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Yi X, Yang H, Li H, Feng X, Liao W, Lin J, Chen Z, Diao D, Ouyang M. Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients. Surg Endosc 2024:10.1007/s00464-024-11149-3. [PMID: 39160312 DOI: 10.1007/s00464-024-11149-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/04/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVE To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes. METHODS A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared. RESULTS For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05). CONCLUSION Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.
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Affiliation(s)
- Xiaojiang Yi
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Huaguo Yang
- First Department of General Surgery, Luzhou Hospital of Traditional Chinese Medicine, Luzhou, 646000, Sichuan, China
| | - Hongming Li
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Xiaochuang Feng
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Weilin Liao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Jiaxin Lin
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China
| | - Zhifeng Chen
- Department of Hepatobiliary Gastrointestinal Thyroid Surgery, Meizhou Hospital of Traditional Chinese Medicine, Meizhou, 514000, Guangdong, China
| | - Dechang Diao
- Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, Guangdong, China.
| | - Manzhao Ouyang
- Department of Gastrointestinal Surgery, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde Foshan), Shunde, Foshan, 528300, Guangdong, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510080, Guangdong, China.
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Huang L, Zhang T, Wang K, Chang B, Fu D, Chen X. Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients. Pain Ther 2024; 13:745-766. [PMID: 38836984 PMCID: PMC11254899 DOI: 10.1007/s40122-024-00619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.
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Affiliation(s)
- Li Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bingcheng Chang
- The Second Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, 550003, China
| | - Daan Fu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
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Taha-Mehlitz S, Wentzler L, Angehrn F, Hendie A, Ochs V, Wolleb J, Staartjes VE, Enodien B, Baltuonis M, Vorburger S, Frey DM, Rosenberg R, von Flüe M, Müller-Stich B, Cattin PC, Taha A, Steinemann D. Machine learning-based preoperative analytics for the prediction of anastomotic leakage in colorectal surgery: a swiss pilot study. Surg Endosc 2024; 38:3672-3683. [PMID: 38777894 PMCID: PMC11219450 DOI: 10.1007/s00464-024-10926-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 05/05/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Anastomotic leakage (AL), a severe complication following colorectal surgery, arises from defects at the anastomosis site. This study evaluates the feasibility of predicting AL using machine learning (ML) algorithms based on preoperative data. METHODS We retrospectively analyzed data including 21 predictors from patients undergoing colorectal surgery with bowel anastomosis at four Swiss hospitals. Several ML algorithms were applied for binary classification into AL or non-AL groups, utilizing a five-fold cross-validation strategy with a 90% training and 10% validation split. Additionally, a holdout test set from an external hospital was employed to assess the models' robustness in external validation. RESULTS Among 1244 patients, 112 (9.0%) suffered from AL. The Random Forest model showed an AUC-ROC of 0.78 (SD: ± 0.01) on the internal test set, which significantly decreased to 0.60 (SD: ± 0.05) on the external holdout test set comprising 198 patients, including 7 (3.5%) with AL. Conversely, the Logistic Regression model demonstrated more consistent AUC-ROC values of 0.69 (SD: ± 0.01) on the internal set and 0.61 (SD: ± 0.05) on the external set. Accuracy measures for Random Forest were 0.82 (SD: ± 0.04) internally and 0.87 (SD: ± 0.08) externally, while Logistic Regression achieved accuracies of 0.81 (SD: ± 0.10) and 0.88 (SD: ± 0.15). F1 Scores for Random Forest moved from 0.58 (SD: ± 0.03) internally to 0.51 (SD: ± 0.03) externally, with Logistic Regression maintaining more stable scores of 0.53 (SD: ± 0.04) and 0.51 (SD: ± 0.02). CONCLUSION In this pilot study, we evaluated ML-based prediction models for AL post-colorectal surgery and identified ten patient-related risk factors associated with AL. Highlighting the need for multicenter data, external validation, and larger sample sizes, our findings emphasize the potential of ML in enhancing surgical outcomes and inform future development of a web-based application for broader clinical use.
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Affiliation(s)
- Stephanie Taha-Mehlitz
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, 4002, Basel, Switzerland
| | - Larissa Wentzler
- Medical Faculty, University Basel, 4056, Basel, Switzerland
- Center for Gastrointestinal and Liver Diseases, Cantonal Hospital Basel-Landschaft, 4410, Liestal, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, 4002, Basel, Switzerland
| | - Ahmad Hendie
- Department of Computer Engineering, McGill University, Montreal, H3A 0E9, Canada
| | - Vincent Ochs
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Hegenheimermattweg 167C Allschwil, 4123, Basel, Switzerland
| | - Julia Wolleb
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Hegenheimermattweg 167C Allschwil, 4123, Basel, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Bassey Enodien
- Department of Surgery, GZO-Hospital, 8620, Wetzikon, Switzerland
| | - Martinas Baltuonis
- Department of Surgery, Emmental Teaching Hospital, 3400, Burgdorf, Switzerland
| | - Stephan Vorburger
- Department of Surgery, Emmental Teaching Hospital, 3400, Burgdorf, Switzerland
| | - Daniel M Frey
- Department of Surgery, GZO-Hospital, 8620, Wetzikon, Switzerland
| | - Robert Rosenberg
- Center for Gastrointestinal and Liver Diseases, Cantonal Hospital Basel-Landschaft, 4410, Liestal, Switzerland
| | | | - Beat Müller-Stich
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, 4002, Basel, Switzerland
| | - Philippe C Cattin
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Hegenheimermattweg 167C Allschwil, 4123, Basel, Switzerland
| | - Anas Taha
- Center for Gastrointestinal and Liver Diseases, Cantonal Hospital Basel-Landschaft, 4410, Liestal, Switzerland.
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Hegenheimermattweg 167C Allschwil, 4123, Basel, Switzerland.
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | - Daniel Steinemann
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, 4002, Basel, Switzerland
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Skinner GC, Liu YZ, Harzman AE, Husain SG, Gasior AC, Cunningham LA, Traugott AL, McCulloh CJ, Kalady MF, Kim PC, Huang ES. Clinical Utility of Laser Speckle Contrast Imaging and Real-Time Quantification of Bowel Perfusion in Minimally Invasive Left-Sided Colorectal Resections. Dis Colon Rectum 2024; 67:850-859. [PMID: 38408871 DOI: 10.1097/dcr.0000000000003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Left-sided colorectal surgery demonstrates high anastomotic leak rates, with tissue ischemia thought to influence outcomes. Indocyanine green is commonly used for perfusion assessment, but evidence remains mixed for whether it reduces colorectal anastomotic leaks. Laser speckle contrast imaging provides dye-free perfusion assessment in real-time through perfusion heat maps and quantification. OBJECTIVE This study investigates the efficacy of advanced visualization (indocyanine green versus laser speckle contrast imaging), perfusion assessment, and utility of laser speckle perfusion quantification in determining ischemic margins. DESIGN Prospective intervention group using advanced visualization with case-matched, retrospective control group. SETTINGS Single academic medical center. PATIENTS Forty adult patients undergoing elective, minimally invasive, left-sided colorectal surgery. INTERVENTIONS Intraoperative perfusion assessment using white light imaging and advanced visualization at 3 time points: T1-proximal colon after devascularization, before transection, T2-proximal/distal colon before anastomosis, and T3-completed anastomosis. MAIN OUTCOME MEASURES Intraoperative indication of ischemic line of demarcation before resection under each visualization method, surgical decision change using advanced visualization, post hoc laser speckle perfusion quantification of colorectal tissue, and 30-day postoperative outcomes. RESULTS Advanced visualization changed surgical decision-making in 17.5% of cases. For cases in which surgeons changed a decision, the average discordance between the line of demarcation in white light imaging and advanced visualization was 3.7 cm, compared to 0.41 cm ( p = 0.01) for cases without decision changes. There was no statistical difference between the line of ischemic demarcation using laser speckle versus indocyanine green ( p = 0.16). Laser speckle quantified lower perfusion values for tissues beyond the line of ischemic demarcation while suggesting an additional 1 cm of perfused tissue beyond this line. One (2.5%) anastomotic leak occurred in the intervention group. LIMITATIONS This study was not powered to detect differences in anastomotic leak rates. CONCLUSIONS Advanced visualization using laser speckle and indocyanine green provides valuable perfusion information that impacts surgical decision-making in minimally invasive left-sided colorectal surgeries. See Video Abstract . UTILIDAD CLNICA DE LAS IMGENES DE CONTRASTE MOTEADO CON LSER Y LA CUANTIFICACIN EN TIEMPO REAL DE LA PERFUSIN INTESTINAL EN RESECCIONES COLORRECTALES DEL LADO IZQUIERDO MNIMAMENTE INVASIVAS ANTECEDENTES:La cirugía colorrectal del lado izquierdo demuestra altas tasas de fuga anastomótica, y se cree que la isquemia tisular influye en los resultados. El verde de indocianina se utiliza habitualmente para evaluar la perfusión, pero la evidencia sobre si reduce las fugas anastomóticas colorrectales sigue siendo contradictoria. Las imágenes de contraste moteado con láser proporcionan una evaluación de la perfusión sin colorantes en tiempo real a través de mapas de calor de perfusión y cuantificación.OBJETIVO:Este estudio investiga la eficacia de la evaluación de la perfusión mediante visualización avanzada (verde de indocianina versus imágenes de contraste moteado con láser) y la utilidad de la cuantificación de la perfusión con moteado láser para determinar los márgenes isquémicos.DISEÑO:Grupo de intervención prospectivo que utiliza visualización avanzada con un grupo de control retrospectivo de casos emparejados.LUGARES:Centro médico académico único.PACIENTES:Cuarenta pacientes adultos sometidos a cirugía colorrectal electiva, mínimamente invasiva, del lado izquierdo.INTERVENCIONES:Evaluación de la perfusión intraoperatoria mediante imágenes con luz blanca y visualización avanzada en tres puntos temporales: T1-colon proximal después de la devascularización, antes de la transección; T2-colon proximal/distal antes de la anastomosis; y T3-anastomosis completa.PRINCIPALES MEDIDAS DE VALORACIÓN:Indicación intraoperatoria de la línea de demarcación isquémica antes de la resección bajo cada método de visualización, cambio de decisión quirúrgica mediante visualización avanzada, cuantificación post-hoc de la perfusión con láser moteado del tejido colorrectal y resultados posoperatorios a los 30 días.RESULTADOS:La visualización avanzada cambió la toma de decisiones quirúrgicas en el 17,5% de los casos. Para los casos en los que los cirujanos cambiaron una decisión, la discordancia promedio entre la línea de demarcación en las imágenes con luz blanca y la visualización avanzada fue de 3,7 cm, en comparación con 0,41 cm (p = 0,01) para los casos sin cambios de decisión. No hubo diferencias estadísticas entre la línea de demarcación isquémica utilizando láser moteado versus verde de indocianina (p = 0,16). El moteado con láser cuantificó valores de perfusión más bajos para los tejidos más allá de la línea de demarcación isquémica y al mismo tiempo sugirió 1 cm adicional de tejido perfundido más allá de esta línea. Se produjo una fuga anastomótica (2,5%) en el grupo de intervención.LIMITACIONES:Este estudio no tuvo el poder estadístico suficiente para detectar diferencias en las tasas de fuga anastomótica.CONCLUSIONES:La visualización avanzada utilizando moteado láser y verde de indocianina proporciona información valiosa sobre la perfusión que impacta la toma de decisiones quirúrgicas en cirugías colorrectales mínimamente invasivas del lado izquierdo. (Traducción-Dr. Ingrid Melo).
