Image-guided percutaneous drainage vs. surgical repair of gastrointestinal anastomotic leaks: is there a difference in hospital course or hospitalization cost?

Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections?

PURPOSE

Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL.

METHODS

All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma).

RESULTS

A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions).

CONCLUSION

In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

Use of endoluminal vacuum therapy after anastomotic leak in a gynecologic oncology patient with rectosigmoid resection: A case report

•Anastomotic leak is an infrequent complication after colon resection and is associated with high morbidity and mortality.•Endoluminal vacuum therapy (EVAT) promotes wound closure by covering anastomotic leaks intraluminally and applying vacuum.•EVAT has been shown to be safe with mild adverse events.•EVAT should be considered in hemodynamically stable gynecologic oncology patients with a confined anastomotic leak.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Management of anastomotic leakage after rectal surgery: a review article

Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.

MANAGEMENT OF POSTOPERATIVE PERITONITIS IN LOW-RESOURCES SERVICES

Background. Postoperative peritonitis (PP) reminds one of the most difficult complications in abdominal surgery with mortality rate 22.3 – 90 %. Methods. In Ivano-Frankivsk Regional (tertiary level) Clinical Hospital (Ivano-Frankivsk, Ukraine) during 2010–2017 were operated 8762 patients with acute and chronic diseases of digestive system (appendicitis, pancreatitis, cholecystitis, bowel obstruction, complicated ulcer of upper gastrointestinal truck, mesenteric vessels thrombosis, abdominal adhesion diseases, hernia, Chron’s diseases, abdominal trauma), among them in 209 (2.4 %) patients developed PP. Local PP (abscess of abdominal cavity) had 142 (67.9 %), diffuse PP – 67 (42.1 %) patients. Results. Clear local symptoms of peritonitis were absent in 178 (85.1 %) of 209 patients. General complication, such as acute respiratory failure had 95 (45.5 %), cardiovascular insufficiency – 68 (32.5 %), hepato-renal dysfunction - 46 (22 %) patients with PP. 129 (61.7 %) patients were treated by minimally invasive approach: 24 patients had laparoscopic lavage with drain of abdominal cavity abscess and 105 - ultrasound guided drain of abscess with catheter. 80 (38.3 %) patients had re-laparotomy (RL): 61 (91 %) from 67 with diffuse PP, 19 (13.4 %) from 142 patients – with local PP. 46 (57.5 %) patients underwent one RL, 26 (32.5 %) – two, 8 (10 %) patients – three RL. With increasing numbers of RL, increase mortality rate: after first RL died 7 (15.2 %) of 46 patients, after second RL – 12 (63.2 %) of 19, after third RL 6 (75 %) of 8 patients. Conclusions. Together with standard surgical methods and precise technique were used lavage of abdominal cavity with 8 – 12 litres of antiseptic solutions, solution for peritoneal dialysis intraabdominally, nasointestinal drain tube, what was favourable for faster treatment of abdominal sepsis, reducing number of RL and postoperative mortality.

Image-guided Percutaneous Drainage for Treatment of Post-Surgical Anastomotic Leak in Patients with Crohn's Disease

BACKGROUND AND AIMS

Anastomotic leaks with abscess formation are a common complication after bowel surgery in Crohn's disease patients. Image-guided percutaneous drainage is an attractive alternative to reoperation because of decreased morbidity and length of hospital stay. Because data for this specific population are scarce, the purpose of this study is to determine the safety and efficacy of image-guided percutaneous drainage in the management of post-surgical anastomotic leak in patients with Crohn's disease.

METHODS

A total of 41 patients who underwent percutaneous drain placement for the treatment of fluid collections due to anastomotic leak from September 2004 to November 2013 were retrospectively identified from the electronic medical record and picture archiving and communication system. Data recorded included number, size, and location of anastomotic leaks, number of drains placed, number of follow-up visits, post-drainage complications, abscess resolution, and subsequent surgeries.

RESULTS

In all, 41 patients with 76 fluid collections were identified as having received percutaneous drains. The mean number of targeted fluid collections per patient was 1.5, and the mean duration between surgery and percutaneous drain placement was 18.5 days. The mean number of drains placed was 1.6, and the median drain size was 10 French [range 8-16 French]. One of 41 [2.4%] patients experienced a minor complication from drain placement [injury to a superficial abdominal artery] and no major complications occurred. Two of 41 [4.9%] patients required repeat surgeries.

CONCLUSIONS

Image-guided percutaneous drainage for the treatment of post-surgical anastomotic leaks in Crohn's patients is effective and safe, with low rates of complications and reoperations.