1
|
de Lima MS, Figueiredo LZ, Furuya CK, Pombo AADM, Hora JAB, Malluf-Filho F. Tube-in-tube endoscopic vacuum therapy for treatment of colorectal anastomotic leaks: A low-cost, patient-friendly, feasible and efficient technical modification of sponge-based endoscopic vacuum therapy. Colorectal Dis 2023. [PMID: 37060149 DOI: 10.1111/codi.16577] [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: 02/24/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND AIMS Colorectal endoscopic vacuum therapy (CR EVT) is usually performed using sponges passed through the anus. It may be associated with patient discomfort and displacement of the aspiration tube. METHODS With the tube-in-tube endoscopic vacuum therapy modification (CR TT-EVT), it is possible to position the aspiration tube in the pelvic cavity through the abdominal wall. In addition, it allows frequent cleaning of the fistula, eliminates the need for programmed device changes, and enables a standardized approach to such a wide variety of fistulas, leaks, and perforations. RESULTS Here is a technical note on how to perform CR TT-EVT, while we are at the early phase of our case series we have reached 100% of technical success.
Collapse
|
2
|
Technical Considerations in Stoma Reversal. SEMINARS IN COLON AND RECTAL SURGERY 2023. [DOI: 10.1016/j.scrs.2023.100957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
|
3
|
Deng S, Liu K, Gu J, Cao Y, Mao F, Xue Y, Jiang Z, Qin L, Wu K, Cai K. Endoscopic fully covered self-expandable metal stent and vacuum-assisted drainage to treat postoperative colorectal cancer anastomotic stenosis with fistula. Surg Endosc 2023; 37:3780-3788. [PMID: 36690896 PMCID: PMC10156781 DOI: 10.1007/s00464-022-09831-5] [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: 03/08/2022] [Accepted: 12/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Digestive tract reconstruction is required after the surgical resection of a colorectal malignant tumor. Some patients may have concomitant anastomotic complications, such as anastomotic stenosis with fistula (ASF), postoperatively. Therefore, we evaluated the efficacy and safety of endoscopic fully covered self-expandable metal stent and homemade vacuum sponge-assisted drainage (FSEM-HVSD) for the treatment of ASF following the radical resection of colorectal cancer. METHODS Patients treated with FESM-HVSD were prospectively analyzed and followed up for ASF following colorectal cancer treatment in our medical center from 2017 to 2021 for the observation and evaluation of its safety and efficacy. RESULTS Fifteen patients with a mean age of 55.80 ± 11.08 years were included. Nine patients (60%) underwent protective ileostomy. All 15 patients were treated with endoscopic FSEM-HVSD. The median time from the index operation to the initiation of FSEM-HVSD was 80 ± 20.34 days in patients who underwent protective ileostomy versus 11.4 ± 4.4 days in those who did not. The average number of endoscopic treatments per patient was 5.70 ± 1.25 times. The mean length of hospital stay was 27.60 ± 4.43 days. FSEM-HVSD treatment was successful in 13 patients, and no patients had any complications. The follow-up time was 1 year. Twelve of 15 (80%) patients achieved prolonged clinical success after FSEM-HVSD treatment, 1 experienced anastomotic tumor recurrence and underwent surgery again, and 1 patient required balloon dilation for anastomotic stenosis recurrence. CONCLUSIONS FSEM-HVSD is an effective, safe, and minimally invasive treatment for ASF following colorectal cancer treatment. This technique could be the preferred treatment strategy for patients with ASF.
Collapse
Affiliation(s)
- Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Ke Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Fuwei Mao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yifan Xue
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Zhenxing Jiang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Le Qin
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
| |
Collapse
|
4
|
Bemelman WA, Arezzo A, Banasiewicz T, Brady R, Espín-Basany E, Faiz O, Jimenez-Rodriguez RM. Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus. BJS Open 2022; 6:6765232. [PMID: 36268752 PMCID: PMC9585396 DOI: 10.1093/bjsopen/zrac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/17/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022] Open
Abstract
Background Anastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons. Method Seven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon. Results Thirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks. Conclusion Although further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.
