Systemic coagulation activation and anastomotic leakage after colorectal cancer surgery

Risk factors for leak after omentopexy for duodenal ulcer perforations

AIMS

Duodenal ulcer perforations are frequently encountered but there is limited literature regarding risk factors for leak after omentopexy.

METHODOLOGY

The record of 100 patients of duodenal ulcer perforation undergoing omentopexy by open approach was prospectively maintained to identify any significant factors contributing towards leak.

RESULTS

Out of 100 patients undergoing omentopexy, 9 (9%) developed leak; when leak occurred, the mortality was very high (44.4%). Patients who developed leak (09) were compared against those who did not (91), and it was seen that seen that duration of symptoms before surgery (> 3 days), amount of intra-abdominal contamination (> 2 L), low body mass index (BMI < 19.35 kg/m²), serum creatinine (> 1.5 mg/dl), and deranged International Normalized Ratio (INR) were found to be significant on univariate analysis; however, multivariate analysis revealed only low BMI and high creatinine to be contributory towards leak.

CONCLUSION

Leak after omentopexy carries a high morbidity and mortality. Identification of risk factors may help in optimizing patients at risk and reduce the incidence of leak and its sequelae.

TRIAL REGISTRATION NUMBER

CTRI/2020/03/023798.

ECG changes after non-cardiac surgery: a prospective observational study in intermediate-high risk patients

BACKGROUND

Efforts to mitigate the risk for perioperative cardiac events focus on both patient's and operation's risk and often include a preprocedural electrocardiogram (ECG). The merits of postprocedural ECG for detection of occult cardiac events occurring during surgery are unknown. We aim to explore the incidence of pre, and new postprocedural ECG pathologies in an intermediate-high risk population undergoing non-cardiac surgery.

METHODS

This single-center, prospective, observational study, included patients older than 18 years with at least two cardiovascular risk factors who were scheduled for non-cardiac surgery. All patients had pre, and postprocedural ECG. The ECG was analyzed and coded according to the Minnesota criteria. A multivariable logistic regression analysis was performed for indices associated with new postoperative ECG pathologies.

RESULTS

A total of 217 patients were enrolled. Preoperative pathologic ECG changes were recorded in 62.2% of the patients. Postoperatively, new ECG pathologies were documented in 49.8% of patients, most commonly T-wave changes (36.4% of changes). Pathologic ECG changes at baseline (OR 3.15, 95% CI [1.61-6.17]; P<0.01), diabetes (OR 1.93, 95% CI [1.02-3.64]; P=0.04), history of ischemic heart disease (OR 2.14, 95% CI [1.03-4.47]; P=0.04), higher volumes of fluid replacement (OR 1.70, 95% CI [1.10-2.61]; P=0.01) and higher levels of preoperative hemoglobin (OR 1.24, 95% CI [1.04-1.47]; P=0.01) were all independently associated with postoperative ECG changes.

CONCLUSIONS

Pre-, but most importantly, postoperative ECG changes are common in intermediate-high risk surgical patients. Postoperative ECG may be valuable to disclose silent cardiovascular events that occurred during surgery.

Towards optimal intraoperative conditions in esophageal surgery: A review of literature for the prevention of esophageal anastomotic leakage

BACKGROUND

Esophageal anastomotic leakage (EAL) is a severe complication following gastric and esophageal surgery for cancer. Several non-modifiable, patient or surgery related risk factors for EAL have been identified, however, the contribution of modifiable intraoperative parameters remains undetermined. This review provides an overview of current literature on potentially modifiable intraoperative risk factors for EAL.

MATERIALS AND METHODS

The PubMed, EMBASE and Cochrane databases were searched by two researchers independently. Clinical studies published in English between 1970 and January 2017 that evaluated the effect of intraoperative parameters on the development of EAL were included. Levels of evidence as defined by the Centre of Evidence Based Medicine (CEBM) were assigned to the studies.

RESULTS

A total of 25 articles were included in the final analysis. These articles show evidence that anemia, increased amount of blood loss, low pH and high pCO2 values, prolonged duration of procedure and lack of surgical experience independently increase the risk of EAL. Supplemental oxygen therapy, epidural analgesia and selective digestive decontamination seem to have a beneficial effect. Potential risk factors include blood pressure, requirement of blood products, vasopressor use and glucocorticoid administration, however the results are ambiguous.