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Affiliation(s)
- Garrett C Skinner
- Department of Surgery, Jacobs School of Medicine and Biochemical Sciences, University at Buffalo, Buffalo, New York
- Activ Surgical, Boston, Massachusetts
| | - Yao Z Liu
- Activ Surgical, Boston, Massachusetts
- Department of Surgery, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Alan E Harzman
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Syed G Husain
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Alessandra C Gasior
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Lisa A Cunningham
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Amber L Traugott
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | | | - Matthew F Kalady
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Peter C Kim
- Activ Surgical, Boston, Massachusetts
- Department of Surgery, The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Emily S Huang
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
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Nijssen DJ, Wienholts K, Postma MJ, Tuynman J, Bemelman WA, Laméris W, Hompes R. The economic impact of anastomotic leakage after colorectal surgery: a systematic review. Tech Coloproctol 2024; 28:55. [PMID: 38769231 PMCID: PMC11106156 DOI: 10.1007/s10151-024-02932-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) remains a burdensome complication following colorectal surgery, with increased morbidity, oncological compromise, and mortality. AL may impose a substantial financial burden on hospitals and society due to extensive resource utilization. Estimated costs associated with AL are important when exploring preventive measures and treatment strategies. The purpose of this study was to systematically review the existing literature on (socio)economic costs associated with AL after colorectal surgery, appraise their quality, compare reported outcomes, and identify knowledge gaps. METHODS Health economic evaluations reporting costs related to AL after colorectal surgery were identified through searching multiple online databases until June 2023. Pairs of reviewers independently evaluated the quality using an adapted version of the Consensus on Health Economic Criteria list. Extracted costs were converted to 2022 euros (€) and also adjusted for purchasing power disparities among countries. RESULTS From 1980 unique abstracts, 59 full-text publications were assessed for eligibility, and 17 studies were included in the review. The incremental costs of AL after correcting for purchasing power disparity ranged from €2250 (+39.9%, Romania) to €83,633 (+ 513.1%, Brazil). Incremental costs were mainly driven by hospital (re)admission, intensive care stay, and reinterventions. Only one study estimated the economic societal burden of AL between €1.9 and €6.1 million. CONCLUSIONS AL imposes a significant financial burden on hospitals and social care systems. The magnitude of costs varies greatly across countries and data on the societal burden and non-medical costs are scarce. Adherence to international reporting standards is essential to understand international disparities and to externally validate reported cost estimates.
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Affiliation(s)
- David J Nijssen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Jurriaan Tuynman
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wytze Laméris
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Rennie O, Sharma M, Helwa N. Colorectal anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks. Front Surg 2024; 11:1371567. [PMID: 38756356 PMCID: PMC11097957 DOI: 10.3389/fsurg.2024.1371567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
Background Anastomotic leaks (ALs) are a significant and feared postoperative complication, with incidence of up to 30% despite advances in surgical techniques. With implications such as additional interventions, prolonged hospital stays, and hospital readmission, ALs have important impacts at the level of individual patients and healthcare providers, as well as healthcare systems as a whole. Challenges in developing unified definitions and grading systems for leaks have proved problematic, despite acknowledgement that colorectal AL is a critical issue in intestinal surgery with serious consequences. The aim of this study was to construct a narrative review of literature surrounding definitions and grading systems for ALs, and consequences of this postoperative complication. Methods A literature review was conducted by examining databases including PubMed, Web of Science, OVID Embase, Google Scholar, and Cochrane library databases. Searches were performed with the following keywords: anastomosis, anastomotic leak, colorectal, surgery, grading system, complications, risk factors, and consequences. Publications that were retrieved underwent further assessment to ensure other relevant publications were identified and included. Results A universally accepted definition and grading system for ALs continues to be lacking, leading to variability in reported incidence in the literature. Additional factors add to variability in estimates, including differences in the anastomotic site and institutional/individual differences in operative technique. Various groups have worked to publish guidelines for defining and grading AL, with the International Study Group of Rectal Cancer (ISGRC/ISREC) definition the current most recommended universal definition for colorectal AL. The burden of AL on patients, healthcare providers, and hospitals is well documented in evidence from leak consequences, such as increased morbidity and mortality, higher reoperation rates, and increased readmission rates, among others. Conclusions Colorectal AL remains a significant challenge in intestinal surgery, despite medical advancements. Understanding the progress made in defining and grading leaks, as well as the range of negative outcomes that arise from AL, is crucial in improving patient care, reduce surgical mortality, and drive further advancements in earlier detection and treatment of AL.
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Affiliation(s)
- Olivia Rennie
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Manaswi Sharma
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
| | - Nour Helwa
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
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7
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Ng AP, Chervu N, Branche C, Bakhtiyar SS, Marzban M, Toste PA, Benharash P. National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer. PLoS One 2024; 19:e0300876. [PMID: 38547215 PMCID: PMC10977786 DOI: 10.1371/journal.pone.0300876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/06/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.
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Affiliation(s)
- Ayesha P. Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, United States of America
| | - Mehrab Marzban
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Paul A. Toste
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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8
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Schootman M, Li C, Ying J, Orcutt ST, Laryea J. Maximizing Readmission Reduction in Colon Cancer Patients. J Surg Res 2024; 295:587-596. [PMID: 38096772 PMCID: PMC10922981 DOI: 10.1016/j.jss.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/09/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Multiple studies have identified risk factors for readmission in colon cancer patients. We need to determine which risk factors, when modified, produce the greatest decrease in readmission for patients so that limited resources can be used most effectively by implementing targeted evidence-based performance improvements. We determined the potential impact of various modifiable risk factors on reducing 30-d readmission in colon cancer patients. METHODS We used a cohort design with the 2012-2020 American College of Surgeons' National Surgical Quality Improvement Program data to track colon cancer patients for 30 d following surgery. Colon cancer patients who received colectomies and were discharged alive were included. Readmission (to the same or another hospital) for any reason within 30 d of the resection was the outcome measure. Modifiable risk factors were the use of minimally invasive surgery (MIS) versus open colectomy, mechanical bowel preparation, preoperative antibiotic use, functional status, smoking, complications (deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, infections, anastomotic leakage, prolonged postoperative ileus, extensive blood loss, and sepsis), serum albumin, and hematocrit. RESULTS 111,691 patients with colon cancer were included in the analysis. About half of the patients were male, most were aged 75 or older, and were discharged home. Overall, 11,138 patients (10.0%) were readmitted within 30 d of surgery. In adjusted analysis, the reduction in readmission would be largest by preventing both prolonged ileus and by switching open colectomies to MIS (28.0% relative reduction) followed by preventing anastomotic leaks (6.2% relative reduction). Improving other modifiable risk factors would have a more limited impact. CONCLUSIONS The focus of readmission reduction should be on preventing prolonged ileus, increasing the use of MIS, and preventing anastomotic leaks.
