Risk factors for clinical anastomotic leakage after right hemicolectomy

Comparative analysis of functional end-to-end and end-to-side anastomosis in laparoscopic right hemicolectomy for colon cancer

BACKGROUND

Despite advancements in laparoscopic right hemicolectomy for right-sided colon cancer, the choice between functional end-to-end anastomosis and end-to-side anastomosis remains a topic of debate. This study aimed to compare these 2 techniques in terms of postoperative complications and disease-free survival.

METHODS

This retrospective analysis included 1,202 patients who underwent laparoscopic right hemicolectomy for nonmetastatic colon cancer at Samsung Medical Center between January 2007 and February 2016. The patients were divided into functional end-to-end anastomosis (n = 968) and end-to-side anastomosis (n = 234) groups based on the anastomosis technique used. Patients' characteristics, oncologic results, operative outcomes, and postoperative complications were analyzed.

RESULTS

The baseline characteristics were similar between the 2 groups, except for a higher incidence of cancer obstruction in the end-to-side anastomosis group (P < .001). After matching, no significant differences were observed in operation time, blood loss, length of hospital stay, time to the first meal, or time to first flatus. Anastomotic leakage rates were comparable (functional end-to-end anastomosis 0.6% vs end-to-side anastomosis 0.4%, P > .999). The functional end-to-end anastomosis group had a higher rate of postoperative ileus (4.9% vs 1.3%, P = .017). Multivariable analysis indicated age, sex, and anastomosis type as significant predictors of postoperative ileus.

CONCLUSION

The study findings demonstrate that both functional end-to-end and end-to-side anastomosis techniques in laparoscopic right hemicolectomy are comparable in terms of operation metrics and disease-free survival. However, functional end-to-end anastomosis is associated with a higher incidence of postoperative ileus. These findings can guide surgical decision-making in the treatment of right-sided colon cancer.

Cost and outcomes of side-to-side versus end-to-end anastomosis in right colectomy: a retrospective cohort study

BACKGROUND

The optimal anastomotic configuration for right-sided colectomies remains controversial, with comparable postoperative outcomes across techniques. Thus, economic considerations may play a larger role in decision-making within cost-constrained healthcare settings.

METHODS

This retrospective cohort study evaluated right-sided colectomies with ileocolic anastomosis at a Swiss tertiary center between 2016 and 2021. We compared costs and outcomes among three anastomotic techniques: end-to-end (EE), side-to-side stapled (SSS), and side-to-side hand-sewn (SSH).

RESULTS

Out of 468 patients (mean age 67.7 ± 16.2 years; 51.7% female), EE was used in 95 cases (20.3%), SSS in 191 (40.8%), and SSH in 182 (38.9%). The majority (72.0%) underwent elective surgery. Insurance coverage included basic (62.2%), semi-private (24.2%), and private (13.7%). Mean operation times were shortest for EE (173.6 ± 72.3 min), followed by SSS (188.0 ± 65.4 min) and SSH (195.1 ± 61.5 min). The median total costs were 26,449 €. The SSS group had the lowest median total costs, 2424 € less than SSH and 2095 € less than EE, with no significant differences (p = 0.1657). Significant differences were observed in operating room (OR) costs, with EE being the lowest and SSH the highest (p < 0.0001). Adjusted OR costs in SSH were 23% more than EE and 21% more than SSS. No significant difference was found between EE and SSS OR costs. For mean OR material costs, EE had the lowest, followed by SSS and SSH. Adjusted costs for EE were 52% lower than SSS (p = 0.0005) and 65% lower than SSH (p = 0.0191). Clavien-Dindo Grade ≥ III complication rates were 2.1% for EE, 1.9% for SSH, and 3.0% for SSS. Anastomotic leakage occurred in 12 cases (2.6%), and in-hospital mortality was 0.9% (no deaths in EE; two in SSS and SSH each).

CONCLUSIONS

EE anastomosis was associated with the lowest OR and material costs in this retrospective analysis while no disadvantages concerning postoperative outcomes could be identified.

Bowel preparation before elective right colectomy: Multitreatment machine-learning analysis on 2,617 patients

BACKGROUND

In the worldwide, real-life setting, some candidates for right colectomy still receive no bowel preparation, some receive oral antibiotics alone, some receive mechanical bowel preparation alone, and some receive mechanical bowel preparation with oral antibiotics, with varying degrees of compliance to preoperative intravenous antibiotic prophylaxis. Previous studies mainly focused on left-sided colorectal anastomoses while less attention has been devoted to right-sided ileocolic anastomoses. When high-level evidence from randomized clinical trials is lacking, multiple-treatment propensity score weighting analysis of prospective data on the basis of generalized boosted model is superior to a simple propensity score-matching analysis and to an inverse probability weighting in terms of external validity and bias reduction.

METHODS

This is an analysis on the basis of machine-learning procedures of 2,617 patients who underwent elective right colectomies.

RESULTS

The risk of surgical-site infections (5.0% after no bowel preparation) was significantly lower after mechanical bowel preparation with oral antibiotics (4.0%, P = .017), significantly greater after mechanical bowel preparation alone (8.6%, P = .019), and comparable after oral antibiotics alone (3.9%). The risk of anastomotic leakage (3.2% after no bowel preparation) was significantly greater after oral antibiotics alone (4.8%, P = .013). Concerning secondary outcomes, no significant differences were recorded for the risk of overall morbidity and reoperation. The risk of readmission (3.0% after no bowel preparation) was significantly reduced after mechanical bowel preparation with oral antibiotics (1.5%, P = .046), and the risk of major morbidity (5.1% after no bowel preparation) was significantly greater after oral antibiotics alone (6.7%, P = .007).

CONCLUSION

This multitreatment machine-learning analysis, despite some limitations, showed that mechanical bowel preparation with oral antibiotics is associated with a decrease in surgical-site infections after elective right colectomy compared with no bowel preparation.

When Is Diversion Indicated After Right-Sided Colon Resections?

