Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis

BACKGROUND

Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective.

METHOD

This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed.

RESULTS

A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was - €74,915.28 per patient without anastomotic complications.

CONCLUSION

The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.

The impact of variations in care and complications within a colorectal enhanced recovery after surgery (ERAS) program on length of stay

Purpose

Enhanced Recovery After Surgery (ERAS) has become standard of care in colorectal surgery. However, there is not a universally accepted colorectal ERAS protocol and significant variations in care exist between institutions. The aim of this study was to examine the impact of variations in ERAS interventions and complications on length of stay (LOS).

Methods

This study was a single-center review of the first 200 consecutive patients recruited into our prospectively collected ERAS database. The primary outcome of this study was to examine the rate of compliance to ERAS interventions and the impact of these interventions on LOS. The secondary outcome was to assess the impact of complications (anastomotic leak, ileus, and surgical site infections) on LOS. ERAS interventions, rate of adherence, LOS, readmissions, morbidity, and mortality were recorded, and statistical analysis was performed.

Results

ERAS variations and complications significantly influenced patient LOS on both univariate and multivariate analysis. ERAS interventions identified as the most important strategies in reducing LOS included laparoscopic surgery, mobilization twice daily postoperative day (POD) 0 to 1, discontinuation of intravenous fluids on POD 0 to 1, upgrading to solid diet by POD 0 to 2, removal of indwelling catheter by POD 0 to 2, avoiding nasogastric tube reinsertion and removing drains early. Both major and minor complications increased LOS. Anastomotic leak and ileus were associated with the greatest increase in LOS.

Conclusion

Seven high-yield ERAS interventions reduced LOS. Major and minor complications increased LOS. Reducing variations in care and complications can improve outcomes following colorectal surgery.

End-to-end versus end-to-side anastomosis for low anterior resection: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Numerous randomized controlled trials comparing end-to-end and end-to-side anastomoses after low anterior resection have been performed. Rates of anastomotic leakage and overall postoperative morbidity, as well as reported quality of postoperative bowel function, vary across individual studies. As such, this study meta-analyzes pooled data comparing end-to-end and end-to-side anastomosis after low anterior resection in terms of anastomotic leak rate and postoperative bowel function.

METHODS

A search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials was performed. Articles were included if they were randomized controlled trials that compared end-to-end and end-to-side anastomosis after low anterior resection for benign or malignant disease. The primary outcome was anastomotic leak rate. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

From 1,452 citations, 6 randomized controlled trials with 270 patients undergoing end-to-end anastomosis (45.9% female, mean age: 63.5 years) and 268 patients undergoing end-to-side anastomosis (52.4% female, mean age: 64.0 years) met inclusion criteria. Patients undergoing end-to-side anastomosis had a significantly lower rate of anastomotic leak (RR 0.37, 95% CI 0.15-0.93, P = .04, I²=0%). There were no differences in rate of anastomotic stenosis (RR 1.03, 95% CI 0.21-5.19, P = .97) or overall postoperative morbidity (RR 0.60, 95% CI 0.33-1.07, P = .08). Narrative review of postoperative bowel function demonstrated evidence of improved Wexner scores for 6 months postoperatively in patients undergoing end-to-side anastomosis.

CONCLUSION

End-to-side anastomosis significantly reduces the risk of anastomotic leak after low anterior resection. Additional prospective trials are warranted to confirm the findings of this review and to contribute to the growing evidence-base aimed at optimization of bowel function after low anterior resection.

Reinforcement of Colonic Anastomosis with Improved Ultrafine Nanofibrous Patch: Experiment on Pig

Anastomotic leakage is a dreadful complication in colorectal surgery. It has a negative impact on postoperative mortality, long term life quality and oncological results. Nanofibrous polycaprolactone materials have shown pro-healing properties in various applications before. Our team developed several versions of these for healing support of colorectal anastomoses with promising results in previous years. In this study, we developed highly porous biocompatible polycaprolactone nanofibrous patches. We constructed a defective anastomosis on the large intestine of 16 pigs, covered the anastomoses with the patch in 8 animals (Experimental group) and left the rest uncovered (Control group). After 21 days of observation we evaluated postoperative changes, signs of leakage and other complications. The samples were assessed histologically according to standardized protocols. The material was easy to work with. All animals survived with no major complication. There were no differences in intestinal wall integrity between the groups and there were no signs of anastomotic leakage in any animal. The levels of collagen were significantly higher in the Experimental group, which we consider to be an indirect sign of higher mechanical strength. The material shall be further perfected in the future and possibly combined with active molecules to specifically influence the healing process.