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Affiliation(s)
- Mario Schootman
- Division of Community Health and Research, Department of Internal Medicine, College of Medicine, The University of Arkansas for Medical Sciences, Springdale, Arkansas; Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jun Ying
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Biostatistics, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sonia T Orcutt
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Surgical Oncology, Department of Surgery, College of Medicine, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jonathan Laryea
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Division of Colorectal Surgery, Department of Surgery, College of Medicine, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
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9
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Farzaneh C, Uppal A, Jafari MD, Duong WQ, Carmichael JC, Mills SD, Stamos MJ, Pigazzi A. Validation of an endoscopic anastomotic grading score as an intraoperative method for assessing stapled rectal anastomoses. Tech Coloproctol 2023; 27:1235-1242. [PMID: 37184769 DOI: 10.1007/s10151-023-02797-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Anastomotic leak is a dreaded complication of colorectal surgery. An endoscopic grading score of the perianastomotic mucosa has been previously developed at our institution (UCI) to assess colorectal anastomotic integrity. The objective of this study is to validate the UCI anastomotic score and determine its impact in anastomotic failure. METHODS As a follow-up study of the UCI grading score implementation during 2011 to 2014, patients undergoing stapled colorectal anastomoses after sigmoidectomy or proctectomy at a single institution from 2015 to 2018 were retrospectively reviewed. Patients were grouped into three tiers based on endoscopic appearance (grade 1, circumferentially normal mucosa; grade 2, ischemia/congestion < 30% of circumference; grade 3, ischemia/congestion > 30% of circumference). RESULTS On the basis of endoscopic mucosal evaluation, grade 1 anastomosis was observed in 299 patients (94%), grade 2 anastomosis in 14 patients (4.4%), and grade 3 anastomosis in 5 patients (1.6%). All grade 3 classifications were immediately and successfully revised intraoperatively with reclassification as a grade 1 anastomosis. The anastomotic leak rate of the follow-up study period from 2015 to 2018 was 6.4% which was lower compared to the anastomotic leak rate of 12.2% in the original study period from 2011 to 2014 (p = 0.07). Anastomotic leak rate for the entire patient series was 8.5%. A grade 2 anastomosis was associated with higher anastomotic leak rate compared to a grade 1 anastomosis (35.7% vs. 7.4%, p < 0.05). None of the five grade 3 anastomoses resulted in an anastomotic leak upon revision. CONCLUSION This study further validates the anastomotic grading score and suggests that its systematic implementation can result in a reduction in anastomotic leaks.
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Affiliation(s)
- C Farzaneh
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - A Uppal
- Division of Surgery, Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M D Jafari
- Department of Surgery, New York Presbyterian Hospital Weill Cornell College of Medicine, 525 E 68th Street, NY, New York, USA
| | - W Q Duong
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - J C Carmichael
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - S D Mills
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - M J Stamos
- Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - A Pigazzi
- Department of Surgery, New York Presbyterian Hospital Weill Cornell College of Medicine, 525 E 68th Street, NY, New York, USA.
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10
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Boatman S, Kaiser T, Nalluri-Butz H, Khan MH, Dietz M, Kohn J, Johnson AJ, Gaertner WB, Staley C, Jahansouz C. Diet-induced shifts in the gut microbiota influence anastomotic healing in a murine model of colonic surgery. Gut Microbes 2023; 15:2283147. [PMID: 37990909 PMCID: PMC10730186 DOI: 10.1080/19490976.2023.2283147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
Host diet and gut microbiota interact to contribute to perioperative complications, including anastomotic leak (AL). Using a murine surgical model of colonic anastomosis, we investigated how diet and fecal microbial transplantation (FMT) impacted the intestinal microbiota and if a predictive signature for AL could be determined. We hypothesized that a Western diet (WD) would impact gut microbial composition and that the resulting dysbiosis would correlate with increased rates of AL, while FMT from healthy, lean diet (LD) donors would reduce the risk of AL. Furthermore, we predicted that surgical outcomes would allow for the development of a microbial preclinical translational tool to identify AL. Here, we show that AL is associated with a dysbiotic microbial community characterized by increased levels of Bacteroides and Akkermansia. We identified several key taxa that were associated with leak formation, and developed an index based on the ratio of bacteria associated with the absence and presence of leak. We also highlight a modifiable connection between diet, microbiota, and anastomotic healing, potentially paving the way for perioperative modulation by microbiota-targeted therapeutics to reduce AL.
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Affiliation(s)
- Sonja Boatman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Thomas Kaiser
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | | | - Mohammad Haneef Khan
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Matthew Dietz
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Julia Kohn
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Abigail J Johnson
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Wolfgang B Gaertner
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Christopher Staley
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- BioTechnology Institute, University of Minnesota, St. Paul, MN, USA
| | - Cyrus Jahansouz
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
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11
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Nwaiwu CA, McCulloh CJ, Skinner G, Shah SK, Kim PCW, Schwaitzberg SD, Wilson EB. Real-time First-In-Human Comparison of Laser Speckle Contrast Imaging and ICG in Minimally Invasive Colorectal & Bariatric Surgery. J Gastrointest Surg 2023; 27:3083-3085. [PMID: 37848691 DOI: 10.1007/s11605-023-05855-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/29/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Chibueze A Nwaiwu
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Activ Surgical Inc., 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | | | - Garrett Skinner
- Activ Surgical Inc., 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY, USA
- Department of Surgery, The State University of New York, Buffalo, NY, USA
- Buffalo General Hospital, Buffalo, NY, USA
| | - Shinil K Shah
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA
| | - Peter C W Kim
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Activ Surgical Inc., 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA.
| | - Steven D Schwaitzberg
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY, USA
- Department of Surgery, The State University of New York, Buffalo, NY, USA
- Buffalo General Hospital, Buffalo, NY, USA
| | - Erik B Wilson
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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12
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Talboom K, Greijdanus NG, Brinkman N, Blok RD, Roodbeen SX, Ponsioen CY, Tanis PJ, Bemelman WA, Cunningham C, de Lacy FB, Hompes R. Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series. Tech Coloproctol 2023; 27:1099-1108. [PMID: 37212927 PMCID: PMC10562258 DOI: 10.1007/s10151-023-02808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/15/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR. METHODS This retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up. RESULTS Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008). CONCLUSION Proactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N G Greijdanus
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N Brinkman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S X Roodbeen
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Y Ponsioen
- Department of Gastro-Enterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F B de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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13
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Mukai T, Maki A, Shimizu H, Kim H. The economic burdens of anastomotic leakage for patients undergoing colorectal surgery in Japan. Asian J Surg 2023; 46:4323-4329. [PMID: 37423861 DOI: 10.1016/j.asjsur.2023.06.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 04/07/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Affiliation(s)
- Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Akihiro Maki
- Johnson & Johnson K.K. Medical Company, 3-5-2 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Hideharu Shimizu
- Johnson & Johnson K.K. Medical Company, 3-5-2 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Hyesung Kim
- Johnson and Johnson Medical, 92 Hangang-daero, Yongsan-gu, Seoul, 04386, South Korea
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14
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Biancucci A, Fassari A, Lucchese S, Santoro E, Lirici MM. Use of quantitative indocyanine green near-infrared fluorescence imaging in bariatric surgery: early results. MINIM INVASIV THER 2023; 32:249-255. [PMID: 37039717 DOI: 10.1080/13645706.2023.2197049] [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: 09/22/2022] [Accepted: 03/22/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION Indocyanine green fluorescence angiography (ICG-FA) is commonly used in general surgery, but its use in bariatric surgery is still marginal. Moreover, post-operative leaks remain a dramatic complication after this surgery and the leak tests available have poor performance preventing them. The aim of the present paper is to assess the use and utility of a new innovative technology based on quantitative measures of fluorescence signal intensity. MATERIAL AND METHODS From January 2022 to June 2022, 40 consecutive patients with a median age of 51 years and a preoperative median body mass index of 45.2 kg/m2 underwent bariatric surgery with quantitative ICG fluorescence angiography in our center. Two different types of surgery, based on the multidisciplinary evaluation, were performed: laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB). For ICG visualization, quantitative laparoscopic ICG platform was used to identify the vascular supply. RESULTS Thirteen patients underwent LSG and 27 patients underwent OAGB. ICG was performed in all patients with no adverse events. An adequate and satisfactory blood supply was assessed in each case. No case of post-operative leak was detected. CONCLUSIONS The quantitative ICG-FA seems to be a useful and promising tool for the prevention of complications in bariatric surgery but further studies are mandatory.