Collapse
Affiliation(s)
- Willem A Bemelman
- Correspondence to: Willem A. Bemelman, Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands (e-mail: )
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Tomasz Banasiewicz
- Poznan University of Medical Sciences, Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznań, Poland
| | - Richard Brady
- Newcastle Centre for Bowel Disease Research Group, Department of Colorectal Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Eloy Espín-Basany
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, University Hospital Vall d’Hebron-Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Rosa M Jimenez-Rodriguez
- Unidad de Coloproctología, Department of Surgery, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| |
Collapse
|
5
|
de Lacy FB, Talboom K, Roodbeen SX, Blok R, Curell A, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum therapy and early surgical closure after pelvic anastomotic leak: meta-analysis of bowel continuity rates. Br J Surg 2022; 109:822-831. [PMID: 35640282 PMCID: PMC10364759 DOI: 10.1093/bjs/znac158] [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: 01/01/2022] [Revised: 04/10/2022] [Accepted: 04/21/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. METHODS A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. RESULTS Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. CONCLUSION EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.
Collapse
Affiliation(s)
- F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Sapho X Roodbeen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Robin Blok
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Anna Curell
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Oncological and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Roel Hompes
- Correspondence to: Roel Hompes, Department of Surgery, Amsterdam UMC, University of Amsterdam, Location AMC, J1A-216, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (e-mail: )
| |
Collapse
|
6
|
Vignali A, De Nardi P. Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis. World J Gastroenterol 2022; 28:1394-1404. [PMID: 35582677 PMCID: PMC9048477 DOI: 10.3748/wjg.v28.i14.1394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/07/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.
Collapse
Affiliation(s)
- Andrea Vignali
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
- Department of Surgery, Vita-Salute University, Milano 20132, Italy
| | - Paola De Nardi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milano 20132, Italy
| |
Collapse
|
7
|
Endoscopic vacuum therapy for the treatment of colorectal leaks - a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:283-292. [PMID: 34817647 PMCID: PMC8803669 DOI: 10.1007/s00384-021-04066-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND During the last two decades, vacuum-assisted wound therapy has been successfully transferred to an endoscopic treatment approach of various upper and lower gastrointestinal leaks called endoscopic vacuum therapy (EVT). As mostly small case series are published in this field, the aim of our systematic review and meta-analysis was to evaluate the efficacy and safety of EVT in the treatment of colorectal leaks. METHODS A systematic search of MEDLINE/PubMed and Cochrane databases was performed using search terms related to EVT and colorectal defects (anastomotic leakage, rectal stump insufficiency) according to the PRISMA guidelines. Randomized controlled trials (RCTs), observational studies, and case series published by December 2020 were eligible for inclusion. A meta-analysis was conducted on the success of EVT, stoma reversal rate after EVT as well as procedure-related complications. Statistical interferences were based on pooled estimates from random effects models using DerSimonian-Laird estimator. RESULTS Only data from observational studies and case series were available. Twenty-four studies reporting on 690 patients with colorectal defects undergoing EVT were included. The mean rate of success was 81.4% (95% CI: 74.0%-87.1%). The proportion of diverted patients was 76.4% (95% CI: 64.9%-85.0%). The mean rate of ostomy reversal across the studies was 66.7% (95% CI: 58.0%-74.4%). Sixty-four patients were reported with EVT-associated complications, the weighted mean complication rate across the studies was 12.1% (95% CI: 9.7%-15.2%). CONCLUSIONS Current medical evidence on EVT in patients with colorectal leaks lacks high quality data from RCTs. Based on the data available, EVT can be seen as a feasible treatment option with manageable risks for selected patients with colorectal leaks.
Collapse
|
8
|
Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
Collapse
Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| |
Collapse
|
9
|
Abstract
Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.