INTRODUCTION

Ileocolonic anastomoses have a low anastomotic leak (AL) risk, resulting in infrequent diverting loop ileostomy use. Identifying patients who warrant diverting loop ileostomy with right-sided resection is challenging due to this low incidence of AL. Therefore, a multicenter database was used to develop an AL risk score to help inform when diversion should be strongly considered after right-sided resections.

MATERIALS AND METHODS

Patients undergoing elective right-sided resections within the 2012-2020 American College of Surgeons National Surgical Quality Improvement Program-targeted colectomy participant user files were identified. Multivariable logistic regression identified AL risk factors that were then converted to point values to develop an AL risk score. The developed AL risk score was then assessed for visual correspondence and analyzed for internal validity.

RESULTS

42,176 patients underwent right-sided resection without diversion, and the incidence of AL was 2.4%. The risk calculator exhibited excellent calibration and fair discrimination. Strong visual correspondence was observed for predicted and actual AL rates within the 95% confidence interval for nine of ten risk score deciles.

CONCLUSIONS

An internally validated AL risk score for elective ileocolic resections was developed. Most patients had scores that categorized them at a low risk of AL. The diversion after elective right-sided resections should be reserved for extreme cases.

The Value of C-Reactive Protein and Peritoneal Cytokines as Early Predictors of Anastomotic Leak after Colorectal Surgery

OBJECTIVES

The aim of this study was to evaluate the accuracy of serum C-reactive protein (CRP) and intraperitoneal CRP, interleukin-6, and tumor necrosis factor-alpha in early diagnostics of anastomotic leakage in the first 4 postoperative days after colorectal surgery.

METHODS

Between January 2023 and June 2023, one hundred patients with colorectal carcinoma were operated on with primary anastomosis. Ten patients had anastomotic leak (10%).

RESULTS

Based on serum CRP, a patient with a leak will be detected with a 78% probability on postoperative day 3 with values above 169.0 mg/L and on postoperative day 4 with values equal to 159.0 mg/L and above. Intraperitoneal CRP values greater than 56 mg/L on the fourth postoperative day indicate a 78% probability of a diagnosis of leakage. An anastomotic leak will be detected with a 70.0% probability based on an IL-6 value on the first day, at a cut-off value of 42,150. The accuracy of TNF-alpha in predicting anastomotic leak in the first two days is 70% at values higher than 78.00 on the first and 58.50 on the second postoperative day.

CONCLUSION

In this study serum CRP proved to be the most accurate in predicting anastomotic dehiscence after colorectal surgery.

Double-layer adhesives for preventing anastomotic leakage and reducing post-surgical adhesion

Preventing anastomotic leakage (AL) and postoperative adhesions after gastrointestinal surgery is crucial for ensuring a favorable surgical prognosis. However, AL prevention using tissue adhesives can unintentionally lead to undesirable adhesion formation, while anti-adhesive agents may interfere with wound healing and contribute to AL. In this study, we have developed a double-layer patch, consisting of an adhesive layer on one side, utilizing gallic acid-conjugated chitosan (CHI-G), and an anti-adhesive layer on the opposite side, employing crosslinked hyaluronic acid (cHA). These CHI-G/cHA double-layer adhesives significantly prevented AL by forming physical barriers of CHI-G and reduced post-surgical adhesion at the anastomosis sites by the anti-adhesive layers of cHA. The bursting pressure (161.1 ± 21.6 mmHg) of double-layer adhesives-applied rat intestine at postoperative day 21 was far higher than those of the control (129.4 ± 5.7 mmHg) and the commercial anti-adhesives-applied group (120.8 ± 5.2 mmHg). In addition, adhesion score of double-layer adhesives-applied rat intestine was 3.6 ± 0.3 at postoperative day 21, which was similar to that of the commercial anti-adhesives-applied group (3.6 ± 0.3) and lower than that of the control group (4.9 ± 0.5). These findings indicate that the double-layer patch (CHI-G/cHA) has the potential to effectively prevent both postoperative adhesions and anastomotic leakage, offering a promising solution for gastrointestinal surgery.

Right hemicolectomy anastomotic leak study: a review of right hemicolectomy in the binational clinical outcomes registry (BCOR)

BACKGROUNDS

Surgery remains mainstay management for colon cancer. Post-operative anastomotic leak (AL) carries significant morbidity and mortality. Rates of, and risk factors associated with AL following right hemicolectomy remain poorly documented across Australia and New Zealand. This study examines the Bowel Cancer Outcomes Registry (BCOR) to address this.

METHODS

A retrospective cohort study was undertaken of consecutive BCOR-registered right hemicolectomy patients undergoing resection for colon cancer (2007-2021). The primary outcome measure was AL incidence. Clinicopathological data were extracted from the BCOR. Factors associated with AL and primary anastomosis were identified using logistic regression. AL-rate trends were assessed by linear regression.

RESULTS

Of 13 512 patients who had a right hemicolectomy (45.2% male, mean age 72.5 years, SD 12.1), 258 (2.0%) had an AL. On multivariate analysis, male sex (OR 1.33; 95% CI 1.03-1.71) and emergency surgery (OR 1.41; 95% CI 1.04-1.92) were associated with AL. Private health insurance status (OR 0.66; 95% CI 0.50-0.88) and minimally-invasive surgery (OR 0.61; 95% CI 0.47-0.79) were protective for AL. Anastomotic technique (handsewn versus stapled) was not associated with AL (P = 0.84). Patients with higher ASA status (OR 0.47; 95% CI 0.39-0.58), advanced tumour stage (OR 0.56; 95% CI 0.50-0.63), and emergency surgery (OR 0.16; 95% CI 0.13-0.20) were less likely to have a primary anastomosis. AL-rate and year of surgery showed no association (P = 0.521).

CONCLUSION

The AL rate in Australia and New Zealand following right hemicolectomy is consistent with the published literature and was stable throughout the study period. Sex, emergency surgery, insurance status, and minimally invasive surgery are associated with AL incidence.