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Affiliation(s)
- Andrea Biancucci
- Department of Surgical Oncology, San Giovanni Addolorata Hospital Complex, Rome, Italy
| | - Alessia Fassari
- Department of Surgical Oncology, San Giovanni Addolorata Hospital Complex, Rome, Italy
| | - Sara Lucchese
- Department of Surgical Oncology, San Giovanni Addolorata Hospital Complex, Rome, Italy
| | - Emanuele Santoro
- Department of Surgical Oncology, San Giovanni Addolorata Hospital Complex, Rome, Italy
| | - Marco Maria Lirici
- Center for Advanced Laparoscopic Surgery and Multidisciplinary Obesity Unit, Nuova Clinica Annunziatella, Rome, Italy
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15
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Gagner M, Cadiere GB, Sanchez-Pernaute A, Abuladze D, Krinke T, Buchwald JN, Van Sante N, Van Gossum M, Dziakova J, Koiava L, Odovic M, Poras M, Almutlaq L, Torres AJ. Side-to-side magnet anastomosis system duodeno-ileostomy with sleeve gastrectomy: early multi-center results. Surg Endosc 2023; 37:6452-6463. [PMID: 37217682 PMCID: PMC10202352 DOI: 10.1007/s00464-023-10134-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/08/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Gastrointestinal anastomoses with classical sutures and/or metal staples have resulted in significant bleeding and leak rates. This multi-site study evaluated the feasibility, safety, and preliminary effectiveness of a novel linear magnetic compression anastomosis device, the Magnet System (MS), to form a side-to-side duodeno-ileostomy (DI) diversion for weight loss and type 2 diabetes (T2D) resolution. METHODS In patients with class II and III obesity (body mass index [BMI, kg/m2] ≥ 35.0- ≤ 50.0 with/without T2D [HbA1C > 6.5%]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating DI; sleeve gastrectomy (SG) was added. There were no bowel incisions or retained sutures/staples. Fused magnets were expelled naturally. Adverse events (AEs) were graded by Clavien-Dindo Classification (CDC). RESULTS Between November 22, 2021 and July 18, 2022, 24 patients (83.3% female, mean ± SEM weight 121.9 ± 3.3 kg, BMI 44.4 ± 0.8) in three centers underwent magnetic DI. Magnets were expelled at a median 48.5 days. Respective mean BMI, total weight loss, and excess weight loss at 6 months (n = 24): 32.0 ± 0.8, 28.1 ± 1.0%, and 66.2 ± 3.4%; at 12 months (n = 5), 29.3 ± 1.5, 34.0 ± 1.4%, and 80.2 ± 6.6%. Group mean respective mean HbA1C and glucose levels dropped to 1.1 ± 0.4% and 24.8 ± 6.6 mg/dL (6 months); 2.0 ± 1.1% and 53.8 ± 6.3 mg/dL (12 months). There were 0 device-related AEs, 3 procedure-related serious AEs. No anastomotic bleeding, leakage, stricture, or mortality. CONCLUSION In a multi-center study, side-to-side Magnet System duodeno-ileostomy with SG in adults with class III obesity appeared feasible, safe, and effective for weight loss and T2D resolution in the short term.
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Affiliation(s)
- Michel Gagner
- Westmount Square Surgical Center, Westmount, QC, Canada.
- Westmount Square Surgical Center, 1 Westmount Square, Suite 801, Westmount, QC, H3Z2P9, Canada.
| | | | | | | | | | - J N Buchwald
- Medwrite Medical Communications, Maiden Rock, WI, USA
| | | | | | | | - Levan Koiava
- Innova Medical Center, Tbilisi, Republic of Georgia
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Dietz DW, Padula WV, Zheng H, Monson JRT, Pronovost PJ. Improving Value in Surgery: Opportunities in Rectal Cancer Care. A Surgical Perspective. Ann Surg 2023; 277:e1193-e1196. [PMID: 36538646 DOI: 10.1097/sla.0000000000005751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- David W Dietz
- Division of Colorectal Surgery, University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - William V Padula
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
| | - Hanke Zheng
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Digestive Health and Surgery Institute, AdventHealth, Orlando, FL
| | - Peter J Pronovost
- Department of Anesthesia and Critical Care Medicine, School of Medicine, University Hospitals, Case Western Reserve University, Cleveland, OH
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Huynh M, Tjandra R, Helwa N, Okasha M, El-Falou A, Helwa Y. Continuous pH monitoring using a sensor for the early detection of anastomotic leaks. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1128460. [PMID: 37275781 PMCID: PMC10235488 DOI: 10.3389/fmedt.2023.1128460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/04/2023] [Indexed: 06/07/2023] Open
Abstract
Anastomotic leaks (AL) and staple line leaks are a serious post-operative complication that can develop following bariatric surgery. The delay in the onset of symptoms following a leak usually results in reactive diagnostics and treatment, leading to increased patient morbidity and mortality, and a clinical and economic burden on both the patient and the hospital. Despite support in literature for pH as a biomarker for early detection of AL, the current methods of pH detection require significant clinician involvement and resources. Presented here is a polyaniline (PANI)-based pH sensor that can be connected inline to surgical drains to continuously monitor peritoneal secretion in real time for homeostatic changes in pH. During this study, the baseline peritoneal fluid pH was measured in two pigs using the PANI sensor and verified using a benchtop pH probe. The PANI sensor was then utilized to continuously monitor the changes in the pH of peritoneal effluent, as a gastric leak was simulated. The inline sensors were able to detect the resulting local changes in drainage pH within 10 min of leak induction. The successful implementation of this sensor in clinical practice can both enable high efficiency continuous monitoring of patient status and drastically decrease the time required to detect AL, thus potentially decreasing the clinical and economic burden incurred by gastric leaks.
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Affiliation(s)
- Michelle Huynh
- FluidAI Medical, Kitchener, ON, Canada
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON, Canada
| | | | | | - Mohamed Okasha
- FluidAI Medical, Kitchener, ON, Canada
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
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18
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Liu YZ, Mehrotra S, Nwaiwu CA, Buharin VE, Oberlin J, Stolyarov R, Schwaitzberg SD, Kim PCW. Real-time quantification of intestinal perfusion and arterial versus venous occlusion using laser speckle contrast imaging in porcine model. Langenbecks Arch Surg 2023; 408:114. [PMID: 36859714 DOI: 10.1007/s00423-023-02845-0] [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: 09/01/2022] [Accepted: 02/16/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Real-time intraoperative perfusion assessment may reduce anastomotic leaks. Laser speckle contrast imaging (LSCI) provides dye-free visualization of perfusion by capturing coherent laser light scatter from red blood cells and displays perfusion as a colormap. Herein, we report a novel method to precisely quantify intestinal perfusion using LSCI. METHODS ActivSight™ is an FDA-cleared multi-modal visualization system that can detect and display perfusion via both indocyanine green imaging (ICG) and LSCI in minimally invasive surgery. An experimental prototype LSCI perfusion quantification algorithm was evaluated in porcine models. Porcine small bowel was selectively devascularized to create regions of perfused/watershed/ischemic bowel, and progressive aortic inflow/portal vein outflow clamping was performed to study arterial vs. venous ischemia. Continuous arterial pressure was monitored via femoral line. RESULTS LSCI perfusion colormaps and quantification distinguished between perfused, watershed, and ischemic bowel in all vascular control settings: no vascular occlusion (p < 0.001), aortic occlusion (p < 0.001), and portal venous occlusion (p < 0.001). LSCI quantification demonstrated similar levels of ischemia induced both by states of arterial inflow and venous outflow occlusion. LSCI-quantified perfusion values correlated positively with higher mean arterial pressure and with increasing distance from ischemic bowel. CONCLUSION LSCI relative perfusion quantification may provide more objective real-time assessment of intestinal perfusion compared to conventional naked eye assessment by quantifying currently subjective gradients of bowel ischemia and identifying both arterial/venous etiologies of ischemia.
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Affiliation(s)
- Yao Z Liu
- Department of Surgery, Brown University, Providence, RI, USA
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | - Saloni Mehrotra
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Chibueze A Nwaiwu
- Department of Surgery, Brown University, Providence, RI, USA
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | | | - John Oberlin
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | - Roman Stolyarov
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA
| | | | - Peter C W Kim
- Department of Surgery, Brown University, Providence, RI, USA.
- Activ Surgical, 30 Thomson Pl, 2nd Floor, Boston, MA, 02210, USA.