Collapse
Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
10
|
Dhindsa BS, Naga Y, Saghir SM, Daid SGS, Chandan S, Mashiana H, Dhaliwal A, Sidhu A, Sayles H, Ramai D, Bhat I, Singh S, McDonough S, Adler DG. Endo-sponge in management of anastomotic colorectal leaks: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1342-E1349. [PMID: 34466357 PMCID: PMC8367445 DOI: 10.1055/a-1490-8783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Following colorectal surgery, anastomotic dehiscence and leak formation has an incidence of 2 % to 7 %. Endo-SPONGE has been applied in the management of anastomatic leaks (ALs) after colorectal surgery. This is the first systematic review and meta analysis to evaluate the efficacy and safety of Endo-SPONGE in the management of colorectal ALs. Patients and methods The primary outcomes assessed were the technical and clinical success of Endo-SPONGE placement in colorectal ALs. The secondary outcomes assessed were the overall adverse events (AEs) and the AE subtypes. Pooled estimates were calculated using random-effects models with 95 % confidence interval (C. I.). The statistical analysis was done using STATA v16.1 software (StataCorp, LLC College Station, Texas, United States). Results The analysis included 17 independent cohort studies with a total of 384 patients. The rate of technical success was 99.86 % (95 % CI: 99.2 %, 100 %; P = 0.00; I 2 = 70.69 %) and the calculated pooled rate of clinical success was 84.99 % (95 % CI: 77.4 %, 91.41 %; P = 0.00; I 2 = 68.02 %). The calculated pooled rate of adverse events was 7.6 % (95 % CI: 3.99 %, 12.21 %; P = 0.03; I 2 = 42.5 %) with recurrent abscess formation and bleeding being the most common AEs. Moderate to substantial heterogeneity was noted in our meta-analysis. Conclusions Endoscopic vacuum therapy appears to be a minimally invasive, safe, and effective treatment modality for patients with a significant colorectal leak without any generalized peritonitis with high clinical and technical success rates and a low rate of adverse events. Further prospective or randomized controlled trials are needed to validate our findings.
Collapse
Affiliation(s)
- Banreet S. Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Yassin Naga
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, United States
| | - Syed M. Saghir
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, United States
| | | | - Saurabh Chandan
- Creighton University Medical Center, Omaha, Nebraska, United States
| | - Harmeet Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, Moffitt Cancer Center, Tampa, Florida, United States
| | - Abhitej Sidhu
- Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Daryl Ramai
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha Nebraska, United States
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| |
Collapse
|
11
|
Sharp G, Steffens D, Koh CE. Evidence of negative pressure therapy for anastomotic leak: a systematic review. ANZ J Surg 2021; 91:537-545. [PMID: 33480168 DOI: 10.1111/ans.16581] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic leak (AL) is a devastating complication. Several new treatment options are available, endoluminal negative pressure therapy is one. The aims of this systematic review are; to report success rates and stoma closure rates following endoluminal negative pressure therapy in colorectal AL patients. METHODS A systematic review of MEDLINE, PubMed, Cochrane and Embase databases from inception to June 2018. Search limits were; English language, humans, sample >5 and >18 years. Search terms were Endospong* OR Endo-spong* OR Endo spong* OR Endoluminal negative pressure OR Endoluninal vac* OR Vacuum assisted OR negative pressure. Combined with colon OR rectum OR colorect* AND anastomotic leak OR leak*. RESULTS Twenty articles met inclusion criteria. There were 334 patients. Reported success rates ranged from 60% to 100%. However, success definition varied considerably. The most widely used definition was endoscopic assessment of residual cavity size, but this also varied from 0.5 cm to 3 cm. Stoma closure rates were only reported in 11 studies and ranged from 31% to 100%. Complication rates were reported in 13 studies (65%). The most common was on-going sepsis. CONCLUSIONS Included studies suggest that 60-100% of ALs heal with endoluminal negative pressure therapy. However, results from this review need to be interpreted with caution because of the variable definition of success. A more objective assessment of success may be stoma closure but this is only reported in 60% of studies. Further studies are needed to assess the benefit of negative pressure therapy in anastomotic leaks.