Anastomotic Leak Impact on Long-Term Survival after Right Colectomy for Cancer: A Propensity-Score-Matched Analysis

Our goal was to assess the impact of anastomotic leaks (ALs) on oncologic outcomes using a case-matched analysis. Patients undergoing right hemicolectomy for cancer between 2014 and 2018 were included. The main variables were the risk factor of anastomotic leak, overall survival and disease-free survival. Propensity score matching was performed according to the patient’s age, co-morbidities and TNM staging as well as the type of procedure. Oncologic outcomes were analyzed. We included 488 patients and performed final analysis on 69 patients. The AL rate was 4.71% (23 patients). Intrahospital mortality was significantly higher in the AL group, at 1.3% (6 of 465) vs. 8.7% (2 of 23), p = 0.05. Three-year overall survival (OS) in the non-AL group was higher, although the difference could not be considered significant (71.5% vs. 37.3%, p = 0.082); similarly, the likelihood for impaired 3-year progression-free survival (PFS) was lower, but the difference here could also not be considered significant (69.3% vs. 37.3%, p = 0.106). Age, advanced tumor stage, lymph node metastases and distant metastases were associated with higher probability of death or recurrence of disease. In contrast, minimally invasive surgery was associated with lower probability of death (HR (95% CI): 0.99 (0.14–0.72); p = 0.023) and recurrence of disease (HR (95% CI): 0.94 (0.13–0.68); p = 0.020). In an adjusted Cox regression analysis, AL, age and distant metastases were associated with poor long-term survival. Moreover, AL, age and distant metastases were associated with higher probability of recurrence of disease. Based on our results, AL is a significant factor for worse oncologic outcomes. Simple summary: we aimed to assess patients with anastomotic leaks following right hemicolectomy for cancer. These patients were matched to patients without leaks. Propensity score analysis demonstrated that anastomotic leak was a marker of worse oncologic outcomes.

Robotic right colectomy with robotic-sewn anastomosis: a pilot case series

The background of this study is to assess the feasibility, clinical utility and safety of intra-corporeal robotic-sewn anastomosis (ICrA) in completely robotic right hemicolectomy (CRH) for adenocarcinoma. A protocol for completely robotic right hemicolectomy (CRH) and intra-corporeal robotic-sewn anastomosis (ICrA), was established at the authors' institution from January 2012 through December 2017. Univariate and multivariable models were constructed to explore the prognostic significance of clinical and surgical findings. Survival and recurrence analysis were performed using standard univariable and multivariable methods. The study population consisted of 123 patients. The median number of examined lymph nodes (ELN) was 25 (range 1-59), the median number of positive lymph nodes (PLN) was 1 (range 0-21). Mean operative time was 240 min (SD 43.56, range 180-360 min), and conversion to open rate was 0%. Anastomotic leaks rate was 1.6%. The median overall survival was 69 months. This pilot series, in which an intra-corporeal robotic-sewn anastomosis (ICrA) was performed during CRH, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, ICrA was associated with post-operative surgical outcomes similar to those reported in the literature. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.

Anastomosis technique and leakage rates in minimally invasive surgery for right-sided colon cancer. A retrospective national cohort study

PURPOSE

The aim of this study was to describe the different techniques currently used in Denmark to construct right-sided ileocolic anastomoses in minimally invasive surgery, and investigate, compare and analyse the anastomotic configurations and their anastomotic leakage (AL) rates.

METHODS

This was a retrospective register-based, study design using prospectively collected data from the Danish Colorectal Cancer Group (DCCG) database. All patients aged 18 years or older with a malignant colorectal tumour in Denmark in the period of 1 February 2015 until 31 December 2019, and who had an elective, curative, minimally invasive right hemicolectomy (MIRH) with ileocolic anastomosis, were included.

RESULTS

Three thousand three hundred ninety-eight patients were included. The most commonly used anastomotic approach was the extracorporeal (EC) hand-sewn anastomosis (HA) with end-to-end configuration (59%) and the second most used was the EC stapled anastomosis (SA) side-to-side configuration (20%). The latter had a higher AL rate compared with the hand-sewn technique (3.8% vs. 1.3%), and had significantly higher odds ratio (OR) (OR: 2.85, 95% CI: 1.56-4.92, p < 0.0001) for AL in the adjusted regression model. The least used technique was the end-to-side HA which also had a significantly higher OR (OR: 3.05, 95% CI: 1.30-7.15, p = 0.010) compared with the end-to-end HA. Smoking was an independent factor associated with higher OR for AL.

CONCLUSION

The ileocolic end-to-end HA was the most commonly used technique and had the lowest AL rate in MIRH for colon cancer. The EC SA technique and tobacco smoking were independent risk factors for leakage of the ileocolic anastomosis.

Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn?

PURPOSE

Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA.

METHODS

This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function.

RESULTS

A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS.

CONCLUSION

ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.

Single Snapshot Imaging of Optical Properties (SSOP) for Perfusion Assessment during Gastric Conduit Creation for Esophagectomy: An Experimental Study on Pigs

Simple Summary

Anastomotic leak is the most dangerous complication occurring after esophagectomy and its relationship with inadequate visceral perfusion is widely recognized. Currently, the adequate perfusion of the gastric conduit is intraoperatively assessed by surgeons using subjective indicators (e.g., serosal color or pulsatile flow of vessels). During the last decades, several innovative optical techniques based on the interaction of light with tissue have been developed to monitor perfusion in esophagogastric surgery. However, these innovative approaches are characterized by a lack of video rate and reproducibility. They also provide operator-dependent results and lengthen the surgical workflow. Single Snapshot imaging of Optical Properties (SSOP) is an optical technique, which can overcome such limitations, providing quantitative information on the optical properties of biological tissues over a large field of view. It is the first study to demonstrate the accuracy of SSOP in the quantification of serosal StO₂% in a porcine gastric conduit model.