Review of Colonic Anastomotic Leakage and Prevention Methods

Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.

Safety of anastomotic techniques and consequences of anastomotic leakage in patients with colorectal cancer: a single surgeon experience

Introduction

Colorectal cancer is a common type of malignant disease of the digestive tract. Anastomotic leakage (AL) still represents a serious complication in gastrointestinal surgery, associated with high morbidity and mortality.

Methods

We conducted a retrospective case-control study and analyzed a single surgeon’s data about 359 patients treated for colorectal cancer. Patients were divided as follows: Study Group (patients with AL - 37 patients) and Control Group (patients without AL - 322 patients). Surgical and anastomotic technique-related information was processed.

Results

Surgical procedures for right sided colon tumors resulted in a significantly lower rate of anastomotic leakage (P=0.0231). For left sided colectomies end to end handsewn double layer anastomosis presented decreased odds (OR=0.176). For sigmoid segmental resection end to end anastomotic techniques developed low rate of fistula formation (handsewn - OR=0.593, stapled - OR=0.685). Performing Dixon type surgical interventions, anastomotic techniques seemed without influence on anastomotic leak appearance (handsewn and stapled), although distal anastomoses were identified as significant risk factors for fistula formation (P=0.0017). In order to perform subtotal colectomy, side to side sutures (handsewn and stapled) seemed safe choices for anastomotic procedure (P=0.0073). Patient with anastomotic leakage suffered a significantly longer hospital stay (P=0.0079), presented higher rate of surgical reintervention (P=0.0001), increased mortality (P=0.0001) and elevated hospitalization costs (P=0.0079).

Conclusion

Postoperative complications like anastomosis leakage significantly increase hospitalization period, necessity of surgical reintervention, mortality and financial costs. In order to avoid these unpleasant events, bowel anastomoses require standardization during surgery.

Impact of the novel powered circular stapler on risk of anastomotic leakage in colorectal anastomosis: a propensity score-matched study

BACKGROUND

Several risk factors for anastomotic leakage (AL) following colorectal surgery have been described. Improvement in devices for performing anastomosis is a modifiable factor that could reduce AL rates. The aim of this study was to assess the impact of technical improvements in the Echelon Circular™ powered stapler (ECPS) on the left-sided colorectal AL rate compared to current manual circular staplers (MCS).

METHODS

A cohort study was carried out on consecutive patients between January 2017 and February 2020 in whom left-sided stapled colorectal anastomosis above 5 cm from anal verge was performed. The primary end point was the risk of AL depending on the type of circular stapler used. The ECPS cases were matched to MCS cases by propensity score matching to obtain comparable groups of patients.

RESULTS

Two hundred seventy-nine patients met the inclusion criteria. A MCS anastomosis was performed in 218 patients and ECPS anastomosis in 61 (21.9%). Overall, AL was observed in 25 (9%) cases. Factors significantly associated with AL were American Society of Anesthesiologists score (p = 0.025) and type of circular stapler used (p = 0.021). After adjusting the cases with propensity score matching (119 cases MCS versus 60 ECPS), AL was observed in 14 (11.8%) patients in MCS group and in 1 (1.7%) patient in the ECPS group (p = 0.022). AL in the MCS group required reoperation in seven cases (5.8%), the remaining seven patients were treated conservatively. The patient in the ECSP group required an urgent Hartmann's procedure CONCLUSIONS: The ECPS device could have a positive impact by reducing AL rates in left-sided colorectal anastomosis. Multicenter controlled trials are needed for stronger evidence to change practice.