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Ben-David M, Carmeli I, Orgad R, Nathansohn-Levi B, Yered T, Shor E, Wasserberg N. Implantation of an Impedance Sensor for Early Detection of Gastrointestinal Anastomotic Leaks. J Surg Res 2022; 278:49-56. [PMID: 35594614 DOI: 10.1016/j.jss.2022.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Accurate early diagnosis of a gastrointestinal anastomotic leak remains a challenge. When an anastomotic leak develops, the electrical properties of the tissue undergoing inflammatory processes change, resulting from the extravasation of inflammatory fluid and cellular infiltration. The method described here intends to provide a novel early anastomotic leak warning system based upon measurable changes in tissue impedance nearby an acute inflammatory process. METHODS A biodegradable Mg-alloy was compared with a nonabsorbable stainless steel (STS) electrode connected to a wireless recording system for impedance measurement. In vitro measurements were made in physiological solutions and small animal (eight mice) and large animal (eight pigs) models with an anastomotic leak simulated by an open colotomy. Measurements were made at 10 mm intervals from the open colon at baseline and up to 120 min comparing these with a sutured colonic wound and normal tissue. RESULTS In-vitro biodegradable magnesium electrode impedance evaluation showed good sensitivity to different media due to its environmental corrosion properties. The impedance of an acidic environment (1.06 ± 0.02 kΩ for citric acid) was twice that of phosphate-buffered saline (PBS) (0.64 ± 0.008 kΩ) with a distinction between Normal Saline (0.42 ± 0.013 kΩ) and PBS (0.64 ± 0.008 kΩ). This was in contrast to the performance characteristics of the control STS electrodes, where impedance in an acidic environment was lower than saline or PBS (citric acid:0.76 ± 0.01 kΩ versus PBS: 1.32 ± 0.014 kΩ). In a mouse model simulating an anastomotic leak, there was a significant increase in impedance after 120 min when compared with controls (99.7% increase versus 9.6% increase, respectively; P < 0.02). This effect was confirmed in a pig model when relative impedance measurements of the leak and control groups were compared (1.86 ± 0.46 versus 1.07 ± 0.02, respectively; P < 0.027). CONCLUSIONS Electrophysiological measurement shows diagnostic sensitivity for a gastrointestinal leak with potential clinical utility in the postoperative detection of early intra-abdominal sepsis. Further investigation of biodegradable tissue sensors capable of monitoring an early anastomotic leak is required.
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Affiliation(s)
- Matan Ben-David
- Upper GI Surgery, Royal Prince Alfred Hospital, University of Sydney, Australia.
| | - Idan Carmeli
- General Surgery, Assuta Ashdod Public Hospital, Ashdod, Israel
| | - Ran Orgad
- Department of Surgery, Rabin Medical Center, Petach Tiqva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tal Yered
- Exero Medical LTD, Or Yehuda, Israel
| | - Erez Shor
- Exero Medical LTD, Or Yehuda, Israel
| | - Nir Wasserberg
- Department of Surgery, Rabin Medical Center, Petach Tiqva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Paradis T, Zorigtbaatar A, Trepanier M, Fiore JF, Fried GM, Feldman LS, Lee L. Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery. J Gastrointest Surg 2020; 24:1392-1401. [PMID: 32314233 DOI: 10.1007/s11605-020-04599-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery. METHODS A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy. RESULTS A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5. CONCLUSIONS The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.
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Affiliation(s)
- Tiffany Paradis
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Anudari Zorigtbaatar
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Maude Trepanier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Gerald M Fried
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
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Assessment of MMP-2/-9 expression by fluorescence endoscopy for evaluation of anastomotic healing in a murine model of anastomotic leakage. PLoS One 2018; 13:e0194249. [PMID: 29566031 PMCID: PMC5863981 DOI: 10.1371/journal.pone.0194249] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/27/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Disturbance of intestinal wound closure leads to insufficient anastomotic healing and is associated with considerable morbidity following colorectal resections. Matrix metalloproteinases (MMPs) play a crucial role in regulation of wound closure. Here fluorescence endoscopy was evaluated for assessment of MMP-2/-9 expression during failed intestinal anastomotic healing. METHODS Distal colonic anastomoses were performed as a model for disturbed healing in 36 Balb/c mice. Healing was evaluated endoscopically, macroscopically, and histologically after 1, 3 and 5 days. For detection of MMP-2/-9 expression fluorescence endoscopy (FE) was used following i.v.-administration of a Cy5.5-labeled MMP-2/-9 specific tracer. FE was complemented by quantification of the fluorescence signal using the MS-FX PRO Optical Imaging System. An overall leakage score was calculated and correlated with the results of FE. RESULTS With increasing incidence of anastomotic leakage from POD1 (17%) to POD5 (83%) the uptake of the MMP tracer gradually increased (signal-to-noise ratio (SNR), POD1: 17.91 ± 1.251 vs. POD3: 30.56 ± 3.03 vs. POD5: 44.8 ± 4.473, P<0.0001). Mice with defective anastomotic healing showed significantly higher uptake compared to non-defective (SNR: 37.37± 3.63 vs. 26.16± 3.635, P = 0.0369). White light endoscopy and FE allowed evaluation of anastomotic healing and visualization of mucosal MMPs in vivo. Using FE based detection of MMPs in the anastomosis, an overall positive predictive value of 71.4% and negative predictive value of 66.6% was calculated for detection of anastomotic leakage. CONCLUSION During disturbed anastomotic healing increased expression of MMP-2/-9 was observed in the anastomotic tissue. Fluorescence endoscopy for detection of MMP-2/-9 during the healing process might be a promising tool for early identification of anastomotic leakage.
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