Abstract

Anastomotic leakage (AL) is a serious complication occurring after esophagectomy. The current knowledge suggests that inadequate intraoperative perfusion in the anastomotic site contributes to an increase in the AL rate. Presently, clinical estimation undertaken by surgeons is not accurate and new technology is necessary to improve the intraoperative assessment of tissue oxygenation. In the present study, we demonstrate the application of a novel optical technology, namely Single Snapshot imaging of Optical Properties (SSOP), used to quantify StO₂% in an open surgery experimental gastric conduit (GC) model. After the creation of a gastric conduit, local StO₂% was measured with a preclinical SSOP system for 60 min in the antrum (ROI-A), corpus (ROI-C), and fundus (ROI-F). The removed region (ROI-R) acted as ischemic control. ROI-R had statistically significant lower StO₂% when compared to all other ROIs at T15, T30, T45, and T60 (p < 0.0001). Local capillary lactates (LCLs) and StO₂% correlation was statistically significant (R = −0.8439, 95% CI −0.9367 to −0.6407, p < 0.0001). Finally, SSOP could discriminate resected from perfused regions and ROI-A from ROI-F (the future anastomotic site). In conclusion, SSOP could well be a suitable technology to assess intraoperative perfusion of GC, providing consistent StO₂% quantification and ROIs discrimination.

Evaluating the Effect of Intraoperative Near-Infrared Observation on Anastomotic Leakage After Stapled Side-to-Side Anastomosis in Colon Cancer Surgery Using Propensity Score Matching

BACKGROUND

Recent studies have clarified that near-infrared observation using indocyanine green has the advantage of evaluating perfusion of the anastomotic site, especially in rectal cancer surgery, resulting in a reduction in anastomotic leak.

OBJECTIVE

The aim of this study was to evaluate the efficacy of near-infrared observation for reducing the anastomotic leak after stapled side-to-side anastomosis in colon cancer surgery.

DESIGN

This was a retrospective propensity score case-matched study.

SETTINGS

The study was conducted at 3 institutions in the Yokohama Clinical Oncology Group.

PATIENTS

From January 2011 to December 2019, patients who underwent colon cancer surgery with stapled side-to-side anastomosis were included.

MAIN OUTCOME MEASURES

The main outcome was the percentage of anastomotic leak within 30 days after surgery.

RESULTS

A total of 1034 patients were collected. There were 532 patients who underwent near-infrared observation and 502 who did not. A total of 370 patients were matched to the near-infrared and non-near-infrared groups. In the near-infrared group, 12 patients (3.2%) were judged to have poor perfusion (4 patients) and no perfusion (8 patients), so the planned transection point was changed. There were no cases of anastomotic leak among these 12 patients. The anastomotic leak rates were 3.5% (13/370) in the non-near-infrared group and 0.8% (3/370) in the near-infrared group. The anastomotic leak and reoperation rates were significantly lower in the near-infrared group than in the non-near-infrared group (OR, 0.224; 95% CI, 0.063-0.794, p = 0.001; OR, 0.348; 95% CI, 0.124-0.977, p = 0.036).

LIMITATIONS

Although we reduced selection bias by performing propensity score matching, this was a retrospective study and was not randomized.

CONCLUSION

This large-scale case-matched study showed that assessing perfusion by near-infrared observation significantly reduced the anastomotic leak and reoperation rates after stapled side-to-side anastomosis in colon cancer surgery and may be better suited to colo-colonic anastomosis. Video Abstract at http://links.lww.com/DCR/B513.Japanese Clinical Trials Registry: UMIN-CTR000039977.

EVALUACIN DEL EFECTO DE LA OBSERVACIN INTRAOPERATORIA CON INFRARROJO CERCANO SOBRE LA FUGA ANASTOMTICA DESPUS DE UNA ANASTOMOSIS LATEROLATERAL CON ENGRAPADORA EN LA CIRUGA DE CNCER DE COLON MEDIANTE EL EMPAREJAMIENTO POR PUNTAJES DE PROPENSIN

ANTECEDENTES:Estudios recientes han aclarado que la observación con infrarrojo cercano con verde de indocianina tiene la ventaja de evaluar la perfusión del sitio anastomótico, especialmente en la cirugía de cáncer de recto, lo que resulta en una reducción de la fuga anastomótica.OBJETIVO:El objetivo de este estudio fue evaluar la eficacia de la observación con infrarrojo cercano para reducir la fuga anastomótica después de una anastomosis latero-lateral con engrapadora en la cirugía de cáncer de colon.DISEÑO:Este fue un estudio retrospectivo emparejado con puntaje de propensión.AJUSTE:El estudio se llevó a cabo en tres instituciones del Grupo de Oncología Clínica de Yokohama.PACIENTES:Desde enero de 2011 hasta diciembre de 2019, se incluyeron pacientes que se sometieron a cirugía de cáncer de colon con anastomosis latero-lateral con engrapadora.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el porcentaje de fuga anastomótica dentro de los 30 días posteriores a la cirugía.RESULTADOS:Se recogió un total de 1034 pacientes. Hubo 532 pacientes que se sometieron a observación con infrarrojo cercano y 502 que no. Un total de 370 pacientes fueron emparejados con los grupos de infrarrojo cercano y no infrarrojo cercano. En el grupo de infrarrojo cercano, se consideró que 12 casos (3,2%) tenían mala perfusión (4 casos) y ninguna perfusión (8 casos), por lo que se cambió el punto de transección planificado. No hubo casos de fuga anastomótica entre estos 12 casos. Las tasas de fuga anastomótica fueron del 3,5% (13/370) en el grupo sin infrarrojo cercano y del 0,8% (3/370) en el grupo con infrarrojo cercano. Las tasas de fuga anastomótica y de reintervención fueron significativamente menores en el grupo con infrarrojo cercano que en el grupo sin infrarrojo cercano (razón de posibilidades 0,224, intervalo de confianza del 95% 0,063-0,794, p = 0,001; razón de posibilidades 0,348, intervalo de confianza del 95% 0,124 -0,977, p = 0,036, respectivamente).LIMITACIONES:Aunque se redujo el sesgo de selección al realizar el emparejamiento por puntaje de propensión, este fue un estudio retrospectivo y no fue aleatorio.CONCLUSIÓN:Este estudio de casos emparejados a gran escala demostró que la evaluación de la perfusión mediante la observación con infrarrojo cercano redujo significativamente la fuga anastomótica y las tasas de reintervención después de la anastomosis latero-lateral con engrapadora en la cirugía de cáncer de colon y puede ser más adecuada para la anastomosis colo-colónica. Consulte Video Resumen en http://links.lww.com/DCR/B513.Registro japonés de ensayos clínicos: UMIN-CTR000039977.

