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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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Gong AT, Yau SWO, Erickson HB, Toepfer RJ, Zhang J, Deschmidt AM, Parsey CJ, Norfleet JE, Sweet RM. Characterizing the Suture Pullout Force for Human Small Bowel. J Biomech Eng 2024; 146:014502. [PMID: 37916891 DOI: 10.1115/1.4063951] [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: 06/09/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
Performing a small bowel anastomosis, or reconnecting small bowel segments, remains a core competency and critical step for the successful surgical management of numerous bowel and urinary conditions. As surgical education and technology moves toward improving patient outcomes through automation and increasing training opportunities, a detailed characterization of the interventional biomechanical properties of the human bowel is important. This is especially true due to the prevalence of anastomotic leakage as a frequent (3.02%) postoperative complication of small bowel anastomoses. This study aims to characterize the forces required for a suture to tear through human small bowel (suture pullout force, SPOF), while analyzing how these forces are affected by tissue orientation, suture material, suture size, and donor demographics. 803 tests were performed on 35 human small bowel specimens. A uni-axial test frame was used to tension sutures looped through 10 × 20 mm rectangular bowel samples to tissue failure. The mean SPOF of the small bowel was 4.62±1.40 N. We found no significant effect of tissue orientation (p = 0.083), suture material (p = 0.681), suture size (p = 0.131), age (p = 0.158), sex (p = .083), or body mass index (BMI) (p = 0.100) on SPOF. To our knowledge, this is the first study reporting human small bowel SPOF. Little research has been published about procedure-specific data on human small bowel. Filling this gap in research will inform the design of more accurate human bowel synthetic models and provide an accurate baseline for training and clinical applications.
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Affiliation(s)
- Alex T Gong
- Department of Surgery, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000
| | - Shi-Wen Olivia Yau
- Department of Surgery, University of Washington, 1959 NE Pacific Ave Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Human Centered Design and Engineering, University of Washington, 3960 Benton Ln NE #428, Seattle, WA 98195-0000
| | - Hans B Erickson
- Department of Surgery, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Mechanical Engineering, University of Washington, 371 Loew Hall, Seattle, WA 98195-0000
| | - Rudolph J Toepfer
- Department of Surgery, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Materials Science and Engineering, University of Washington, 302 Roberts Hall, Seattle, WA 98195-2120
| | - Jessica Zhang
- Department of Surgery, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Biochemistry, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences J405, Seattle, WA 98195-0000
| | - Aleah M Deschmidt
- Benaroya Research Institute at Virginia Mason, 1201 Ninth Ave, Seattle, WA 98101
| | - Conner J Parsey
- Medical Simulation Research Branch Simulation and Training Technology Center, U.S. Army DEVCOM Soldier Center, 12423 Research Parkway, Orlando, FL 32826
| | - Jack E Norfleet
- Medical Simulation Research Branch Simulation and Training Technology Center, U.S. Army DEVCOM Soldier Center, 12423 Research Parkway, Orlando, FL 32826
| | - Robert M Sweet
- Department of Surgery, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Urology, University of Washington, 1959 NE Pacific Ave, Magnuson Health Sciences T293, Seattle, WA 98195-0000; Department of Bioengineering, University of Washington, 3720 15th Ave NE, Seattle, WA 98195-0000
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Bhattacharya P, Hussain MI, Zaman S, Randle S, Tanveer Y, Faiz N, Sarma DR, Peravali R. Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:454. [PMID: 38041773 DOI: 10.1007/s00423-023-03181-z] [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: 08/16/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse. METHODS A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis. RESULTS Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches. CONCLUSIONS A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.