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Flor-Lorente B, Noguera-Aguilar JF, Delgado-Rivilla S, García-González JM, Rodriguez-Martín M, Salinas-Ortega L, Casado MÁ, Álvarez M. The economic impact of anastomotic leak after colorectal cancer surgery. HEALTH ECONOMICS REVIEW 2023; 13:12. [PMID: 36795234 PMCID: PMC9933261 DOI: 10.1186/s13561-023-00425-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To determine the economic impact of the incremental consumption of resources for the diagnosis and treatment of anastomotic leak (AL) in patients after resection with anastomosis for colorectal cancer compared to patients without AL on the Spanish health system. METHOD This study included a literature review with parameters validated by experts and the development of a cost analysis model to estimate the incremental resource consumption of patients with AL versus those without. The patients were divided into three groups: 1) colon cancer (CC) with resection, anastomosis and AL; 2) rectal cancer (RC) with resection, anastomosis without protective stoma and AL; and 3) RC with resection, anastomosis with protective stoma and AL. RESULTS The average total incremental cost per patient was €38,819 and €32,599 for CC and RC, respectively. The cost of AL diagnosis per patient was €1018 (CC) and €1030 (RC). The cost of AL treatment per patient in Group 1 ranged from €13,753 (type B) to €44,985 (type C + stoma), that in Group 2 ranged from €7348 (type A) to €44,398 (type C + stoma), and that in Group 3 ranged from €6197 (type A) to €34,414 (type C). Hospital stays represented the highest cost for all groups. In RC, protective stoma was found to minimize the economic consequences of AL. CONCLUSIONS The appearance of AL generates a considerable increase in the consumption of health resources, mainly due to an increase in hospital stays. The more complex the AL, the higher the cost associated with its treatment. INTEREST OF THE STUDY: it is the first cost-analysis study of AL after CR surgery based on prospective, observational and multicenter studies, with a clear, accepted and uniform definition of AL and estimated over a period of 30 days.
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Affiliation(s)
- Blas Flor-Lorente
- Colorectal Surgery Unit. Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | | | - María Álvarez
- Health Economics & Outcomes Research Unit (Medtronic Ibérica, S.A.), Madrid, Spain.
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20
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Nwaiwu CA, Buharin VE, Mach A, Grandl R, King ML, Dechert AF, O'Shea L, Schwaitzberg SD, Kim PCW. Feasibility and comparison of laparoscopic laser speckle contrast imaging to near-infrared display of indocyanine green in intraoperative tissue blood flow/tissue perfusion in preclinical porcine models. Surg Endosc 2023; 37:1086-1095. [PMID: 36114346 DOI: 10.1007/s00464-022-09583-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if laser speckle contrast imaging (LSCI) mitigates variations and subjectivity in the use and interpretation of indocyanine green (ICG) fluorescence in the current visualization paradigm of real-time intraoperative tissue blood flow/perfusion in clinically relevant scenarios. METHODS De novo laparoscopic imaging form-factor detecting real-time blood flow using LSCI and blood volume by near-infrared fluorescence (NIRF) of ICG was compared to ICG NIRF alone, for dye-less real-time visualization of tissue blood flow/perfusion. Experienced surgeons examined LSCI and ICG in segmentally devascularized intestine, partial gastrectomy, and the renal hilum across six porcine models. Precision and accuracy of identifying demarcating lines of ischemia/perfusion in tissues were determined in blinded subjects with varying levels of surgical experience. RESULTS Unlike ICG, LSCI perfusion detection was real time (latency < 150 ms: p < 0.01), repeatable and on-demand without fluorophore injection. Operating surgeons (n = 6) precisely and accurately identified concordant demarcating lines in white light, LSCI, and ICG modes immediately. Blinded subjects (n = 21) demonstrated similar spatial-temporal precision and accuracy with all three modes ≤ 2 min after ICG injection, and discordance in ICG mode at ≥ 5 min in devascularized small intestine (p < 0.0001) and in partial gastrectomy (p < 0.0001). CONCLUSIONS Combining LSCI for near real-time blood flow detection with ICG fluorescence for blood volume detection significantly improves precision and accuracy of perfusion detection in tissue locations over time, in real time, and repeatably on-demand than ICG alone.
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Affiliation(s)
- Chibueze A Nwaiwu
- Department of Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Vasiliy E Buharin
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Anderson Mach
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Robin Grandl
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Matthew L King
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Alyson F Dechert
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | - Liam O'Shea
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA
| | | | - Peter C W Kim
- Department of Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA.
- Activ Surgical Inc, 30 Thomson Place, 2nd Floor, Boston, MA, 02127, USA.
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21
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Weber MC, Berlet M, Stoess C, Reischl S, Wilhelm D, Friess H, Neumann PA. A nationwide population-based study on the clinical and economic burden of anastomotic leakage in colorectal surgery. Langenbecks Arch Surg 2023; 408:55. [PMID: 36683099 PMCID: PMC9868041 DOI: 10.1007/s00423-023-02809-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/11/2023] [Indexed: 01/24/2023]
Abstract
AIM Anastomotic leakage (AL) is one of the most dreaded complications in colorectal surgery. In 2013, the International Classification of Diseases code K91.83 for AL was introduced in Germany, allowing nationwide analysis of AL rates and associated parameters. The aim of this population-based study was to investigate the current incidence, risk factors, mortality, clinical management, and associated costs of AL in colorectal surgery. METHODS A data query was performed based on diagnosis-related group data of all hospital cases of inpatients undergoing colon or sphincter-preserving rectal resections between 2013 and 2018 in Germany. RESULTS A total number of 690,690 inpatient cases were included in this study. AL rates were 6.7% for colon resections and 9.2% for rectal resections in 2018. Regarding the treatment of AL, the application of endoluminal vacuum therapy increased during the studied period, while rates of relaparotomy, abdominal vacuum therapy, and terminal enterostomy remained stable. AL was associated with significantly increased in-house mortality (7.11% vs. 20.11% for colon resections and 3.52% vs. 11.33% for rectal resections in 2018) and higher socioeconomic costs (mean hospital reimbursement volume per case: 14,877€ (no AL) vs. 37,521€ (AL) for colon resections and 14,602€ (no AL) vs. 30,606€ (AL) for rectal resections in 2018). CONCLUSIONS During the studied time period, AL rates did not decrease, and associated mortality remained at a high level. Our study provides updated population-based data on the clinical and economic burden of AL in Germany. Focused research in the field of AL is still urgently necessary to develop targeted strategies to prevent AL, improve patient care, and decrease socioeconomic costs.
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Affiliation(s)
- Marie-Christin Weber
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Maximilian Berlet
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christian Stoess
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Reischl
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, Munich, Germany.
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22
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Liu RQ, Elnahas A, Tang E, Alkhamesi NA, Hawel J, Alnumay A, Schlachta CM. Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery. Surg Endosc 2022; 36:9281-9287. [PMID: 35290507 DOI: 10.1007/s00464-022-09166-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. METHODS A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. RESULTS The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. CONCLUSION Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.
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Affiliation(s)
- Rachel Q Liu
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Ahmad Elnahas
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Ephraim Tang
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Nawar A Alkhamesi
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Abdulaziz Alnumay
- Department of Surgery, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Christopher M Schlachta
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada.
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada.
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23
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Rama NJG, Lourenço Ó, Motta Lima PC, Guarino MPS, Parente D, Castro R, Bento A, Rocha A, Castro-Poças F, Pimentel J. Development of a warning score for early detection of colorectal anastomotic leakage: Hype or hope? World J Gastrointest Surg 2022; 14:1297-1309. [PMID: 36504511 PMCID: PMC9727571 DOI: 10.4240/wjgs.v14.i11.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/12/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL), a severe postoperative complication, is associated with high morbidity, hospital readmission, and overall healthcare costs. Early detection of CAL remains a challenge in clinical practice. However, some decision models have been developed to increase the diagnostic accuracy of this event.
AIM To develop a score based on easily accessible variables to detect CAL early.
METHODS Based on the least absolute shrinkage and selection operator method, a predictive classification system was developed [Early ColoRectAL Leakage (E-CRALL) score] from a prospective observational, single center cohort, carried out in a colorectal division from a non-academic hospital. The score performance and CAL threshold from postoperative day (POD) 3 to POD5 were estimated. Based on a precise analytical decision model, the standard clinical practice was compared with the E-CRALL adoption on POD3, POD4, or POD5. A cost-minimization analysis was conducted, on the assumption that all alternatives delivered similar health-related effects.
RESULTS In this study, 396 patients who underwent colorectal resection surgery with anastomosis, and 6.3% (n = 25) developed CAL. Most of the patients who developed CAL (n = 23; 92%) were diagnosed during the first hospital admission, with a median time of diagnosis of 9.0 ± 6.8 d. From POD3 to POD5, the area under the receiver operating characteristic curve of the E-CRALL score was 0.82, 0.84, and 0.95, respectively. On POD5, if a threshold of 8.29 was chosen, 87.4% of anastomotic failures were identified with E-CRALL adoption. Additionally, score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d, if used on POD3 and POD5, respectively. Regardless of score adoption, episode comprehensive costs were markedly greater (up to four times) in patients who developed CAL in comparison with patients who did not develop CAL. Nonetheless, the use of the E-CRALL warning score was associated with cost savings of €421442.20, with most (92.9%) of the savings from patients who did not develop CAL.
CONCLUSION The E-CRALL score is an accessible tool to predict CAL at an early timepoint. Additionally, E-CRALL can reduce overall healthcare costs, mainly in the reduction of hospital costs, independent of whether a patient developed CAL.