The Impact of Indocyanine Green Fluorescence Angiography on Intraoperative Decision Making in Right Hemicolectomy: A Case-Control Study

INTRODUCTION

Anastomotic leak (AL) after right hemicolectomy remains a significant clinical challenge with an incidence of 4.2% to 8.2% in European series. Near infrared imaging with indocyanine green (NIR-ICG) allows real-time assessment of bowel perfusion. However, there is a lack of published data assessing the clinical utility of this new technology in right sided colonic resection.

MATERIALS AND METHODS

Data from electronic records were retrospectively analyzed for consecutive patients undergoing right hemicolectomy in a single center between March 1, 2016 and October 31, 2019. Primary outcomes were the incidence of AL and the frequency with which ICG-NIR imaging altered the intraoperative course.

RESULTS

Our study included 127 patients, with 65 in the NIR-ICG group and 62 in the control group. Median length of follow-up was 24 months. There was no significant difference in demographic or pathologic characteristics between the 2 cohorts. There was no significant difference in operation length between the NIR-ICG and control groups (164.7 vs. 162.9 min, P=0.88). The use of NIR-ICG altered the intraoperative course in 4/65 (6.2%) patients. The rate of AL was lower in the NIR-ICG group (1.5% vs. 4.8%), although this did not reach statistical significance.

CONCLUSION

The use of NIR-ICG altered the intraoperative course for notable subset of patients undergoing right hemicolectomy without prolonging operative time. Larger prospective studies are required to evaluate the potential for the routine use of this technology to reduce AL rate in right hemicolectomy.

C-reactive protein level on postoperative day 3 as a predictor of anastomotic leakage after elective right-sided colectomy

PURPOSE

To investigate the factors predictive of anastomotic leakage in patients undergoing elective right-sided colectomy.

METHODS

The subjects of this retrospective study were 247 patients who underwent elective right hemicolectomy or ileocecal resection with ileocolic anastomosis between April 2012 and March 2019, at our institution.

RESULTS

Anastomotic leakage occurred in 9 of the 247 patients (3.6%) and was diagnosed on median postoperative day (POD) 7 (range POD 3-12). There were no significant differences in the background factors or preoperative laboratory data between the patients with anastomotic leakage (anastomotic leakage group) and those without anastomotic leakage (no anastomotic leakage group). Open surgery was significantly more common than laparoscopic surgery (P = 0.027), and end-to-side anastomosis was less common (P = 0.025) in the anastomotic leakage group. The C-reactive protein (CRP) level in the anastomotic leakage group was higher than that in the no anastomotic leakage group on PODs 3 (P < 0.001) and 5 (P < 0.001). ROC curve analysis revealed that anastomotic leakage was significantly more frequent in patients with a serum CRP level ≥ 11.8 mg/dL [area under the curve (AUC) 0.83].

CONCLUSION

A serum CRP level ≥ 11.8 mg/dL on POD 3 was predictive of anastomotic leakage being detected on median POD 7.

Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome

Colon cancer is the third most common cancer in man and woman in the developed world. Laparoscopic right colectomy is the standard of care for right colon cancer. Since the first report on laparoscopic approach in 1991, the surgical technique has been improved and currently all procedure is performed intracorporeally. The ileo-colic anastomosis can be performed either intracorporeal and extracorporeal: the differences in clinical outcome, complications rate, hospital stay and quality of life between that two techniques are not still clear and a large number of studies has been published about that. According to most recent meta-analysis, intracorporeal anastomosis have showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function.

Quantitative fluorescence angiography aids novice and experienced surgeons in performing intestinal resection in well-perfused tissue

Background

Anastomotic leakage (AL) after gastrointestinal resection is a devastating complication with huge consequences for the patient. As AL is associated with poor blood supply, tools for objective assessment of perfusion are in high demand. Indocyanine green angiography (ICG-FA) and quantitative analysis of ICG-FA (q-ICG) seem promising. This study aimed to investigate whether ICG-FA and q-ICG could improve perfusion assessment performed by surgeons of different experience levels.

Methods

Thirteen small bowel segments with a varying degree of devascularization, including two healthy sham segments, were constructed in a porcine model. We recruited students, residents, and surgeons to perform perfusion assessment of the segments in white light (WL), with ICG-FA, and after q-ICG, all blinded to the degree of devascularization.

Results

Forty-five participants fulfilled the study (18 novices, 12 intermediates, and 15 experienced). ICG and q-ICG helped the novices correctly detect the healthy bowel segments to experienced surgeons’ level. ICG and q-ICG also helped novice surgeons to perform safer resections in healthy tissue compared with normal WL. The relative risk (RR) of leaving ischemic tissue in WL and ICG compared with q-ICG, even for experienced surgeons was substantial, intermediates (RR = 8.9, CI95% [4.0;20] and RR = 6.2, CI95% [2.7;14.1]), and experienced (RR = 4.7, CI95% [2.6;8.7] and RR = 4.0, CI95% [2.1;7.5]).

Conclusion

Q-ICG seems to guide surgeons, regardless of experience level, to safely perform resection in healthy tissue, compared with standard WL. Future research should focus on this novel tool’s clinical impact.