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Affiliation(s)
- Pratik Bhattacharya
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK.
| | - Mohammad Iqbal Hussain
- Department of General Surgery, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Sophie Randle
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Yousaf Tanveer
- Department of General Surgery, Craigavon Area Hospital, Portadown, Northern Ireland, UK
| | - Nameer Faiz
- Department of General Surgery, The Dudley Group NHS Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Diwakar Ryali Sarma
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
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Dhanasekara CS, Marschke B, Morris E, Bashrum BS, Shrestha K, Richmond R, Dissanaike S, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner J, Keith SL, Mcnutt MK, Kregel H, Gandhi R, Schroeppel T, Margulies DR, Hashim Y, Herrold J, Goetz M, Simpson L, Xuan-Lan D. Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study. Am J Surg 2023; 226:770-775. [PMID: 37270399 DOI: 10.1016/j.amjsurg.2023.05.032] [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: 03/24/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Bryan S Bashrum
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Ara Ko
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Frank C Wood
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Maggie Brandt
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Michelle K Mcnutt
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Rajesh Gandhi
- Department of Surgery, JPS Health Network, Ft. Worth, TX, USA
| | - Thomas Schroeppel
- Department of Surgery, UCHealth, Memorial Hospital, Colorado Springs, CO, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - LeRone Simpson
- McAllen Medical Center Trauma Department, McAllen, TX, USA
| | - Doan Xuan-Lan
- McAllen Medical Center Trauma Department, McAllen, TX, USA
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5
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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6
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Patel DD, Abdulkarim AB, Behrman SW. Segmental Duodenal Resections: Toward Defining Indications, Complexity, and Coding. J Gastrointest Surg 2023; 27:2373-2379. [PMID: 37749459 DOI: 10.1007/s11605-023-05837-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: 05/23/2023] [Accepted: 09/08/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Segmental resections of the duodenum are uncommonly performed and are technically challenging due to intimate relationships with the biliary tree, pancreas, and superior mesenteric vessels. The objective of this study was to assess indications, operative strategy, and outcomes of duodenal resections and to advocate that this form of resection deserves its own unique Current Procedural Terminology (CPT) and Relative Value Unit (RVU) structure. METHODS Patients undergoing isolated and partial duodenal resection from 2008-2023 at University of Tennessee Health Science Center affiliated hospitals were retrospectively reviewed. Factors examined included clinical presentation, diagnostic evaluation, operative time, and technique, 90-day morbidity and mortality, and pathologic and survival outcomes. RESULTS Thirty-one patients were identified with majority female and a median age of 61. Diagnostic studies included computed tomography and upper (including push) endoscopy. Reconstruction most often involved side-to-side duodenojejunostomy following distal duodenal resection. Intraoperative evaluation (IOE) of the biliary tree was utilized to assess and protect pancreaticobiliary structures in eleven patients. Median operative time was 206 min, increasing to 236 min when IOE was necessary. Procedure-related morbidity was 23% with one 90-day mortality. Median postoperative length of stay was 9 days. Pathology included benign adenoma, adenocarcinoma, GIST, neuroendocrine neoplasms, and erosive metastatic deposit. CONCLUSION Duodenal resections can be effectively employed to safely address diverse pathologies. These procedures are characterized by long operative times, extended hospital stays, and an incidence of postoperative complications that mimics that of pancreatic resection. This work highlights the need for modification to the CPT system to accurately define these distinct procedures for future research endeavors and development of a more accurate valuation unit.
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Affiliation(s)
- Devanshi D Patel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Ahmad B Abdulkarim
- Department of Surgery, Veterans Administration Hospital, Memphis, TN, USA
- Department of Surgery, Baptist Memorial Medical Education, 6025 Walnut Grove Road, Suite 207, Memphis, TN, 38120, USA
| | - Stephen W Behrman
- Department of Surgery, Baptist Memorial Medical Education, 6025 Walnut Grove Road, Suite 207, Memphis, TN, 38120, USA.