Collapse
Affiliation(s)
- Gary Sharp
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Şandra-Petrescu F, Tzatzarakis E, Kähler G, Reissfelder C, Herrle F. Management of colorectal anastomotic leakage using endoscopic negative pressure therapy with or without protective ostomy: a retrospective study. Int J Colorectal Dis 2021; 36:2261-2269. [PMID: 34455472 PMCID: PMC8426235 DOI: 10.1007/s00384-021-04011-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Management of colorectal anastomotic leakage (AL) is patient-oriented and requires an interdisciplinary approach. We analyzed the management of AL according to its severity and presence of ostomy and proposed a therapy algorithm. METHODS We identified all patients who underwent colorectal surgery and developed an AL in our clinic between 2012 and 2017. The management of AL was retrospectively analyzed according to the severity grade: asymptomatic (A), requesting interventional or antibiotic therapy (B), undergoing re-operation (C). The groups were compared according to the leakage characteristics, presence of ostomy, and patient clinical conditions. RESULTS We identified 784 consecutive patients meeting the inclusion criteria. Of these, 10.8% experienced an AL (A = 18%, B = 48%, and C = 34%). The rate of successful ostomy closure was 100% (A), 68% (B), and 62% (C), respectively. Within group B, 91% of the patients were treated solely by endoscopic negative pressure therapy (ENPT), whereas 37% of the patients within group C required ENPT in addition to surgery. Seven cases within group B (17%) required no protective ostomy (nOB) during ENPT which was itself shorter and required less cycles in comparison to group B with ostomy (OB) (p = 0.017 and 0.111, respectively). Moreover, the leakage distance to anal verge was higher in the OB subgroup (p < 0.001). CONCLUSION ENPT for the treatment of colorectal AL is efficient in combination with operative revision or protective ostomy. In selected patients, it is feasible also in the absence of a protective ostomy.
Collapse
Affiliation(s)
- Flavius Şandra-Petrescu
- grid.411778.c0000 0001 2162 1728Chirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Emmanouil Tzatzarakis
- grid.411778.c0000 0001 2162 1728Chirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Georg Kähler
- grid.411778.c0000 0001 2162 1728Interdisziplinäre Endoskopie, Chirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Christoph Reissfelder
- grid.411778.c0000 0001 2162 1728Chirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Florian Herrle
- grid.411778.c0000 0001 2162 1728Chirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| |
Collapse
|
13
|
The "impossible" rectal anastomosis: a novel use for endoluminal vacuum-assisted therapy. Tech Coloproctol 2020; 25:125-130. [PMID: 33216246 PMCID: PMC7847453 DOI: 10.1007/s10151-020-02363-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/18/2020] [Indexed: 11/18/2022]
Abstract
Purpose Low rectal anastomoses can safely be performed, usually secured by a diverting ostomy. However, in cases of inflammation, extensive scarring, after extensive radiation, or after severe stapler dysfunction the risk for an anastomotic leak may become prohibitively high. We present a novel use for endoluminal vacuum-assisted therapy (EVAT) for otherwise “impossible” low rectal anastomoses. Methods Our initial series consisted of 14 consecutive patients who underwent prophylactic EVAT treatment due to unsafe low colorectal anastomosis. The vacuum sponge was placed intraoperatively in cases otherwise calling for a Hartmann’s procedure. An open-pored polyurethane sponge was placed prophylactically transanally for a mean duration of 11 days. Patient characteristics, complications, and risk factors were prospectively collected from medical records and analyzed. Results Between March 2017 and September 2019, we performed this novel technique in 14 patients enabling us to perform an anastomosis. Our collective consisted of 4 female (29%) and 10 male (71%) patients with a medium age of 59 years. Underlying disease was colorectal cancer in 10 patients, ovarian cancer, perforated sigmoid diverticulitis, ischemic colitis and sarcoma in one patient each. Dominant factors putting the anastomosis at extremely high risk were acute inflammation (n = 2), frozen pelvis (n = 2), intraoperative local chemotherapy (n = 2), stapler dysfunction (n = 2), non-closable rectal stump (n = 2), empty pelvis (n = 1) and ultra-low anastomosis (n = 3). Prophylactic EVAT was successful in 92% and gastrointestinal continuity was preserved in all patients. Conclusion This is the first description of prophylactic EVAT treatment. It seems to be a simple and safe method to enforce the high-risk low rectal anastomosis.