Early postoperative pain as a marker of anastomotic leakage in colorectal cancer surgery

PURPOSE

Even though anastomotic leakage after colorectal surgery is a major clinical problem in need of a timely diagnosis, early indicators of leakage have been insufficiently studied. We therefore conducted a population-based observational study to determine whether the patient's early postoperative pain is an independent marker of anastomotic leakage.

METHODS

By combining the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry, we retrieved prospectively collected data on 3084 patients who underwent anastomotic colorectal surgery for cancer in 2014-2017. Postoperative pain, measured with the numerical rating scale (NRS), was considered exposure, while anastomotic leakage and reoperation due to leakage were outcomes. We performed logistic regression to evaluate associations, estimating odds ratios (ORs) and 95% confidence intervals (CIs), while multiple imputation was used to handle missing data.

RESULTS

In total, 189 patients suffered from anastomotic leakage, of whom 121 patients also needed a reoperation due to leakage. Moderate or severe postoperative pain (NRS 4-10) was associated with an increased risk of anastomotic leakage (OR 1.69, 95% CI 1.21-2.38), as well as reoperation (OR 2.17, 95% CI 1.41-3.32). Severe pain (NRS 8-10) was more strongly related to leakage (OR 2.38, 95% CI 1.44-3.93). These associations were confirmed in multivariable analyses and when reoperation due to leakage was used as an outcome.

CONCLUSION

In this population-based retrospective study on prospectively collected data, increased pain in the post-anaesthesia care unit is an independent marker of anastomotic leakage, possibly indicating a need for further diagnostic measures.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

Incidence and risk factors for fluorescence abnormalities on near-infrared imaging using indocyanine green in stapled functional end-to-end anastomosis in laparoscopic colectomy

PURPOSE

Recently, several studies have suggested that near-infrared (NIR) imaging using indocyanine green (ICG) may contribute to the reduction of anastomotic leakage (AL) after colorectal cancer (CRC) surgery. However, few reports have focused on the usefulness of NIR imaging for AL after stapled functional end-to-end anastomosis (stapled FEEA). The purpose of this study was to clarify the frequency of fluorescence abnormalities on NIR imaging, in cases reconstructed with stapled FEEA.

METHODS

This retrospective study included patients with colon or appendiceal cancer who underwent laparoscopic colectomy with stapled FEEA reconstruction between March 2016 and August 2019.

RESULTS

A total of 400 patients who were managed at our three institutions were included in the present study. The rate of Clavien-Dindo (CD) grade > III AL was 1.0% (4/400). The median length of postoperative hospital stay was 7 days (IQR 25-75th percentile 6-8 days). In 11 patients (2.8%), the transection line was changed by NIR imaging, due to fluorescence abnormalities. The rate of transverse colon involvement in anastomosis was significantly higher in cases with fluorescence abnormalities than in cases with normal fluorescence (p = 0.035).

CONCLUSIONS

The frequency of fluorescence abnormalities on NIR was 2.8% in cases of colon resection with reconstruction by using stapled FEEA. There was a probability of abnormal fluorescence on NIR in cases where the transverse colon was involved in the anastomosis. This means that NIR may have potential benefit in such cases.

TRIAL REGISTRATION

UMIN000039977.

Clinical impact of leakage in patients with handsewn vs stapled anastomosis after right hemicolectomy: a retrospective study

AIM

Anastomotic leakage is a major complication after right hemicolectomy leading to increased morbidity, mortality, length of stay and hospital costs. Previous studies have shown that the type of anastomosis (handsewn or stapled) is a major risk factor for anastomotic leakage. The purpose of this study was to evaluate the clinical impact of anastomotic leakage depending on the type of anastomotic technique (handsewn vs stapled).

METHOD

This was an observational, retrospective, cross-sectional study. Data were collected at two major hospitals in Spain from January 2010 to December 2016. Patients had elective right colectomy for cancer with handsewn or stapled ileocolic anastomosis. The main outcome was the grading of postoperative treatments needed to manage anastomotic leakage according to two major classification systems. The other outcomes were demographics, time of hospitalization and death rate.

RESULTS

Patients (n = 961) underwent elective surgery for neoplasia of the right colon. Anastomotic leakage was diagnosed in 116 patients (12.07%). Patients with handsewn anastomosis had more Type IIIA surgical complications and received milder treatments than patients with stapled anastomosis (SA) who had more Type IIIB complications and more re-laparotomies (P = 0.004). The clinical impact of anastomotic leakage was significantly more severe (Grade C) in patients with SA than in patients with a handsewn anastomosis (P = 0.007). No differences were found for hospital stay of patients with anastomotic leakage depending on the type of anastomosis (P = 0.275). Death due to anastomotic leakage was similar in both groups.

CONCLUSIONS

The clinical impact of anastomotic leakage in patients with handsewn anastomosis is lower than in patients with SA.

Predictors for Anastomotic Leak, Postoperative Complications, and Mortality After Right Colectomy for Cancer: Results From an International Snapshot Audit

BACKGROUND

A right hemicolectomy is among the most commonly performed operations for colon cancer, but modern high-quality, multination data addressing the morbidity and mortality rates are lacking.

OBJECTIVE

This study reports the morbidity and mortality rates for right-sided colon cancer and identifies predictors for unfavorable short-term outcome after right hemicolectomy.

DESIGN

This was a snapshot observational prospective study.

SETTING

The study was conducted as a multicenter international study.

PATIENTS

The 2015 European Society of Coloproctology snapshot study was a prospective multicenter international series that included all patients undergoing elective or emergency right hemicolectomy or ileocecal resection over a 2-month period in early 2015. This is a subanalysis of the colon cancer cohort of patients.

MAIN OUTCOME MEASURES

Predictors for anastomotic leak and 30-day postoperative morbidity and mortality were assessed using multivariable mixed-effect logistic regression models after variables selection with the Lasso method.