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7
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Johnson G, Ziegler J, Helewa R, Askin N, Rabbani R, Abou-Setta AM. Preoperative oral fluoroquinolone antibiotics in elective colorectal surgery to prevent surgical site infections: a systematic review and meta-analysis. Can J Surg 2023; 66:E21-E31. [PMID: 36653030 PMCID: PMC9854941 DOI: 10.1503/cjs.019721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Preoperative treatment with oral neomycin combined with erythromycin or metronidazole is recommended to decrease the risk of surgical site infections (SSIs) in elective colorectal surgery. However, oral neomycin is not commercially available in Canada, and therefore it is not routinely used. Fluoroquinolones are widely available and have excellent activity against aerobic Gram-negative bacteria. The aim of this systematic review was to identify, critically appraise and summarize the evidence on the efficacy and safety of preoperative use of oral fluoroquinolone antibiotics for the prevention of SSIs in adult patients undergoing elective colorectal resection. METHODS Following Cochrane guidelines, we included English-language randomized controlled trials (RCTs) comparing oral fluoroquinolones plus routine preoperative intravenous antibiotics against intravenous antibiotics alone from MEDLINE (Ovid), Embase (Ovid), the Cochrane Central Register of Controlled Trials( Ovid) and ClinicalTrials.gov. RESULTS We included 3 RCTs (1136 patients). Risk of bias was uncertain in 2 trials and high in 1 trial. Preoperative oral fluoroquinolones led to significantly decreased total SSIs (risk ratio [RR] 0.43, 95% confidence interval [CI] 0.32-0.57, I 2 = 0%), superficial incisional (RR 0.38, 95% CI 0.22-0.68, I 2 = 32%), deep incisional (RR 0.19, 95% CI 0.06-0.65, I 2 = 0%) and organ/space SSIs (RR 0.34, 95% CI 0.12-0.90, I 2 = 33%). There was also a significant reduction in anastomotic leaks (RR 0.22, 95% CI 0.06-0.87, I 2 = 0%). No antibiotic-related adverse events were reported. CONCLUSION This review suggests that preoperative oral fluoroquinolones with intravenous antibiotics are superior to intravenous antibiotics alone for preventing SSIs after colorectal surgery. If neomycin is unavailable, oral fluoroquinolones should be considered as a reasonable alternative. Future trials are required to further compare the relative efficacy of oral antibiotic regimens.
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Affiliation(s)
- Garrett Johnson
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Jennifer Ziegler
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Ramzi Helewa
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Nicole Askin
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Rasheda Rabbani
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
| | - Ahmed M Abou-Setta
- From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Helewa); the Clinician Investigator Program, University of Manitoba, Winnipeg, Man. (Johnson); the Department of Internal Medicine, University of Manitoba, Winnipeg, Man. (Ziegler); the University of Manitoba, Winnipeg, Man. (Askin); the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta); and the Department of Community Health Sciences, University of Manitoba, Winnipeg, Man. (Rabbani, Abou-Setta)
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8
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Kassahun CW, Melekamu S, Alemu MT. Clinical anastomosis leakage and associated factors among patients who had intestinal anastomosis in northwest referral hospitals, Ethiopia. PLoS One 2022; 17:e0275536. [PMID: 36584017 PMCID: PMC9803163 DOI: 10.1371/journal.pone.0275536] [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: 05/14/2022] [Accepted: 09/19/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Clinical anastomosis leakage leads to increased hospital costs, lengths of stay, readmissions, reoperations, and death. Therefore, this study aimed to assess clinical anastomotic leakage and associated factors among patients who had intestinal anastomosis in Northwest referral Hospitals, Ethiopia. METHOD A retrospective cross-sectional study design was conducted among 411 randomly selected patients. The patient's medical records from February 2017 to February 2020 were used. The date range during which patients' medical records were extracted was from March 1 to June 2020. Patient medical record charts and data extraction sheets were used to collect the data. Data was entered into EPI-DATA version 3.1 and exported into SPSS version 25 for analysis. Binary and multiple logistic regression analysis was used to assess the association between dependent and independent variables. P-value of less than 0.05 and odds ratio with 95% CI were used to declare the presence of association. RESULTS The response rate of the study was 99.8%. Of 411 patients, 38 (9.2%) patients developed clinical anastomotic leakage. Age group 0-10 years (AOR = 6.85 95% CI: 1.742-26.97), emergency presentation (AOR = 3.196 95% CI: 1.132-9.025), and pre-operative comorbid disease (AOR = 7.62 95% CI: 2.804-20.68) were significantly associated with anastomotic leak. CONCLUSIONS Clinical anastomotic leakage is higher than the expected rate (4.9%-7.2%). Age, emergency presentation, and comorbidities were associated with clinical anastomotic leak. Hence, attention to early identification of risk factors and providing optimal pre-operative, operative, and post-operative care is necessary.