Collapse
|
14
|
Weréen A, Dahlberg M, Heinius G, Pieniowski E, Saraste D, Eklöv K, Nygren J, Pekkari K, Everhov ÅH. Long-Term Results after Anastomotic Leakage following Rectal Cancer Surgery: A Comparison of Treatment with Endo-Sponge and Transanal Irrigation. Dig Surg 2020; 37:456-462. [PMID: 32829324 DOI: 10.1159/000508935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/19/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE We aimed to evaluate long-term results in patients from regular health care treated with endoscopic transanal closure system, that is, endoscopic vacuum-assisted closure system (EVAC) compared to transanal irrigation. METHODS In this retrospective, medical chart-based, observational study, we included patients with anastomotic leakage after low anterior resection for rectal cancer from 3 Stockholm hospitals 2006-2016 and compared time to first stoma closure in a Kaplan-Meier model and the proportion of patients who were stoma-free at end of follow-up. RESULTS Anastomotic leakage was found in 81 patients who were followed up in median 5.9 years (min-max: 0.53-13). EVAC was used on 14 (17%) patients and transanal irrigation on 34 (42%) patients. The remaining 33 (41%) patients either got a permanent colostomy or were treated only with antibiotics and percutaneous drainage. Treatment with EVAC or transanal irrigation led to similar rates of stoma closure, both when comparing all patients, and when comparing patients with similar defects. At the end of follow-up, 43% of patients treated with EVAC and 50% of patients treated with repeated irrigation were stoma-free (p = 0.75). CONCLUSIONS We found no evidence of better outcomes in patients treated with EVAC. The study was, however, limited by small sample size.
Collapse
Affiliation(s)
- Alice Weréen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Göran Heinius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Emil Pieniowski
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Deborah Saraste
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Karolina Eklöv
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, .,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,
| |
Collapse
|
15
|
Mahendran B, Rossi B, Coleman M, Smolarek S. The use of Endo-SPONGE ® in rectal anastomotic leaks: a systematic review. Tech Coloproctol 2020; 24:685-694. [PMID: 32377984 DOI: 10.1007/s10151-020-02200-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. METHODS All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. CONCLUSIONS Endo-SPONGE® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.
Collapse
Affiliation(s)
- B Mahendran
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK.
| | - B Rossi
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - M Coleman
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| | - S Smolarek
- Department of Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| |
Collapse
|
16
|
Chorti A, Stavrou G, Stelmach V, Tsaousi G, Michalopoulos A, Papavramidis TS, Kotzampassi K. Endoscopic repair of anastomotic leakage after low anterior resection for rectal cancer: A systematic review. Asian J Endosc Surg 2020; 13:141-146. [PMID: 31297989 DOI: 10.1111/ases.12733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re-operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over-The-Scope-Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy. METHOD A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed. RESULTS The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70-68.76), the male-to-female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03-6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39-74.90). Vacuum-assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum-assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%). CONCLUSION Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results.
Collapse
Affiliation(s)
- Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Veronica Stelmach
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonios Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| |
Collapse
|
17
|
Popivanov GI, Mutafchiyski VM, Cirocchi R, Chipeva SD, Vasilev VV, Kjossev KT, Tabakov MS. Endoluminal negative pressure therapy in colorectal anastomotic leaks. Colorectal Dis 2020; 22:243-253. [PMID: 31274227 DOI: 10.1111/codi.14754] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
AIM The aim of the present work was to perform an up-to-date review of the literature on endoluminal negative pressure therapy for colorectal anastomotic leak. METHOD An electronic search in PubMed and Google Scholar and a manual search without language restrictions were performed on 25 January 2019. Only original series reporting endoluminal negative pressure therapy in colorectal anastomotic leaks were included. The primary outcome was the success rate (complete closure of the abscess cavity). The secondary outcomes were the rates of complications and stoma closure. RESULTS Nineteen series with a total of 295 cases were analysed. The median distance of the anastomosis from the anal verge and the size of the abscess were 5.65 cm (4.9-10) and 6.0 cm (5-8.1) respectively. In 84.5% (78%-91%) the stoma was created at the first intervention. Neoadjuvant therapy was performed in 48.6% (3%-60%). Median 7 sponges (2-34) were used with median negative pressure 150 mmHg (125-700) for a median of 31 days (14-127). The success rate was 85.4% (80%-91%) with ileostomy closure in 72.6%. Complications were observed in 19% (13%-25%): abscesses 11.5% and anastomotic stenosis 4.4%. Laparotomy was required in 15% of the complications. The stoma was the only significant predictor for the success of the therapy (0.007, SE 0.004, P = 0.040). CONCLUSIONS The initial experience looks promising with an 85% success rate, which precludes risky re-resections with redo anastomosis or Hartmann's procedure. Despite the good initial results, definitive conclusions cannot be drawn because of the small sample size and the lack of high-quality comparative studies.