RESULTS

Of the 2515 included patients, an anastomosis was performed in 97.2% (n = 2444), handsewn in 38.5% (n = 940) and stapled in 61.5% (n = 1504) cases. The overall anastomotic leak rate was 7.4% (180/2444), 30-day morbidity was 38.0% (n = 956), and mortality was 2.6% (n = 66). Patients with anastomotic leak had a significantly increased mortality rate (10.6% vs 1.6% no-leak patients; p > 0.001). At multivariable analysis the following variables were associated with anastomotic leak: longer duration of surgery (OR = 1.007 per min; p = 0.0037), open approach (OR = 1.9; p = 0.0037), and stapled anastomosis (OR = 1.5; p = 0.041).

LIMITATIONS

This is an observational study, and therefore selection bias could be present. For this reason, a multivariable logistic regression model was performed, trying to correct possible confounding factors.

CONCLUSIONS

Anastomotic leak after oncologic right hemicolectomy is a frequent complication, and it is associated with increased mortality. The key contributing surgical factors for anastomotic leak were anastomotic technique, surgical approach, and duration of surgery. See Video Abstract at http://links.lww.com/DCR/B165. PREDICTORES DE FUGA ANASTOMóTICA, COMPLICACIONES POSTOPERATORIAS Y MORTALIDAD DESPUéS DE LA COLECTOMíA DERECHA POR CáNCER: RESULTADOS DE UNA AUDITORíA INTERNACIONAL DE CORTO PLAZO: La hemicolectomía derecha se encuentra entre las operaciones más frecuentemente realizadas para cáncer de colon, pero faltan datos modernos multinacionales de alta calidad, que aborden las tasas de morbilidad y mortalidad.Reportar la tasa de morbilidad y mortalidad para cáncer de colon del lado derecho, e identificar predictores de resultados desfavorables a corto plazo, después de la hemicolectomía derecha.Estudio prospectivo observacional de corto plazo.Estudio multicéntrico internacional.El estudio de corto plazo de la Sociedad Europea de Coloproctología de 2015, fue una serie prospectiva multicéntrica internacional, que incluyó a todos los pacientes sometidos a hemicolectomía derecha electiva, de emergencia o resección ileocecal, por un período de dos meses y a principios de 2015. Este es un subanálisis, cohorte de pacientes con cáncer de colon.Los predictores de fuga anastomótica, morbilidad y mortalidad postoperatorias a los 30 días, se evaluaron usando modelos de regresión logística de efectos multivariables mixtos, después de la selección de variables con el método Lasso.De los 2,515 pacientes incluidos, se realizó una anastomosis en el 97,2% (n = 2,444); sutura manual en 38.5% (n = 940) y por engrapadora en 61.5% (n = 1504) casos. La tasa global de fuga anastomótica fue del 7,4% (180/2,444), morbilidad a los 30 días fue del 38,0% (n = 956) y la mortalidad fue del 2,6% (n = 66). Los pacientes con fuga anastomótica tuvieron una tasa de mortalidad significativamente mayor (10,6% frente al 1,6% de pacientes sin fuga, p> 0,001). En el análisis multivariable, las siguientes variables se asociaron con la fuga anastomótica: mayor duración de la cirugía (OR 1.007 por minuto, p = 0.0037), abordaje abierto (OR 1.9, p = 0.0037) y anastomosis por engrapadora (OR 1.5, p = 0.041).Este es un estudio observacional y por lo tanto podría estar presente el sesgo de selección. Por esta razón, se realizó un modelo de regresión logística multivariable, tratando de corregir posibles factores de confusión.La fuga anastomótica después de la hemicolectomía derecha oncológica, es una complicación frecuente y asociada a mayor mortalidad. Los factores quirúrgicos clave que contribuyeron a la fuga anastomótica, fueron la técnica anastomótica, abordaje quirúrgico y duración de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B165. (Traducción-Dr. Fidel Ruiz Healy).

Risk factors for ileocolic anastomosis dehiscence; a cohort study

BACKGROUND

Anastomotic leak (AL) after ileocolic anastomosis influences morbidity, mortality, length of hospitalization and costs. This study analyzes risk and protective factors for AL on ileocolic anastomoses.

METHODS

We retrospectively analyzed our single institution patients' series undergoing elective ileocolic anastomosis for AL between 1/2008-12/2017. AL grade A/B (antibiotic treatment and/or radiological drainage) were summarized as mild, grade C (surgical re-intervention) corresponds to severe AL.

RESULTS

We included 470 patients (mean age 70.8 years, 43.2% females). Overall AL rate was 9.4% (44 patients) with 6.0% severe and 3.4% mild AL. There was no difference in AL between hand sewn and stapled anastomoses. Multivariate analysis revealed preoperative serum albumin (p = 0.004), smoking habits (p = 0.005) and perioperative blood transfusion (p = 0.038) as risk factors for AL. Suture oversewing as anastomotic reinforcement resulted as independent protective factor (p < 0.001).

CONCLUSION

Poor nutritional status, smoking habits and perioperative blood transfusion are negative factors influencing on AL. Suture oversewing as anastomotic reinforcement associates with significantly less AL.

Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques

INTRODUCTION

There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn).

MATERIALS AND METHODS

This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed.

RESULTS

We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified.

CONCLUSION

Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Colorectal Anastomosis Leak: Rate , Risk Factors and Outcome in a Tertiary Teaching Hospital, Addis Ababa Ethiopia, a Five Year Retrospective Study

BACKGROUND

Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of perioperative risk factors for colorectal anastomosis leak helps to identify patients requiring increased postoperative surveillance.

METHODS

Institution based retrospective study was done to determine colorectal anastomosis leak rate and risk factors associated with it at a teaching hospital in Addis Ababa Ethiopia. Patients operated from January 2013 to December 2017 G.C were included. Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events on postoperative anastomotic leakage.

RESULTS

Inclusion criteria were met by 221 patients. Mean age of patients was 46.44(SD=19.1) with range of 1 to 85 years. Male accounted to 166 (74.8%) of the patients. Anastomotic leakage occurred in 12 (5.2%) of the patients. Mean time to diagnosis was 9.55 days (95% CI, 7.2-11.8) after surgery. Univariate analyses showed high preoperative level of creatinine, ASA score III and IV, emergency operation, operative time more than three hours, and malignant diseases were associated with colorectal anastomosis leak. Multivariate logistic regression model failed to show an association. Colorectal anastomosis leak increased the inpatient mortality rate by 50%. Median length of hospitalization in colorectal anastomosis leak group was 27.5 days, versus 7 days in patients without leak.

