Regenerated oxidized cellulose reinforcement of low rectal anastomosis: do we still need diversion?

High Probability of an Underlying Colorectal Cancer Among Patients Treated for Acute Diverticulitis. A Population-Based Cohort Follow-Up Study

INTRODUCTION

Patients treated conservatively for acute diverticulitis (AD) are recommended colonic assessment to rule out an underlying Colorectal cancer (CRC). This has been questioned in patients with a CT diagnosis of uncomplicated AD. We analyzed the frequency of CRC and compared the characteristics of the CRC patients with controls.

METHOD

A cohort of patients treated conservatively for AD during 2005-2011 was identified through an administrative database. Patients diagnosed with CRC within 1 year after the index admission and four randomly selected controls were identified. The patients' files were reviewed to verify the diagnosis and obtain information about the clinical characteristics and the management. A blinded review was performed of CT examinations. The expected number of CRC was calculated from age, sex, and period-specific incidence data. The characteristics of the CRC patients were compared with the controls in a nested case-control study.

RESULTS

890 patients (298 men and 592 women) were treated conservatively for AD. 12 patients were diagnosed with CRC within 1 year, and ten of them in the sigmoid, giving a Standardized Incidence Ratio of 20.0 (95 % CI 10.2-35.7, p<0.001) for sigmoidal cancer. All CRC patients were aged over 70 years. The cancer was missed in six CT scans at the primary reading and in five at the blinded review.

CONCLUSION

Patients conservatively treated for AD are at high risk for an underlying CRC, especially if older than 70 years, which motivates routine follow-up. A CT diagnosis of uncomplicated AD does not rule out CRC.

Enhanced intestinal anastomotic healing with gelatin hydrogel incorporating basic fibroblast growth factor

Anastomotic leakage is a common complication of intestinal surgery. In an attempt to resolve this issue, a promising approach is enhancement of anastomotic wound healing. A method for controlled release of basic fibroblast growth factor (bFGF) using a gelatin hydrogel was developed with the objective of investigating the effects of this technology on intestinal anastomotic healing. The small intestine of Wistar rats was cut, end-to-end anastomosis was performed and rats were divided into three groups: bFGF group (anastomosis wrapped with a hydrogel sheet incorporating bFGF), PBS group (wrapped with a sheet incorporating phosphate-buffered saline solution) and NT group (no additional treatment). Degradation profiles of gelatin hydrogels in vivo and histological examinations were performed using gelatin hydrogels with various water contents and bFGF concentrations to define the optimal bFGF dose and hydrogel biodegradability. The anastomotic wound healing process was evaluated by histological examinations, adhesion-related score and bursting pressure. The optimal water content of the hydrogel and bFGF dose was determined as 96% and 30 µg per sheet, respectively. Application of bFGF significantly enhanced neovascularization, fibroblast infiltration and collagen production around the anastomotic site when compared with the other groups. Bursting pressure was significantly increased in the bFGF group. No significant difference was observed in the adhesion-related score among the groups and no anastomotic obstruction and leakage were observed. Therefore controlled release of bFGF enhanced healing of an intestinal anastomosis during the early postoperative period and is a promising method to suppress anastomotic leakage. Copyright © 2013 John Wiley & Sons, Ltd.

Management and outcome of colorectal anastomotic leaks

PURPOSE

Anastomotic leak is a devastating complication of an intestinal anastomosis. Optimal management and outcome is not routinely described, and much of our knowledge relies upon historical data. We wished to examine the management and outcome of anastomotic leaks on a colorectal surgery unit in the twenty-first century.

METHOD

A retrospective audit of all patients who had a colorectal anastomotic leak between January 2002 and December 2008 in a large university teaching hospital. Data collected included patient characteristics, primary diagnosis, mode of diagnosis and time to diagnosis of anastomotic leak, inpatient management, morbidity and mortality, permanent stoma rate, use of hospital resources.

RESULTS

Thirty patients (16 male, 14 female), with a median age of 60 years (range 25-84 years), had an anastomotic leak. The median time to presentation of clinically suspected leaks was 12 days (range 3-56 days). Fourteen patients required reoperation, with ten needing the anastomosis take down. Average hospital stay was 40 days. The permanent stoma rate following a rectal anastomotic leak was 27% and 57.1% from a colonic leak. Overall mortality in this series was 27%. Mortality was higher after leak from a colonic anastomosis than after leak from a rectal anastomosis (43.8% vs. 7.1%, respectively).

CONCLUSIONS

Anastomotic leaks are not detected until late in the post-operative period and are associated with a high mortality. Demand on hospital resources is high. In this series, patients who leaked after a colonic anastomosis had a higher mortality and permanent stoma rate than after leaks from a rectal anastomosis.