Collapse
Affiliation(s)
- G I Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - V M Mutafchiyski
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - R Cirocchi
- Department of Surgery and Surgical Science, University of Perugia, Perugia, Italy
| | - S D Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
| | - V V Vasilev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - K Ts Kjossev
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria
| | - M S Tabakov
- Clinic of Abdominal Surgery, MHAT 'Sv. Ivan Rilski', Sofia, Bulgaria
| |
Collapse
|
18
|
Can a Local Drainage Salvage a Failed Colorectal or Coloanal Anastomosis? A Prospective Cohort of 54 Patients. Dis Colon Rectum 2020; 63:93-100. [PMID: 31804271 DOI: 10.1097/dcr.0000000000001516] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Local drainages can be used to manage leakage in select patients without peritonitis. OBJECTIVE The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anastomosis after anastomotic leakage. DESIGN A retrospective observational study was performed on a prospectively maintained database. SETTINGS The study was performed between 2014 and 2017 in a tertiary referral center. PATIENTS Patients undergoing rectal resections with either a colorectal or coloanal anastomosis with diverting stoma were identified. Anastomotic leakages requiring a radiological or transanal drainage without peritonitis were included. MAIN OUTCOME MEASURES The primary outcome was the maintenance of the primary anastomosis after local drainage of an anastomotic leakage and stoma reversal. RESULTS A low anastomosis for rectal cancer with diverting stoma was performed in 326 patients. A total of 77 anastomotic leakages (24%) occurred, of which, 6 (8%) required abdominal surgery, 17 (22%) were treated conservatively (medical management), and 54 (70%) were managed by drainage. Surgical transanal drainage was performed in 21 patients (39%), with radiologic drainage procedures performed in 33 patients (61%). The median interval between surgery and drainage was 13 days (range, 9-21 d). Five patients (9%) required emergency abdominal surgery. Twenty-seven patients (50%) did not require any additional intervention after drainage procedure, whereas 21 patients (39%) underwent redo anastomotic surgery. Forty-three patients (80%) had no stoma at the end of follow-up. Failure to maintain the primary anastomosis after local drainage was associated with increased age (p = 0.04), a pelvic per-operative drainage (p = 0.05), a drainage duration >10 days (p = 0.002), the time between surgery and drainage >15 days (p = 0.03), a side-to-end or J-pouch anastomosis (p = 0.04), and surgical transanal drainage (p = 0.03). LIMITATIONS The small sample size of the study was the main limitation. CONCLUSIONS Local drainage procedures maintained primary anastomosis in 50% of cases after an anastomotic leakage. See Video Abstract at http://links.lww.com/DCR/B57. ¿PUEDE UN DRENAJE LOCAL SALVAR UNA ANASTOMOSIS COLORRECTAL O COLOANAL FALLIDA? UNA COHORTE PROSPECTIVO DE 54 PACIENTES: Los drenajes locales se pueden utilizar para controlar las fugas en pacientes seleccionados sin peritonitis.El objetivo de este estudio fue evaluar la eficacia de los procedimientos de drenaje, para mantener una anastomosis primaria baja, después de una fuga anastomótica.Se realizó un estudio observacional retrospectivo en una base de datos mantenida prospectivamente.El estudio se realizó entre 2014-2017, en un centro de referencia terciaria.Se identificaron pacientes sometidos a resecciones rectales con anastomosis colorrectal o coloanal y estoma de derivación. Se incluyeron fugas anastomóticas sin peritonitis, que requirieron drenaje radiológico o transanal.El resultado primario fue el mantenimiento de la anastomosis primaria, después del drenaje local de una fuga anastomótica y la reversión del estoma.Se realizó una anastomosis baja para cáncer rectal con estoma derivativo en 326 pacientes. Se produjeron 77 (24%) fugas anastomóticas, de las cuales 6 (8%) requirieron cirugía abdominal, 17 (22%) fueron tratadas de forma conservadora (tratamiento médico) y 54 (70%) fueron manejadas por drenaje. Se realizó drenaje transanal en 21 pacientes (39%) y procedimientos de drenaje radiológico en 33 pacientes (61%). La mediana del intervalo entre la cirugía y el drenaje fue de 13 días [9-21]. 