CONCLUSION

Colorectal anastomosis leak remains common problem after colorectal surgery resulting significant post-operative mortality and morbidity.

Laser speckle contrast imaging and quantitative fluorescence angiography for perfusion assessment

PURPOSE

Indocyanine green fluorescence angiography (ICG-FA) is an established technique for assessment of intestinal perfusion during gastrointestinal surgery, whereas quantitative ICG-FA (q-ICG) and laser speckle contrast imaging (LSCI) are relatively unproven. The study aimed to investigate whether the techniques could be applied interchangeably for perfusion assessment.

METHODS

Nineteen pigs underwent laparotomy, two minor resections of the small bowel, and anastomoses. Additionally, seven pigs had parts of their stomach and small intestine de-vascularized. Data was also collected from an in vivo model (inferior caval vein measurements in two additional pigs) and an ex vivo flow model, allowing for standardization of experimental flow, distance, and angulation. Q-ICG and LSCI were performed, so that regions of interest were matched between the two modalities in the analyses, ensuring coverage of the same tissue.

RESULTS

The overall correlation of q-ICG and LSCI evaluated in the porcine model was modest (rho = 0.45, p < 0.001), but high in tissue with low perfusion (rho = 0.74, p < 0.001). Flux values obtained by LSCI from the ex vivo flow model revealed a decreasing flux with linearly increasing distance as well as angulation to the model. The Q-ICG perfusion values obtained varied slightly with increasing distance as well as angulation to the model.

CONCLUSIONS

Q-ICG and LSCI cannot be used interchangeably but may supplement each other. LSCI is profoundly affected by angulation and distance. In comparison, q-ICG is minimally affected by changing experimental conditions and is more readily applicable in minimally invasive surgery.

Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study

BACKGROUND

Data on anastomotic leak rates after stapled versus handsewn ileocolic anastomosis are conflicting. In a Cochrane review, the combined estimate favored the stapled technique, but recent cohort studies demonstrated a 2-fold increase in anastomotic leak with the stapled approach.

OBJECTIVE

The purpose of this study was to investigate anastomotic leak rates following stapled versus handsewn ileocolic anastomosis.

DESIGN

This was a nationwide, retrospective cohort study.

SETTING

Data were obtained from the Danish Colorectal Cancer Group and National Patient Registry databases.

PATIENTS

Danish patients, ≥18 years of age, undergoing right hemicolectomy for a first-time diagnosis of adenocarcinoma in the right colon with primary anastomosis between October 2014 and December 2015 were included.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic leak rate. Secondary outcomes included 30-day mortality. Covariates included demographics, comorbidity, tumor stage, and surgical variables. Multivariable logistic regression and propensity score matching were used to adjust for confounding.

RESULTS

The 1414 patients included 391 (28%) in the stapled group and 1023 (72%) in the handsewn group. Forty-five patients (3.2%) developed anastomotic leak: 21 of 391 (5.4%) and 24 of 1023 (2.4%) in the stapled and handsewn group (p = 0.004). This difference was confirmed in multivariable analysis (adjusted OR, 2.91; 95% CI, 1.53-5.53; p < 0.001), and after propensity score matching (OR, 2.41; 95% CI, 1.24-4.67; p = 0.009). Thirty-day mortality was 15.6% (7/45) and 2.1% (29/1369) in patients with and without anastomotic leak (p < 0.001), with no difference between the stapled and handsewn approach.

LIMITATIONS

The study's design was retrospective, with no information on allocation to the stapled or handsewn approach.

CONCLUSIONS

The present study demonstrated a 2-fold increase in anastomotic leak after stapled versus handsewn ileocolic anastomoses. Previous opinions on the optimal anastomosis technique for colon cancer should be scrutinized given the devastating short-term outcome of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A819.

Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI)

BACKGROUND

Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period.

METHODS

A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses.

RESULTS

Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120-150] min ISO vs. 140 [127-160] ANTI, p = 0.481), nor in anastomotic time (19 [17-22] vs. 20 [16-25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in "time to first flatus" and "time to first deposition" were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2-6] isoperistaltic vs. 3 [2-4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541).

CONCLUSIONS

The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration.

TRIAL REGISTRATION

Randomised Clinical trial (Identifier: NCT02309931).

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery

BACKGROUND

Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery.

METHODS

This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone.

RESULTS

Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology.

CONCLUSION

Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Very Early Colorectal Anastomotic Leakage within 5 Post-operative Days: a More Severe Subtype Needs Relaparatomy

Early anastomotic leakage (AL), usually defined as leakage within 30 post-operative days, represents a severe entity. However, mounting evidence has indicated that majorities of leakage occur within one week after surgery, making late AL rarity. Here we analyzed 101 consecutive colorectal AL, all of which occurred within 30 post-operative days, during Jan 2013 and Dec 2015 in cancer hospital of Fudan University. AL occurring within 5 post-operative days was defined as very early AL (vE-AL). We evaluated risk factors of vE-AL compared with non-vEAL and correlated with post-leakage peritonitis and need of relaparatomy. We found that AL occurred at median time of 7 days after surgery. 23 cases were vE-AL. Reconstruction of post-peritoneum for mid-low rectal carcinoma significantly reduced incidence of vE-AL compared with non-vE-AL (p = 0.042). Patients with vE-AL was associated with presence of peritonitis (p = 0.031), the latter significantly correlated with increased re-operation rate (p = 6.8E-13). Besides, patients with vE-AL trended to correlate with increased re-operation rate after leakage (p = 0.088). In concludsion, vE-AL occurring within 5 post-operative days represents a severe subtype associated with general peritonitis and need of relaparatomy.