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Affiliation(s)
- Chanyalew Worku Kassahun
- Department of Medical Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Senetsuhuf Melekamu
- Department of Surgical Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
| | - Mahlet Temesgen Alemu
- Department of Surgical Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
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9
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Scott BB, Wang Y, Wu RC, Randolph MA, Redmond RW. Light-activated photosealing with human amniotic membrane strengthens bowel anastomosis in a hypotensive, trauma-relevant swine model. Lasers Surg Med 2022; 54:407-417. [PMID: 34664720 DOI: 10.1002/lsm.23485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Gastrointestinal anastomotic leakage is a dreaded complication despite advancements in surgical technique. Photochemical tissue bonding (PTB) is a method of sealing tissue surfaces utilizing photoactive dye. We evaluated if crosslinked human amniotic membrane (xHAM) photosealed over the enteroenterostomy would augment anastomotic strength in a trauma-relevant swine hemorrhagic shock model. METHODS Yorkshire swine (40-45 kg, n = 14) underwent midline laparotomy and sharp transection of the small intestine 120 cm proximal to the ileocecal fold. Immediately following intestinal transection, a controlled arterial bleed was performed to reach hemorrhagic shock. Intestinal repair was performed after 60 minutes and autotransfusion of the withdrawn blood was performed for resuscitation. Animals were randomized to small intestinal anastomosis by one of the following methods (seven per group): suture repair (SR), or SR with PTB augmentation. Animals were euthanized at postoperative Day 28 and burst pressure (BP) strength testing was performed on all excised specimens. RESULTS Mean BP for SR, PTB, and native tissue groups were 229 ± 40, 282 ± 21, and 282 ± 47 mmHg, respectively, with the SR group statistically significantly different on analysis of variance (p = 0.02). Post-hoc Tukey all-pairs comparison demonstrated a statistically significant difference in burst pressure strength between the SR only and the PTB group (p = 0.04). All specimens in SR group ruptured at the anastomosis upon burst pressure testing, while all specimens in the PTB group ruptured at least 2.5 cm from the anastomosis. CONCLUSION Photosealing with xHAM significantly augments the strength of small intestinal anastomosis performed in a trauma porcine model.
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Affiliation(s)
- Benjamin B Scott
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
- Plastic Surgery Research Laboratory, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ying Wang
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ruby C Wu
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark A Randolph
- Plastic Surgery Research Laboratory, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert W Redmond
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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10
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Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn? Int J Colorectal Dis 2022; 37:673-681. [PMID: 35124716 DOI: 10.1007/s00384-022-04102-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA. METHODS This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function. RESULTS A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS. CONCLUSION ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.
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11
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Hernandez PT, Paspulati RM, Shanmugan S. Diagnosis of Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:391-399. [PMID: 34853560 DOI: 10.1055/s-0041-1735270] [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
Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.
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Affiliation(s)
- Paul T Hernandez
- Division of Colorectal Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Raj M Paspulati
- Department of Radiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Skandan Shanmugan
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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12
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Vomhof-DeKrey EE, Stover A, Basson MD. Microbiome diversity declines while distinct expansions of Th17, iNKT, and dendritic cell subpopulations emerge after anastomosis surgery. Gut Pathog 2021; 13:51. [PMID: 34376235 PMCID: PMC8353768 DOI: 10.1186/s13099-021-00447-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/30/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anastomotic failure causes morbidity and mortality even in technically correct anastomoses. Initial leaks must be prevented by mucosal reapproximation across the anastomosis. Healing is a concerted effort between intestinal epithelial cells (IECs), immune cells, and commensal bacteria. IEC TLR4 activation and signaling is required for mucosal healing, leading to inflammatory factor release that recruits immune cells to limit bacteria invasion. TLR4 absence leads to mucosal damage from loss in epithelial proliferation, attenuated inflammatory response, and bacteria translocation. We hypothesize after anastomosis, an imbalance in microbiota will occur due to a decrease in TLR4 expression and will lead to changes in the immune milieu. RESULTS We isolated fecal content and small intestinal leukocytes from murine, Roux-en-Y and end-to-end anastomoses, to identify microbiome changes and subsequent alterations in the regulatory and pro-inflammatory immune cells 3 days post-operative. TLR4+ IECs were impaired after anastomosis. Microbiome diversity was reduced, with Firmicutes, Bacteroidetes, and Saccharibacteria decreased and Proteobacteria increased. A distinct TCRβhi CD4+ T cells subset after anastomosis was 10-20-fold greater than in control mice. 84% were Th17 IL-17A/F+ IL-22+ and/or TNFα+. iNKT cells were increased and TCRβhi. 75% were iNKT IL-10+ and 13% iNKTh17 IL-22+. Additionally, Treg IL-10+ and IL-22+ cells were increased. A novel dendritic cell subset was identified in anastomotic regions that was CD11bhi CD103mid and was 93% IL-10+. CONCLUSIONS This anastomotic study demonstrated a decrease in IEC TLR4 expression and microbiome diversity which then coincided with increased expansion of regulatory and pro-inflammatory immune cells and cytokines. Defining the anastomotic mucosal environment could help inform innovative therapeutics to target excessive pro-inflammatory invasion and microbiome imbalance.