5 (9%) pacientes requirieron cirugía abdominal de emergencia. Veintisiete (50%) pacientes no requirieron ninguna intervención adicional después del procedimiento de drenaje, mientras que 21 pacientes (39%) se sometieron a una reparación quirúrgica anastomótica. 43 pacientes (80%) no tuvieron estoma al final del seguimiento. El fracaso para mantener la anastomosis primaria después del drenaje local, se asoció con un aumento de la edad (p = 0.04), un drenaje pélvico preoperatorio (p = 0.05), una duración del drenaje >10 días (p = 0.002), el tiempo entre la cirugía y el drenaje >15 días (p = 0.03), anastomosis termino lateral o bolsa en J (p = 0.04) y drenaje quirúrgico transanal (p = 0.03).El pequeño tamaño de la muestra del estudio fue la principal limitación.Después de la fuga anastomótica, los procedimientos del drenaje local conservaron la anastomosis primaria en el 50% de los casos. Vea el Resumen del Video en http://links.lww.com/DCR/B57.
Collapse
|
19
|
Tsai YY, Chen WTL. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019; 10:1229-1237. [PMID: 31949944 DOI: 10.21037/jgo.2019.07.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.
Collapse
Affiliation(s)
- Yuan-Yao Tsai
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - William Tzu-Liang Chen
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| |
Collapse
|
20
|
Adipose tissue grafting for management of persistent anastomotic leak after low anterior resection. Tech Coloproctol 2019; 23:981-985. [PMID: 31617034 DOI: 10.1007/s10151-019-02095-7] [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: 06/12/2019] [Accepted: 09/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND An anastomotic leak is the most dreaded complication after low anterior resection. Adipose tissue grafting may induce healing in a persistent anastomotic defect. The aim of the present study was to report retrospectively reviewed outcomes for a series of patients who were managed with heterotopic grafted adipose tissue to facilitate anastomotic healing. METHODS Patients with anastomotic leakage after low anterior resection sequentially treated with grafting of adipose tissue were included in the study. All patients had pelvic radiation during treatment and had a diverting ileostomy in situ. The cohort had a persistent defect despite being treated with available modalities such as suture repair, fibrin glue, Endo-Sponge and surgical debridement. The outcomes were reviewed and reported. RESULTS There were 11 patients (8 males and 3 females) with a median age of 54 years (range 33-72 years). Five patients experienced complete healing of the anastomotic defect with successful reversal of the diverting ileostomy. The anastomotic defect of one other patient in the series appeared to have healed and hence his diverting ileostomy was reversed. However, he presented with a recurrent leak, which ultimately necessitated an abdominoperineal resection. Another patient had a persistent defect after an attempt at adipose tissue grafting and opted to proceed with a takedown of the anastomosis. In the remaining four patients, the outcome after adipose tissue grafting remains unknown, as two patients succumbed to metastatic disease, one was lost to follow-up and the remaining patient developed a recurrence which required pelvic exenteration. Procedural associated morbidity occurred in one patient who developed fat embolism, which was treated expectantly. CONCLUSIONS Adipose tissue grafting is safe and feasible, though its effectiveness remains uncertain. It may be useful selectively in the management of persistent anastomotic leak after radiation and low anterior resection.
Collapse
|
21
|
Allaix ME, Rebecchi F, Famiglietti F, Arolfo S, Arezzo A, Morino M. Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter? Surg Endosc 2019; 34:4166-4176. [DOI: 10.1007/s00464-019-07189-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022]
|
22
|
Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects. RECENT FINDINGS The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.
Collapse
|
25
|
Shelygin YA, Nagudov MA, Ponomarenko AA, Alekseev MV, Rybakov EG, Tarasov MA, Achkasov SI. [Meta-analysis of management of colorectal anastomotic leakage]. Khirurgiia (Mosk) 2018:30-41. [PMID: 30199049 DOI: 10.17116/hirurgia201808230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.