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Affiliation(s)
- Nuno J G Rama
- Division of Colorectal Surgical, Leiria Hospital Centre, Leiria 2410-021, Portugal
- Abel Salazar Biomedical Institute, University of Oporto, Oporto 4099-002, Portugal
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Óscar Lourenço
- Faculty of Economics, CeBER, University of Coimbra, Coimbra 3000-137, Portugal
| | | | - Maria Pedro S Guarino
- Center for Innovative Care and Health Technology (ciTechCare), Polytechnic of Leiria, Leiria 2410-541, Portugal
| | - Diana Parente
- Division of Colorectal Surgical, Leiria Hospital Centre, Leiria 2410-021, Portugal
| | - Ricardo Castro
- Division of Clinical Pathology, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Ana Bento
- Division of Clinical Pathology, Leiria Hospital Centre, Leiria 2410-541, Portugal
| | - Anabela Rocha
- Abel Salazar Biomedical Institute, University of Oporto, Oporto 4099-002, Portugal
- Division of Surgical, Oporto Hospital Centre, Oporto 4099-001, Portugal
| | - Fernando Castro-Poças
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Oporto 4099-001, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of OPorto, Oporto 4099-001, Portugal
| | - João Pimentel
- Faculty of Medicine, University of Coimbra, Coimbra 3004-531, Portugal
- Division of Surgical, Montes Claros Hospital, Coimbra 3030-320, Portugal
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24
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Talboom K, Greijdanus NG, Ponsioen CY, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum-assisted surgical closure (EVASC) of anastomotic defects after low anterior resection for rectal cancer; lessons learned. Surg Endosc 2022; 36:8280-8289. [PMID: 35534735 PMCID: PMC9613741 DOI: 10.1007/s00464-022-09274-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic vacuum-assisted surgical closure (EVASC) is an emerging treatment for AL, and early initiation of treatment seems to be crucial. The objective of this study was to report on the efficacy of EVASC for anastomotic leakage (AL) after rectal cancer resection and determine factors for success. METHODS This retrospective cohort study included all rectal cancer patients treated with EVASC for a leaking primary anastomosis after LAR at a tertiary referral centre (July 2012-April 2020). Early initiation (≤ 21 days) or late initiation of the EVASC protocol was compared. Primary outcomes were healed and functional anastomosis at end of follow-up. RESULTS Sixty-two patients were included, of whom 38 were referred. Median follow-up was 25 months (IQR 14-38). Early initiation of EVASC (≤ 21 days) resulted in a higher rate of healed anastomosis (87% vs 59%, OR 4.43 [1.25-15.9]) and functional anastomosis (80% vs 56%, OR 3.11 [1.00-9.71]) if compared to late initiation. Median interval from AL diagnosis to initiation of EVASC was significantly shorter in the early group (11 days (IQR 6-15) vs 70 days (IQR 39-322), p < 0.001). A permanent end-colostomy was created in 7% and 28%, respectively (OR 0.18 [0.04-0.93]). In 17 patients with a non-defunctioned anastomosis, and AL diagnosis within 2 weeks, EVASC resulted in 100% healed and functional anastomosis. CONCLUSION Early initiation of EVASC for anastomotic leakage after rectal cancer resection yields high rates of healed and functional anastomosis. EVASC showed to be progressively more successful with the implementation of highly selective diversion and early diagnosis of the leak.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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25
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Hornock S, Grasso S, Hamdan M, Bader J, Ahnfeldt E, Clapp B. Does endoscopy at the time of revisional bariatric surgery decrease complication rates? an analysis of the NSQIP database. Surg Endosc 2022:10.1007/s00464-022-09648-2. [PMID: 36315283 DOI: 10.1007/s00464-022-09648-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Endoscopy is performed routinely during bariatric surgery. It is often used for provocative testing and intraluminal inspection during Roux-en-Y gastric bypass (RNYGB) and sleeve gastrectomy (SG). Recent publications would indicate about one-quarter of bariatric cases are performed with concurrent endoscopy, resulting in a slight increase in time but no increase in complications within 30 days compared with cases where no endoscopy is performed. Do these results persist for endoscopy during revisional bariatric surgery (RBS)? METHODS An analysis of the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) was conducted for the years 2005-2017. Seventeen postoperative outcomes were analyzed in this database. A 1:1 propensity score matching analysis was completed for 13 patient comorbidities and demographics. A McNemar's test for paired categorical variables and a paired t-test for continuous variables were completed, with a significant P value of 0.05. The results were reported as the frequency and percentage for categorical variables and the mean (± standard deviation) for continuous variables. RESULTS A total of 7249 RBS cases were identified. After propensity score matching for patient comorbidities and demographics 2329 cases remained. Esophagogastroduodenoscopy (EGD) was performed in 375 (16%) of these patients. There were no differences in complication rates between the two groups. CONCLUSIONS Similar to non-revisional bariatric surgery, there is no difference in 30-day postoperative complications when endoscopy is performed in RBS. Endoscopy is performed in about one-sixth of RBS cases.
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Affiliation(s)
- Sasha Hornock
- Department of Surgery, William Beaumont Army Medical Center, 18511 Highlander Medics St., El Paso, TX, 79918, USA.
| | - Samuel Grasso
- Department of Surgery, William Beaumont Army Medical Center, 18511 Highlander Medics St., El Paso, TX, 79918, USA
| | - Marah Hamdan
- Department of Surgery, Lehigh Valley Health Network, Allentown, PA, USA
| | - Julia Bader
- Department of Surgery, William Beaumont Army Medical Center, 18511 Highlander Medics St., El Paso, TX, 79918, USA
| | - Eric Ahnfeldt
- Department of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Benjamin Clapp
- Department of Surgery, Texas Tech Health Sciences Center, El Paso, TX, USA
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26
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Talboom K, Greijdanus NG, van Workum F, Ubels S, Rosman C, Hompes R, de Wilt JHW, Tanis PJ. International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study. Int J Colorectal Dis 2022; 37:2049-2059. [PMID: 36002748 PMCID: PMC9436864 DOI: 10.1007/s00384-022-04240-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Little is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide. METHODS In this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases). RESULTS In total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy. CONCLUSION This TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
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27
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Burstein MD, Myneni AA, Towle-Miller LM, Simmonds I, Gray J, Schwaitzberg SD, Noyes K, Hoffman AB. Outcomes following robot-assisted versus laparoscopic sleeve gastrectomy: the New York State experience. Surg Endosc 2022; 36:6878-6885. [PMID: 35157123 DOI: 10.1007/s00464-022-09026-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) represents more than half of all bariatric procedures in the USA, and robot-assisted sleeve gastrectomy (RSG) is becoming increasingly common. There is a paucity of evidence regarding postoperative surgical outcomes (> 30 days) in RSG patients, especially as these patients move between multiple hospital systems. METHODS Using 2012-2018 New York State's inpatient and ambulatory data from the Statewide Planning and Research Cooperative System, bivariate and multivariate analyses were employed to examine patient long-term outcomes, postoperative complications, and charges following RSG versus LSG in unmatched and propensity score-matched (PSM) samples. RESULTS Among the 72,157 minimally invasive sleeve gastrectomies identified, 2365 (2.6%) were RSGs. In the PSM sample (2365 RSG matched to 23,650 LSG), RSG cases were more likely to be converted to an open procedure (2.3% vs 0.2% LSG patients, p < 0.01) and had a longer mean length of stay (LOS; 2.1 vs. 1.8 days LSG, p < 0.01). Postoperative complications were not different between RSG and LSG patients, but the proportion of emergency room visits resulting in inpatient readmissions was higher among RSG patients (5.5% vs. 4.2% in LSG patients, p < .01). Among the super obese (body mass index ≥ 50) patients, conversions to open procedure and LOS were also significantly higher for RSG versus LSG cases. Average hospital charges for the index admission ($47,623 RSG vs $35,934 LSG) and cumulative changes for 1 year from the date of surgery ($57,484 RSG vs $43,769 LSG) were > 30% higher for RSG patients. CONCLUSIONS RSG patients were more likely to have conversions to open procedures, longer postoperative stay, readmissions, and higher charges for both the index admission and beyond, compared to LSG patients. No clear advantages emerged for the utilization of the robotic platform for either average risk or extremely obese patients.
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Affiliation(s)
- Matthew D Burstein
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Ajay A Myneni
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Lorin M Towle-Miller
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Iman Simmonds
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Justin Gray
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Steven D Schwaitzberg
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Katia Noyes
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Aaron B Hoffman
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA.