CONCLUSION

Apart from fixed surgical and patient related factors, several intraoperative factors that can be modified in clinical practice can influence the risk of developing EAL. More prospective, observational studies are necessary focusing on modifiable intraoperative parameters to assess more evidence and to elucidate optimal values of these factors.

Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery

BACKGROUND

Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL.

METHODS

A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016.

RESULTS

Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960.

CONCLUSION

Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.

Which Comorbid Conditions Predict Complications after Surgery for Colorectal Cancer?

BACKGROUND

Accurate presurgical assessment is important to anticipate postoperative complications, especially in the growing proportion of elderly cancer patients. We designed a study to define which comorbid conditions at the time of diagnosis predict complications after surgery for colorectal cancer.

PATIENTS

A random sample of 431 patients recorded in the population-based Eindhoven Cancer Registry who underwent resection for stage I-III colorectal cancer, newly diagnosed between 1995 and 1999 were entered into this study.

METHODS

The influence of specific comorbid conditions on the incidence and type of complications after surgery for colorectal cancer was analyzed.

RESULTS

Overall, patients with comorbidity did not develop more surgical complications. However, patients with a tumor located in the colon who suffered from concomitant chronic obstructive pulmonary disease (COPD) more often developed pneumonia (18% versus 2%; P = 0.0002) and hemorrhage (9% versus 1%; P = 0.02). Patients with colon cancer who suffered from deep vein thrombosis (DVT) at the time of cancer diagnosis more often had surgical complications (67% versus 30%; P = 0.04), especially more minor infections (44% versus 11%; P = 0.002) and major infections (56% versus 10%; P < 0.0001), pneumonia (22% versus 2%; P = 0.01), and thromboembolic complications (11% versus 3%; P = 0.02). Patients with a tumor located in the rectum who suffered from COPD more frequently had any surgical complication (73% versus 46%; P = 0.04), and the presence of DVT at the time of cancer diagnosis was predictive of thromboembolic complications (17% versus 4%; P = 0.045). The presence of DVT remained significant after adjustment for relevant patient and tumor characteristics (odds ratio 9.0, 95% confidence interval 1.1-27.9).

CONCLUSIONS

Among patients undergoing surgery for colorectal cancer, development of complications was especially predicted by presence of COPD and DVT. In patients with the latter comorbidity, regulation of the pre- and postsurgical hemostatic balance needs full attention.

Anastomotic leak in colorectal surgery: a single surgeon's experience

BACKGROUND

Anastomotic leakage following colorectal resection and anastomosis has been proposed as a colorectal surgical indicator. Leak rates after elective surgery vary and tend to be higher as anastomoses become lower. The present study audits leak rates and outcomes of patients undergoing colorectal surgery, under the care of a single surgeon, in two geographically different centres.

METHODS

Patients presenting to the University Colorectal Service in Wellington between 1975 and 1990 and patients presenting to the colorectal service at King Faisal Specialist Hospital (KFSH) between 1990 and 1999 were recorded in computerized databases. These databases were searched for patients who developed anastomotic leakage. The records of patients identified were examined in relation to diagnoses, presentation, primary operation, further surgery performed, and final outcome.

RESULTS

Two thousand and 11 patients were entered into the Wellington database and 1,348 were entered into the Riyadh database. Twenty-nine patients with a leaking anastomosis (3.6%) were identified. There were 19 male patients. The postoperative mortality rate in patients who did not leak was 1.7% but in patients who developed a leak after the same operation this rate was 24.1%. Most patients who sustained a leak had an original diagnosis of colorectal cancer. More non-leaking anastomoses were sutured. Sixteen patients with leaks (55.2%) received perioperative total parenteral nutrition (TPN) (9.2% in the no-leak group). Leaking anastomoses were associated with more postoperative respiratory problems (55.2% vs 24.0%) and wound infections (65.5% vs 14.8%). Of the 22 living patients, seven had no surgical intervention, 14 had stomata (two stomata were retained) and one patient with a localized leak was drained percutaneously. Five other patients in addition to having a stoma constructed were drained percutaneously. No patient developed an enteric fistula following leakage.

CONCLUSION

Anastomotic leakage may be minimized by ensuring that patients are as fit as possible prior to surgery, stomata are used liberally, particularly in emergency patients, and a good anastomotic technique is utilized at all times. Despite these precautions some patients will still develop a leak and if timely and appropriate action is taken the majority will survive and have their stomata closed.

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.