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Affiliation(s)
- Emilie E. Vomhof-DeKrey
- Department of Surgery, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
- Department of Biomedical Sciences, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
| | - Allie Stover
- Department of Biomedical Sciences, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
| | - Marc D. Basson
- Department of Surgery, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
- Department of Biomedical Sciences, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
- Department of Pathology, University of North Dakota School of Medicine and the Health Sciences, 1301 North Columbia Road, Stop 9037, Grand Forks, ND 58202 USA
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13
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Schiellerup NS, Wismann J, Madsen GI, Le DQS, Qvist N, Ellebæk MB. Incorporation of a Poly-ε-Caprolactone Scaffold in a ;Circular Stapled End-To-End Small Intestine Anastomosis Does Not Have Any Adverse Effects Within 30 days: A Study in Piglets. Surg Innov 2021; 28:679-687. [PMID: 33745358 DOI: 10.1177/1553350621999294] [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: 11/15/2022]
Abstract
Background. Incorporation of a poly-ε-caprolactone (PCL) scaffold in circular stapled anastomoses has been shown to increase the anastomotic tensile strength on postoperative day (POD) 5 in a pig model. The aim of this study was to investigate the effects of incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis, with stricture formation and anastomotic histology as primary outcomes in a 30-day observation period. Methods. A total of 15 piglets were included. In each piglet, three circular stapled end-to-end anastomoses were made in the small intestines. Two were interventional and one was a control. On POD 10, 20, or 30, the anastomoses were subjected to in vivo intraluminal contrast study, and the index for anastomotic lumen was calculated. The anastomotic segment was resected and subjected to a tensile strength test and histological examination. Results. At POD 10, the mean ± SD value for anastomotic index was .749 ± .065 in control anastomoses and .637 ± .051 in interventional anastomosis (P = .0046), at POD 20, .541 ± .150 and .724 ± .07 (P = .051), and at POD 30, .645 ± .103 and .686 ± .057 (P = .341), respectively. No significant difference was observed in maximum tensile strength and histology at POD 30. Conclusions. The incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis does not increase the risk of stricture or impair wound healing after 30 days.