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The Effects of Anastomotic Leaks on the Net Revenue from Colon Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159426. [PMID: 35954784 PMCID: PMC9368338 DOI: 10.3390/ijerph19159426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 01/27/2023]
Abstract
Background: Complications in colon surgery can have severe health consequences, while at the same time, they are associated with increased costs. An anastomotic leak (AL) is associated with significantly increased costs compared to cases without. The aim of our analysis was to evaluate, which individual processes and patient-unrelated factors influencing the treatment process of colon surgery are responsible for the financial burden in patients with AL. Methods: Data from 263 patients who underwent colon surgery in Wetzikon hospital between January 2018 and December 2020 and was analyzed. In these 263 cases, 12 anastomotic leaks occurred and were compared with 36 cases without AL using a Propensity Score Matching (PSM). The covariates for the PSM have been Age, Sex, and Type of Surgery (t value: −3.26, p-value: 0.001). Results: A total of 48 surgeries were broken down in terms of costs and profitability. This reflected a mean deficit of −37,527 CHF per case (range from −130.05 to +755 CHF) for patients with AL, whereas a mean profit of 1590 CHF per case (range from −24.37 to +12.65 CHF) for those without AL (p < 0.001). Thus, the difference in profit showed a factor of 24.6 with an overall significant negative outcome for the occurrence of AL. The main cost contributing factors were the length of hospital stay (~p < 0.05) and length of intensive care (p < 0.05), whereas neither surgical operation time and anesthesia time nor surgical access, insurance status, indication or type of operation had a significant influence on the net revenue. Conclusion: AL after colon surgery leads to a significant deficit regarding the net revenue. Regarding process optimization, our analysis identified several sectors of non-patient-related, yet cost-influencing variables that should be addressed in future evaluations and optimization of the colon surgery treatment processes.
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Carlini M, Grieco M, Spoletini D, Menditto R, Napoleone V, Brachini G, Mingoli A, Marcellinaro R. Implementation of the gut microbiota prevents anastomotic leaks in laparoscopic colorectal surgery for cancer:the results of the MIRACLe study. Updates Surg 2022; 74:1253-1262. [PMID: 35739383 DOI: 10.1007/s13304-022-01305-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/17/2022] [Indexed: 10/17/2022]
Abstract
The aim of this pilot study was to evaluate the effects of a novel perioperative treatment for the implementation of the gut microbiota, to prevent anastomotic fistula and leakage (AL) in patients undergoing laparoscopic colorectal resections for cancer. A series of 60 patients who underwent elective colorectal surgery at S. Eugenio Hospital (Rome-Italy) between December 1, 2020 and November 30, 2021 and received a novel perioperative preparation following the MIRACLe (Microbiota Implementation to Reduce Anastomotic Colorectal Leaks) protocol (oral antibiotics, mechanical bowel preparation and perioperative probiotics), was compared to a group of 500 patients (control group) operated on between March 2015 and November 30, 2020, who received a standard ERAS protocol. In the MIRACLe Group only 1 anastomotic leak was registered. In this group the incidence of AL was just 1.7% vs. 6.4% in the control group (p = 0.238) and the incidence of surgical site infections (1.7% vs. 3.6%; p = 0.686), reoperations (1.7% vs. 4.2%; p = 0.547) and postoperative mortality (0% vs. 2.2%; p = 0.504) were lower. The postoperative outcomes were also better: the times to first flatus, to first stool and to oral feeding were shorter (1 vs. 2, 2 vs. 3 and 2 vs. 3 days, respectively; p < 0.001). Additionally, the postoperative recovery was faster, with a shorter time to discharge (4 vs. 6 days; p < 0.001). In this pilot study, the MIRACLe protocol appeared to be safe and considerably reduced anastomotic leaks in elective laparoscopic colorectal surgery for cancer, even if not statistically significant, due to the small number of cases.
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Affiliation(s)
- Massimo Carlini
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Michele Grieco
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Domenico Spoletini
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | - Rosa Menditto
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy
| | | | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Rosa Marcellinaro
- Department of General Surgery, S. Eugenio Hospital, Piazzale dell'Umanesimo, 10, 00144, Rome, Italy.
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Rosendorf J, Klicova M, Herrmann I, Anthis A, Cervenkova L, Palek R, Treska V, Liska V. Intestinal Anastomotic Healing: What do We Know About Processes Behind Anastomotic Complications. Front Surg 2022; 9:904810. [PMID: 35747439 PMCID: PMC9209641 DOI: 10.3389/fsurg.2022.904810] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Colorectal surgery has developed rapidly in the recent decades. Nevertheless, colorectal anastomotic leakage continues to appear postoperatively in unpleasant rates and leads to life-threatening conditions. The development of valid complication-preventing methods is inefficient in many aspects as we are still lacking knowledge about the basics of the process of anastomotic wound healing in the gastrointestinal tract. Without the proper understanding of the crucial mechanisms, research for prevention of anastomotic leakage is predestined to be unsuccessful. This review article discusses known pathophysiological mechanisms together with the most lately found processes to be further studied. The aim of the article is to facilitate the orientation in the topic, support the better understanding of known mechanisms and suggest promising possibilities and directions for further research.
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Affiliation(s)
- J. Rosendorf
- Department of Surgery, University Hospital in Pilsen, Pilsen, Czech Republic
- Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Correspondence: Jachym Rosendorf
| | - M. Klicova
- Department of Nonwovens and Nanofibrous Materials, Faculty of Textile Engineering, Technical University of Liberec, Liberec, Czech Republic
| | - I. Herrmann
- Department of Mechanical and Process Engineering, Nanoparticle Systems Engineering Laboratory, ETH Zurich, Switzerland
| | - A. Anthis
- Department of Mechanical and Process Engineering, Nanoparticle Systems Engineering Laboratory, ETH Zurich, Switzerland
| | - L. Cervenkova
- Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - R. Palek
- Department of Surgery, University Hospital in Pilsen, Pilsen, Czech Republic
- Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - V. Treska
- Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - V. Liska
- Department of Surgery, University Hospital in Pilsen, Pilsen, Czech Republic
- Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Balla A, Corallino D, Quaresima S, Palmieri L, Meoli F, Cordova Herencia I, Paganini AM. Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study. Front Surg 2022; 9:906133. [PMID: 35693301 PMCID: PMC9178117 DOI: 10.3389/fsurg.2022.906133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/11/2022] [Indexed: 01/17/2023] Open
Abstract
Aims Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate. Methods Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2–58.7 years) and preoperative median body mass index of 42.6 kg/m2 (CI, 95% 36 to 49.3 kg/m2) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures. Results Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case. Conclusions ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions.
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Kang J, Kim H, Park H, Lee B, Lee KY. Risk factors and economic burden of postoperative anastomotic leakage related events in patients who underwent surgeries for colorectal cancer. PLoS One 2022; 17:e0267950. [PMID: 35584082 PMCID: PMC9116683 DOI: 10.1371/journal.pone.0267950] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Nationwide research about the clinical and economic burden caused by anastomotic leakage (AL) has not been published yet in Korea. This study assessed the AL rate and quantified the economic burden using the nationwide database. Methods This real world evidence study used health claims data provided by the Korean Health Insurance Review and Assessment Service (HIRA, which showed that 156,545 patients underwent anterior resection (AR), low anterior resection (LAR), or ultra-low anterior resection (uLAR) for colorectal cancer (CRC) between January 1, 2007 and January 31, 2020. The incidence of AL was identified using a composite operational definition, a composite of imaging study, antibacterial drug use, reoperation, or image-guided percutaneous drainage. Total hospital costs and length of stay (LOS) were evaluated in patients with AL versus those without AL during index hospitalization and within 30 days after the surgery. Results Among 120,245 patients who met the eligibility criteria, 7,194 (5.98%) patients had AL within 30 days after surgery. Male gender, comorbidities (diabetes, metastatic disease, ischemic heart disease, ischemic stroke), protective ostomy, and multiple linear stapler use, blood transfusion, and urinary tract injury were associated with the higher odds of AL. Older age, rectosigmoid junction cancer, AR, LAR, and laparoscopic approach were related with the reduced odds of AL. Patients with AL incurred higher costs for index hospitalization compared to those without AL (8,991 vs. 7,153 USD; p<0.0001). Patients with AL also required longer LOS (16.78 vs. 14.22 days; p<0.0001) and readmissions (20.83 vs. 13.93 days; p<0.0001). Conclusion Among patients requiring resection for CRC, the occurrence of AL was associated with significantly increased costs and LOS. Preventing AL could not only produce superior clinical outcomes, but also reduce the economic burden for patients and payers.
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Affiliation(s)
- Jeonghyun Kang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyesung Kim
- HEMA, Johnson & Johnson Medical Korea, Seoul, Republic of Korea
| | - HyeJin Park
- HEMA, Johnson & Johnson Medical Korea, Seoul, Republic of Korea
| | - Bora Lee
- Institute of Health & Environment, Seoul National University, Seoul, Korea
- RexSoft Corporation, Seoul, South Korea
| | - Kang Young Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Ghosh NK, Kumar A. Colorectal cancer: Artificial intelligence and its role in surgical decision making. Artif Intell Gastroenterol 2022; 3:36-45. [DOI: 10.35712/aig.v3.i2.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/02/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
Despite several advances in the oncological management of colorectal cancer (CRC), there still remains a lacuna in the treatment strategy, which differs from center to center and on the philosophy of the treating clinician that is not without bias. Personalized treatment is essential for the treatment of CRC to achieve better long-term outcomes and to reduce morbidity. Surgery has an important role to play in the treatment. Surgical treatment of CRC is decided based on clinical parameters and investigations and hence likely to have judgmental errors. Artificial intelligence has been reported to be useful in the surveillance, diagnosis, treatment, and follow-up with accuracy in several malignancies. However, it is still evolving and yet to be established in surgical decision making in CRC. It is not only useful preoperatively but also intraoperatively. Artificial intelligence helps to rectify the human surgical decision when clinical data and radiological and laboratory parameters are fed into the computer and may guide correct surgical treatment.
