once daily until killing (six animals per group; 2, 4 and 6 days after surgery). Bursting pressure measurements, histological evaluation, morphometric analysis, mucin and collagen staining, and 5-bromo-2'-deoxyuridine (BrdU) immunohistochemistry of the anastomotic site were undertaken.

RESULTS

Administration of tKGF, IGF-I and the combination of both growth factors significantly increased anastomotic bursting pressure at postoperative day 2 (63, 71 and 113 per cent respectively), day 4 (68, 83 and 80 per cent) and day 6 (48, 43 and 43 per cent) compared with the control group. No intergroup differences were found. Histological examination, mucin and BrdU staining, and measurement of colonic crypt depth indicated less inflammation, increased acidic mucin content, a higher crypt cell proliferation rate and thickened mucosal layer in the growth factor-treated animals than in controls. Enhanced collagen staining was observed only in IGF-treated animals.

CONCLUSION

tKGF and IGF-I markedly accelerate the healing of colonic anastomoses in rats. However, combined administration of the two growth factors does not show additional benefit. Both growth factors may be acting to accelerate host reparative processes as well as to enhance protection of the anastomotic wound bed.

Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective, randomized study

PURPOSE

Efficient mechanical bowel preparation has been regarded as essential in preventing postoperative complications of colorectal surgery, but the necessity of bowel cleansing has been disputed recently. The aim of this study was to evaluate the outcome of elective colorectal surgery in patients with or without bowel preparation.

METHODS

Altogether, 267 consecutive adult patients admitted for elective open colorectal surgery were randomly assigned either to the bowel preparation group with oral polyethylene glycol electrolyte solution (138 patients) or no preparation group (129 patients). Patients who were unable to drink polyethylene glycol electrolyte solution, those who had had bowel preparation within the previous week, and patients not needing opening of the bowel were excluded. Routine colorectal surgery was undertaken, and infectious and other complications were registered daily. Late complications were checked up one to two months after surgery.

RESULTS

No deaths were recorded, and 76 percent of the patients in the polyethylene glycol electrolyte solution group and 81 percent in the unprepared group recovered without complication. Anastomotic leaks occurred in 4 percent of the polyethylene glycol electrolyte solution patients and in 2 percent of the other cases, and other surgical site infections occurred in 6 and 5 percent, respectively. None of the differences was statistically significant. There was no difference in restoration of bowel function. The median postoperative stay was eight days in both groups.

CONCLUSIONS

Preoperative bowel preparation seems to offer no benefit in elective open colorectal surgery.

Primary Resection and Anastomosis for Perforated Left Colon Lesions

The records of 33 patients with perforated left colon lesions over a 6-year period from 1992 to 1998 were examined retrospectively for clinical course and complications. All patients had a free perforation, feculent or purulent peritonitis, and/or a large inflammatory mass. All patients had primary resection and anastomosis without a protective colostomy or ileostomy. Indications included diverticulitis in 28 patients, obstructing colorectal carcinoma in 3, and iatrogenic perforations in 2. Complications occurred in 10 patients, including atelectasis in 1, urinary retention in 2, urinary tract infections in 2, wound infections in 3, line catheter sepsis in 1, and acute tubular necrosis in 1. There was one anastomotic dehiscence, which was successfully converted to a Hartmann procedure. Patients were discharged an average of 7 days after surgery. Two patients required surgery after discharge: one had a fascial dehiscence and the other an incisional ventral hernia. There was no mortality. Primary resection and anastomosis of selected perforated left colon lesions can be performed with a morbidity and mortality rate lower than that usually reported for the Hartmann procedure.

Keratinocyte growth factor promotes healing of left-sided colon anastomoses

BACKGROUND

Inadequate healing and consequent leakage from bowel anastomoses are a significant cause of postoperative morbidity and mortality. Systemic application of keratinocyte growth factor (KGF) has been shown to promote mucosal healing in models of colitis in rats and mice. The aim of the present study was to evaluate the effect of systemic KGF administration on healing of colonic anastomoses in rats.

METHODS

Rats underwent laparotomy, division of the left colon, and sigmoido-sigmoidostomy. KGF (5 mg/kg) or vehicle were administered intraperitoneally in two groups (n = 30 per group) 12 hours prior to surgery, and then once daily until sacrifice (6 animals per group; 2, 4, 7, 12, and 21 days after surgery). Bursting pressure measurements, histologic evaluation, morphometric analysis, mucin and collagen staining, and hydroxyproline measurements of the anastomotic site were performed.

RESULTS

Administration of KGF significantly increased anastomotic bursting pressure on postoperative days 2, 4, and 7 by 34%, 49%, and 19%, respectively. Histology, mucin staining, and measurements of the colonic crypt depth showed markedly less extended inflammation with an increased acidic mucin content and a significantly thickened mucosal layer in the KGF treated group when compared with vehicle-treated animals.

CONCLUSIONS

KGF promotes healing of colonic anastomoses in rats during a 1-week postoperative period following large bowel surgery. KGF may be acting to accelerate host reparative processes as well as to enhance protection of the anastomotic wound bed by increased colonic epithelium proliferation, increased mucus production, and reduction of the inflammatory activity at the anastomotic site.

Risk factors for anastomotic leakage after resection of rectal cancer

BACKGROUND

The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage, which is associated with a 6-22 per cent mortality rate. The aim of this retrospective study was to evaluate the risk factors for clinical anastomotic leakage after anterior resection for cancer of the rectum.

METHODS

From 1980 to 1995, 272 consecutive anterior resections for rectal cancer were performed by the same surgical team; 131 anastomoses were situated 5 cm or less from the anal verge. The associations between clinical anastomotic leakage and 19 patient-, tumour-, surgical-, and treatment-related variables were studied by univariate and multivariate analysis.

RESULTS

The rate of clinical anastomotic leakage was 12 per cent (32 of 272). Multivariate analysis of the overall population showed that only male sex and level of anastomosis were independent factors for development of anastomotic leakage. The risk of leakage was 6.5 times higher for anastomoses situated less than 5 cm from the anal verge than for those situated above 5 cm; it was 2.7 times higher for men than for women. In a second analysis of low anastomoses (5 cm or less from the anal verge; n = 131), obesity was statistically associated with leakage.

CONCLUSION

A protective stoma is suitable after sphincter-saving resection for rectal cancer for anastomoses situated at or less than 5 cm from the anal verge, particularly for men and obese patients.

Esophagojejunostomy with manual single layer suturing after a total gastrectomy for gastric cancer

BACKGROUND

We wished to verify the clinical usefulness of manually performed single layer suturing for an esophagojejunostomy after a total gastrectomy versus stapled suturing.

METHODS

We compared retrospectively 24 patients who underwent manual single layer suturing with 38 patients who underwent stapled suturing.

RESULTS

Anastomotic leakage was seen in one patient (4%) with single layer suturing and one patient (3%) with stapled suturing. No anastomotic stenosis was seen in the patients with single layer suturing. There was no difference in the operative time, blood loss, postoperative days for oral intake, or the length of hospital stay between the patients with single layer suturing and those with stapled suturing.

CONCLUSIONS

Manual single layer suturing is considered to be as safe as stapled suturing and is also thought to be clinically useful in reducing anastomotic failure for esophagojejunostomy.