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Affiliation(s)
| | - Joakim Wismann
- Department of Surgery, 573154Odense University Hospital, Odense, Denmark
| | - Gunvor I Madsen
- Department of Pathology, 573154Odense University Hospital, Odense, Denmark
| | - Dang Q S Le
- Department of Clinical Medicine, 1006Aarhus University, Aarhus C, Denmark
| | - Niels Qvist
- Department of Surgery, 573154Odense University Hospital, Odense, Denmark.,Danish Centre for Regenerative Medicine (CRM), 573154Odense University Hospital, Odense, Denmark
| | - Mark B Ellebæk
- Department of Surgery, 573154Odense University Hospital, Odense, Denmark
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Impact of Protocol Utilizing Water-Soluble Contrast for Adhesive Small Bowel Obstruction. J Surg Res 2020; 259:487-492. [PMID: 33127063 DOI: 10.1016/j.jss.2020.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/20/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Adhesive small bowel obstruction (ASBO) has classically been managed with nasogastric tube decompression and watchful waiting. Our group developed an evidence-based protocol to manage ASBO utilizing a water-soluble contrast (WSC) agent. We hypothesized the protocol would decrease the length of stay (LOS) for patients admitted with ASBO along with the time interval from admission to surgery. METHOD From 2010 to 2018, a retrospective review was performed, including all patients admitted with a diagnosis of ASBO. These patients were divided into two groups: the preprotocol group included years 2010-2013 and the postprotocol group included years 2015-2018. A Student t-test and a two-proportion z-test were used for statistical analysis. RESULT We captured 767 patients; 296 in the preprotocol group and 471 in the postprotocol group. We found a significant decrease in overall LOS between the preprotocol and postprotocol groups (6.56 d versus 4.08 d; P < 0.001) along with decreases in LOS for patients managed nonoperatively (5.36 d versus 3.42 d; P < 0.001) and operatively (16.09 d versus 9.47 d; P < 0.001). Time interval from admission to the operation was significantly decreased in the postprotocol group (3.79 d versus 2.10 d; P < 0.050). We identified a trend toward decreased rates of bowel ischemia and resections with our protocol. CONCLUSIONS These results reaffirm previous reports of WSC's impact on overall LOS in ASBO while showing a similar impact on both operative and nonoperative groups. The decreased time interval between admission and operation may impact the incidence of bowel ischemia and resections.
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15
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Ghufran S, Janjua AA, Chaudary SM, Munawwar F, Hassan M, Changazi SH. Outcome of Enhanced Recovery After Surgery Protocols in Patients Undergoing Small Bowel Surgery. Cureus 2020; 12:e11073. [PMID: 33224667 PMCID: PMC7676946 DOI: 10.7759/cureus.11073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
Background and objective Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways to help patients achieve early recovery after surgical procedures. However, no evidence could be found about its role in patients undergoing small bowel surgery. This study's objective was to determine the outcome of applying ERAS protocols in patients undergoing small bowel surgery. Materials and methods This study was a descriptive case series conducted in the Department of Surgery at Services Hospital in Lahore, Pakistan, from September 2017 to August 2019. One hundred forty patients who underwent small bowel resection anastomosis were subjected to ERAS protocols. Written informed consent was received from all patients. Results The mean age of the patients was 34.1 ± 7.1 years. There were 101 (72.1%) men and 39 (27.9%) women in the study sample. The mean length of postoperative hospital stay was 4.59 ± 1.69 days. Postoperative wound infection occurred in six (4.3%) patients, while anastomotic leakage was observed in 12 (8.6%) patients. Five (3.6%) patients died within 30 days of surgery. A significantly increased length of postoperative hospital stay was associated with anastomotic leakage (9.08 ± 1.975 vs. 4.16 ± 0.83 days; p=0.00). Similarly, the frequency of wound infection (41.7% vs. 0.8%; p=0.00) and 30-day patient mortality (41.7% vs. 0%; p=0.00) was also significantly higher among those patients who acquired anastomotic leakage. Conclusion ERAS protocols were associated with a significant reduction in length of hospital stay of the patients undergoing small bowel surgery without any significant increase is anastomotic leakage, wound infection or mortality. Furthermore, anastomotic leakage occurred in the patients was significantly associated with a longer hospital stay, wound infection, and 30-day mortality. Therefore, ERAS protocols can be safely applied to small bowel surgery.