Collapse
Affiliation(s)
- Yu A Shelygin
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Nagudov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - A A Ponomarenko
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M V Alekseev
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - E G Rybakov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Tarasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - S I Achkasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| |
Collapse
|
26
|
Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, Festen S, van der Zaag EJ, Tanis PJ, Bemelman WA. Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc 2017; 32:315-327. [PMID: 28664443 PMCID: PMC5770507 DOI: 10.1007/s00464-017-5679-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/19/2017] [Indexed: 12/13/2022]
Abstract
Introduction Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of anastomotic leakage after pre-treatment with the Endosponge® therapy. Methods In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed. Results Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient. Conclusion Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
Collapse
Affiliation(s)
- W A A Borstlap
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - G D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - L P S Stassen
- Department of Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands
| | | | - D Hess
- Department of Surgery, Antonius Zorggroep, Sneek, The Netherlands
| | - S van Dieren
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - S Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - E J van der Zaag
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| |
Collapse
|
27
|
Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
Collapse
|
28
|
Abstract
The aim of this article is to present strategies for preventing and managing the failure of the surgical restoration of intestinal continuity. Despite improvements in surgical technique and perioperative care, anastomotic leaks still occur, and with them occur increased morbidity, mortality, length of stay, and costs. Due to the devastating consequences for patients with failed anastomoses, there have been a myriad of materials and techniques used by surgeons to create better intestinal anastomoses. We will also discuss the management strategies for anastomotic leak when they do inevitably occur.
Collapse
Affiliation(s)
- Michael S Thomas
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, University of Queensland Ochsner Clinical School, New Orleans, Louisiana
| | - David A Margolin
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, University of Queensland Ochsner Clinical School, New Orleans, Louisiana
| |
Collapse
|
29
|
Abstract
INTRODUCTION Endoscopic vacuum therapy (EVT) has been established in Germany for the treatment of anastomotic leakage after rectal resection. Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema promoting perfusion and granulation at the same time. However, data for use and long-term results of EVT in colorectal surgery are still scarce and are often limited by short-term follow-up. OBJECTIVES Here, we aimed at analyzing the treatment spectrum and long-term outcome of EVT for defects of the lower gastrointestinal tract. METHODS This is a retrospective single-center analysis of EVT for defects of the lower gastrointestinal tract of different etiology in 41 patients over a time period of 8 years (2007-2015) with a mean follow-up of 36 (2-89) months. RESULTS In total, 426 polyurethane sponges were placed in lower GI defects of 41 patients (31 male, 10 female) with a median age of 70 years (range, 29-91). Most frequent indications for EVT were anastomotic leakage after rectal resection (n = 20), Hartmann's stump insufficiency (n = 12), and rectal perforation (n = 3). The median number of sponge insertions was six (range, 1-37) with a mean changing interval of 3 days (range, 1-5). Median time of therapy was 20 days. A successful vacuum therapy with local control of the septic focus was achieved in 18 of 20 patients (90 %) with anastomotic leakage after rectal resection and in nine of 12 patients with a Hartmann's stump insufficiency. In 15 of 19 (79 %) patients with a diverting stoma, take-down after successful treatment was possible. Median time to closure was 244 days (range, 152-488 days). CONCLUSION To our knowledge, this retrospective observation of EVT application for rectal lesions represents the largest patient series in literature. EVT has earned its indication in complication management after colorectal surgery and can achieve a successful control of a local septic focus in the majority of patients.
Collapse
|
30
|
Blumetti J, Abcarian H. Management of low colorectal anastomotic leak: Preserving the anastomosis. World J Gastrointest Surg 2015; 7:378-383. [PMID: 26730283 PMCID: PMC4691718 DOI: 10.4240/wjgs.v7.i12.378] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
Collapse
|
31
|
Rogalski P, Daniluk J, Baniukiewicz A, Wroblewski E, Dabrowski A. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol 2015; 21:10542-10552. [PMID: 26457014 PMCID: PMC4588076 DOI: 10.3748/wjg.v21.i37.10542] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/01/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.
Collapse
|
32
|
Baruah A, Kee Song LMW, Buttar NS. Endoscopic management of fistulas, perforations, and leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|