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Affiliation(s)
- Nalini Kanta Ghosh
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, UP, India
| | - Ashok Kumar
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, UP, India
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Talboom K, Tanis PJ, Bemelman WA, Hompes R. Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How? Clin Colon Rectal Surg 2022; 35:155-164. [PMID: 35237112 PMCID: PMC8885159 DOI: 10.1055/s-0041-1742117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.
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Affiliation(s)
- K. Talboom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - P. J. Tanis
- Department of Surgery, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands,Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center, Rotterdam, the Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands,Address for correspondence P. J. Tanis, MD, PhD Department of Surgery, Amsterdam UMCDe Boelelaan 1117, 1081 HV AmsterdamThe Netherlands
| | - W. A. Bemelman
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - R. Hompes
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
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Keller DS, Talboom K, van Helsdingen CPM, Hompes R. Treatment Modalities for Anastomotic Leakage in Rectal Cancer Surgery. Clin Colon Rectal Surg 2021; 34:431-438. [PMID: 34853566 DOI: 10.1055/s-0041-1736465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite advances in rectal cancer surgery, anastomotic leakage (AL) remains a common complication with a significant impact on patient recovery, health care costs, and oncologic outcomes. The spectrum of clinical severity associated with AL is broad, and treatment options are diverse with highly variable practices across the colorectal community. To be effective, the treatment must match not only the patient's current status but also the type of leak, the surgeon's skill, and the resources available. In this chapter, we will review the current and emergent treatment modalities for AL after rectal cancer surgery.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, University of California at Davis Medical Center, Sacramento, California
| | - K Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - C P M van Helsdingen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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An international assessment of the adoption of enhanced recovery after surgery (ERAS®) principles across colorectal units in 2019-2020. Colorectal Dis 2021; 23:2980-2987. [PMID: 34365718 DOI: 10.1111/codi.15863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/08/2021] [Accepted: 07/31/2021] [Indexed: 02/08/2023]
Abstract
AIM The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. METHOD An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. RESULTS Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. CONCLUSIONS Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.
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Hassan OU, Ghanem OM. Comment on: The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study. Surg Obes Relat Dis 2021; 18:60-61. [PMID: 34785139 DOI: 10.1016/j.soard.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Omer Ul Hassan
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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38
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Bedrikovetski S, Dudi-Venkata NN, Kroon HM, Vather R, Sammour T. Towards a zero percent anastomotic leak rate using a defined risk reduction strategy. Eur Surg 2021. [DOI: 10.1007/s10353-021-00739-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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39
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Rosendorf J, Klicova M, Cervenkova L, Horakova J, Klapstova A, Hosek P, Palek R, Sevcik J, Polak R, Treska V, Chvojka J, Liska V. Reinforcement of Colonic Anastomosis with Improved Ultrafine Nanofibrous Patch: Experiment on Pig. Biomedicines 2021; 9:102. [PMID: 33494257 PMCID: PMC7909771 DOI: 10.3390/biomedicines9020102] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Jachym Rosendorf
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic;
| | - Marketa Klicova
- Department of Nonwovens and Nanofibrous Materials, Faculty of Textile Engineering, Technical University of Liberec, 460 01 Liberec, Czech Republic; (M.K.); (J.H.); (A.K.); (J.C.)
| | - Lenka Cervenkova
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
| | - Jana Horakova
- Department of Nonwovens and Nanofibrous Materials, Faculty of Textile Engineering, Technical University of Liberec, 460 01 Liberec, Czech Republic; (M.K.); (J.H.); (A.K.); (J.C.)
| | - Andrea Klapstova
- Department of Nonwovens and Nanofibrous Materials, Faculty of Textile Engineering, Technical University of Liberec, 460 01 Liberec, Czech Republic; (M.K.); (J.H.); (A.K.); (J.C.)
| | - Petr Hosek
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
| | - Richard Palek
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic;
| | - Jan Sevcik
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
| | - Robert Polak
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic;
| | - Vladislav Treska
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic;
| | - Jiri Chvojka
- Department of Nonwovens and Nanofibrous Materials, Faculty of Textile Engineering, Technical University of Liberec, 460 01 Liberec, Czech Republic; (M.K.); (J.H.); (A.K.); (J.C.)
| | - Vaclav Liska
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic; (L.C.); (P.H.); (R.P.); (J.S.); (R.P.)
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, 301 00 Pilsen, Czech Republic;
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Fortin SP, Johnston SS, Chaudhuri R, Fryrear R, Roy S. Incidence, predictors, and economic burden of circular anastomotic complications in left-sided colorectal reconstructions involving manual circular staplers. J Med Econ 2021; 24:255-265. [PMID: 33576292 DOI: 10.1080/13696998.2021.1880749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
STUDY AIM Manual circular staplers are widely used in colorectal surgery; however, limited literature exists examining complications related to circular anastomoses when such devices are used. The present study evaluated the incidence, predictors, and economic burden of circular anastomotic complications in left-sided colorectal reconstructions involving manual circular staplers. MATERIALS AND METHODS Patients aged ≥18 years who underwent hemicolectomy, low anterior resection, or sigmoidectomy between 1 October 2016 and 31 December 2018 were identified from the Premier Healthcare Database. Manual circular stapler use was identified from hospital administrative billing records. Circular anastomotic complications were defined as a composite endpoint of multiple circular stapler use (proxy for stapler failure) or other circular anastomotic complications (anastomotic leak, bleeding, device/surgical complications, infection, and transfusion). Multivariable analyses were used to model the associations between circular anastomotic complications and total hospital costs, length of stay, operating room time, and 30-, 60-, and 90-day readmission rates. RESULTS A total of 13,167 patients met the study criteria, of whom 2,984 (22.7%) had circular anastomotic complications. Predictors of circular anastomotic complications included age, procedure type, provider region, and select patient comorbidities. As compared with those who did not, patients who suffered circular anastomotic complications had significantly higher adjusted total hospital costs ($26,924 vs. $18,748; p < .0001), length of stay (7.79 vs. 4.99 days; p < .0001), operating room time (280 vs. 239 min; p < .0001), non-home discharge status (9.63% vs. 4.61%; p < .0001), and all-cause readmission at 30 days (12.2% vs. 8.7%; p < .0001), 60 days (16.0% vs. 11.6%; p < .0001), and 90 days (18.5% vs. 13.4%; p < .0001). LIMITATIONS The present study is limited by the observational nature and potential for measurement error that is inherent to administrative healthcare databases. CONCLUSIONS In this analysis of patients undergoing left-sided colorectal reconstructions involving a manual circular stapler, circular anastomotic complications were associated with adverse economic consequences.
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Affiliation(s)
- Stephen P Fortin
- Medical Devices - Epidemiology, Johnson & Johnson Co., New Brunswick, NJ, USA
| | - Stephen S Johnston
- Medical Devices - Epidemiology, Johnson & Johnson Co., New Brunswick, NJ, USA
| | | | - Raymond Fryrear
- Preclinical, Clinical, Medical Centre, Ethicon Inc., Cincinnati, OH, USA
| | - Sanjoy Roy
- Franchise Health Economics and Market Access, Ethicon Inc., Cincinnati, OH, USA
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Primary Medical Effects and Economic Impact of Anastomotic Leakage in Patients with Colorectal Cancer. A Middle-Income Country Perspective. JOURNAL OF INTERDISCIPLINARY MEDICINE 2020. [DOI: 10.2478/jim-2020-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Anastomotic leakage is one of the most serious surgical complications that can increase the potential postoperative morbidity, mortality, and overall costs of patient care. Aim of study: To assess the economic burden of anastomotic leakage and to estimate its major clinical effects on patient evaluation.
Materials and methods: We retrospectively reviewed single-surgeon data about patients who underwent surgical intervention for colorectal cancer at the 2nd Surgery Department of the Mureș County Emergency Clinical Hospital between January 2019 and July 2020. We assessed general characteristics, surgical data, postoperative information, oncologic results, and financial aspects for each patient. Depending on the presence of anastomotic leakage, patients were divided into two groups: a study group (SG) – patients with postoperative anastomotic failure, and a control Group (CG) – patients without postoperative anastomotic failure.
Results: Patients with anastomotic leakage presented increased use of antibiotics, greater number of surgical reinterventions, longer period of intensive care treatment, prolonged hospitalization, increased overall costs, and significantly greater financial loss for the hospital.
Conclusion: Anastomotic leakage leads to important negative effects, including longer hospitalization, prolonged intensive care unit stay, greater incidence of surgical reintervention, increased hospitalization costs, and significant financial loss.
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