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Affiliation(s)
- Samar Ghufran
- General Surgery, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Atif A Janjua
- General Surgery, Services Hospital Lahore, Lahore, PAK
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16
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Postoperative administration of non-steroidal anti-inflammatory drugs in colorectal cancer surgery does not increase anastomotic leak rate; A systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:2167-2173. [PMID: 32792221 DOI: 10.1016/j.ejso.2020.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Evidence on the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on anastomotic leak (AL) rate after colorectal surgery is conflicting. Effects of NSAIDs might depend on the underlying disease. This meta-analysis aimed to review the effect of NSAIDs on AL rate in a homogeneous colorectal cancer patient population. METHODS A systematic literature search using MEDLINE and EMBASE database was performed for studies with AL as primary outcome comparing NSAID use in the early postoperative phase with no NSAID administration in colorectal cancer patients undergoing surgical resection. RESULTS Nine studies including 10,868 patients met the inclusion criteria. The majority, 7689 patients (70.7%) underwent low anterior resection and 3050 patients (28.1%) underwent colonic resection. The pooled incidence of AL was 8.6% (95%CI 7.0-10.0). Overall AL rate after colorectal cancer surgery was not increased in patients using NSAIDs for postoperative analgesia compared to non-users (p = 0.34, RR 1.23; 95%CI 0.81-1.86). This effect remained non-significant after stratification for low anterior resections (p = 0.07). Stratification for colonic resections could not be performed because AL results for this subgroup were not reported separately. Neither non-selective NSAID use nor COX-2 selective NSAID use caused an increased AL rate (p = 0.19, p = 0.26). The results were robust throughout sensitivity analyses. CONCLUSION Use of NSAIDs in cohorts with patients undergoing surgical resection for colorectal cancer does not increase overall AL rate. Since results were robust throughout several subgroup and sensitivity analyses, prescription of NSAIDs after colorectal cancer surgery seems safe.
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Dawka S. An Invited Commentary on “The relationship between aortic calcification and anastomotic leak following gastrointestinal resection: A systematic review” (Int J Surg 2019; Epub ahead of print). Int J Surg 2020; 74:40. [DOI: 10.1016/j.ijsu.2019.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 11/24/2022]
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Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2018; 3:153-160. [PMID: 30957061 PMCID: PMC6433422 DOI: 10.1002/bjs5.50124] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
Background Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. Methods A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. Results Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. Conclusion EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.
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Affiliation(s)
- M Shalaby
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of General Surgery Rome Tor Vergata University Rome Italy
| | - S Emile
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - H Elfeki
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of Surgery, Colorectal Surgery Unit Aarhus University Aarhus Denmark
| | - A Sakr
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - S D Wexner
- Department of Colorectal Surgery Cleveland Clinic Florida Weston Florida USA
| | - P Sileri
- Department of General Surgery Rome Tor Vergata University Rome Italy
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Shalaby M, Thabet W, Buonomo O, Lorenzo ND, Morshed M, Petrella G, Farid M, Sileri P. Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection. Ann Coloproctol 2018; 34:317-321. [PMID: 30572421 PMCID: PMC6347340 DOI: 10.3393/ac.2017.10.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/18/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). Methods Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. Results Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20–35 kg/m2). The median tumor distance from the anal verge was 8 cm (range, 4–12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. Conclusion These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy.,Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Waleed Thabet
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Oreste Buonomo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Di Lorenzo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mosaad Morshed
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Giuseppe Petrella
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mohamed Farid
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
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20
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Routine Drainage of Colorectal Anastomoses: An Evidence-Based Review of the Current Literature. Gastroenterol Res Pract 2017; 2017:6253898. [PMID: 29158731 PMCID: PMC5660819 DOI: 10.1155/2017/6253898] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/01/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022] Open
Abstract
Background The use of prophylactic drainage after colorectal anastomoses has been long debated. This report aimed to review the current literature discussing routine drainage of colorectal anastomoses highlighting two opposite perspectives (prodrainage and antidrainage) to demonstrate the clinical utility of prophylactic drainage and its proper indications. Methods An organized literature search was conducted querying electronic databases and Google Scholar. Articles evaluating the role of routine prophylactic drainage after colorectal anastomosis were included and divided into two categories: articles supporting the use of drains (prodrainage) and articles disputing routine drainage (antidrainage). Results There were seven systematic reviews and/or meta-analyses, one Cochrane review, one randomized controlled trial, and six prospective or retrospective cohort studies. Six studies supported prophylactic drainage of colorectal anastomoses; the quality of these studies ranged between grade II and IV. Nine studies recommended against the use of prophylactic drainage, six studies were grade I, one was grade II, and two were grade IV. Conclusion Since level I evidence studies including well-designed randomized trials and meta-analyses recommended against the use of pelvic drainage as a routine practice after colorectal anastomoses, we conclude no significant impact of routine drainage on the risk of anastomotic leakage after colorectal anastomoses.
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