Post colon surgery complications: imaging findings

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BACKGROUND

Anastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.

CASE PRESENTATION

In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.

CONCLUSIONS

We reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Safety and efficacy of adding intravenous N-acetylcysteine to parenteral L-alanyl-L-glutamine in hospitalized patients undergoing surgery of the colon: a randomized controlled trial

BACKGROUND

Colon surgery can cause systemic inflammatory response syndrome (SIRS). There is a recent trend towards the use of antioxidant agents in the prevention or alleviation of the severity of postoperative SIRS, but its use is controversial as studies have shown conflicting results.

OBJECTIVES

Investigate the efficacy and tolerability of perioperative intravenous administration of N-acetylcysteine (NAC) as an antioxidant and anti-inflammatory agent in patients undergoing colon surgery.

DESIGN

Randomized, double-blinded, and controlled clinical trial.

SETTING

Surgical critical care unit in Egypt.

PATIENTS AND METHODS

Sixty patients who required admission to the ICU following colon surgery were enrolled in the study between July 2015 and October 2016. Eligibility included the need for parenteral nutrition for at least 5 days due to failure of or contraindication to enteral nutrition. Patients were randomly allocated using a computer-generated list to a loading dose of NAC followed by continuous infusion started one hour prior to induction, and continued over 48 hours, or to the control group, who received the same volume of dextrose 5%. Allocation was concealed using opaque, sealed envelopes under pharmacy control. The researcher, the anesthesiologist, the surgeon, and patients were blinded to the treatment allocation.

MAIN OUTCOME MEASURES

Clinical and laboratory evaluation for manifestations of SIRS, serum levels of tumor necrosis factor alpha and malondialdehyde, and occurrence of side effects in the study group.

SAMPLE SIZE

60 patients with mean (SD) ages of 56 (15.1) years in the study group (n=30) and 57.7 (12.3) years in the control group (n=30).

RESULTS

There was a significant difference in the mean serum level of ALT (22.6 (9.9) U/L in the study group vs. 31.1 (17.8) U/L in the control group, P=.028) after treatment with NAC, but differences between the groups in the serum level of tumor necrosis factor alpha and malondialdehyde after treatment were not significant. Serum levels of malondialdehyde increased in both groups after treatment P<.001. There was no statistically significant difference from baseline or between the groups after treatment in other clinical data and laboratory parameters following NAC administration, and only 6.6% of the patients in the study group experienced mild side effects.

CONCLUSIONS

Preoperative administration of NAC is safe, but its efficacy as an antioxidant and anti-inflammatory agent was not statistically significant and requires further investigation in a larger sample.

LIMITATIONS

Single-center study, small sample size, and short duration of NAC administration.

CLINICAL TRIALS REGISTRY

NCT03589495.

CONFLICT OF INTEREST

None.

Urgent Multidetector Computed Tomography in Colon Cancer: Postsurgical Changes and Early Complications

Complications after surgery for colorectal cancer are common in emergency departments. Multidetector computed tomography plays a fundamental role in the follow-up of patients after surgery, because it enables the detection of relapse and complications. Radiologists need to be familiar with different surgical techniques and the normal postsurgical changes so that we can differentiate them from potential complications and relapse. This article reviews the multidetector computed tomography findings that can be considered normal after surgical intervention for colorectal cancer as well as the most common early complications seen in postsurgical colorectal cancer patients presenting at emergency departments.

Imaging of the Postoperative Colon

Recognition of postoperative complications is important for the immediate diagnosis and treatment needed for appropriate patient care. Identification of postoperative complications from colon surgery requires not only knowledge of the type of procedure, but also the expected normal postoperative appearance. The purpose of this article is to discuss and review the expected anatomic changes after colorectal surgery, and the appearance of the most common postoperative complications.

Post-operative colon and urinary diversions: surgical techniques, anatomy, and imaging findings

This article discusses the commonly encountered operative procedures of the colon and urinary diversions and provides a comprehensive review of indications, contraindications, surgical techniques with emphasis on normal and abnormal multimodality imaging findings.

Imaging the postoperative patient: long-term complications of gastrointestinal surgery

OBJECTIVES

The objectives of this review are (1) to become acquainted with the long-term complications of surgery of the gastrointestinal tract, and (2) to appreciate the appropriate use of imaging in the assessment of long-term complications.

BACKGROUND

Gastrointestinal tract surgery comprises a group of procedures performed for a variety of both benign and malignant diseases. In the late postoperative setting, adhesions and internal hernias are the most important complications. and they can be further complicated by volvulus and ischemia. At present, computed tomography (CT) is the workhorse for evaluating late postoperative complications. Accurate imaging assessment of patients is essential for adequate treatment planning.

IMAGING FINDINGS OR PROCEDURE DETAILS

In this pictorial essay we will review the most frequent long-term complications after gastrointestinal surgery, including adhesions, afferent loop syndrome, closed-loop obstruction, strangulated obstruction, internal hernias, external hernias, anastomotic strictures and disease recurrence. Examples will be depicted using iconography from the authors' imaging department.

CONCLUSIONS

Knowledge of the most frequent complications after gastrointestinal surgery in the late postoperative period is of paramount importance for every radiologist, so that potentially life-threatening situations can be promptly diagnosed and adequate therapy can be planned.

TEACHING POINTS

• Long-term postoperative complications of gastrointestinal tract surgery can be divided into procedure-related and disease-related categories. • The most common procedure-related complications are internal hernias and adhesions. • The most frequent disease-related complications are mainly associated with neoplastic or inflammatory recurrence. • Computed tomography is the most useful examination when such complications are suspected.

Anastomotic leakage after colorectal surgery: diagnostic accuracy of CT

OBJECTIVES

To evaluate the diagnostic accuracy of CT in postoperative colorectal anastomotic leakage (AL).

METHODS

Two independent blinded radiologists reviewed 153 CTs performed for suspected AL within 60 days after surgery in 131 consecutive patients, with (n = 58) or without (n = 95) retrograde contrast enema (RCE). Results were compared to original interpretations. The reference standard was reoperation or consensus (a radiologist and a surgeon) regarding clinical, laboratory, radiological, and follow-up data after medical treatment.

RESULTS

AL was confirmed in 34/131 patients. For the two reviewers and original interpretation, sensitivity of CT was 82 %, 87 %, and 71 %, respectively; specificity was 84 %, 84 %, and 92 %. RCE significantly increased the positive predictive value (from 40 % to 88 %, P = 0.0009; 41 % to 92 %, P = 0.0016; and 40 % to 100 %, P = 0.0006). Contrast extravasation was the most sensitive (reviewers, 83 % and 83 %) and specific (97 % and 97 %) sign and was significantly associated with AL by univariate analysis (P < 0.0001 and P < 0.0001). By multivariate analysis with recursive partitioning, CT with RCE was accurate to confirm or rule out AL with contrast extravasation.

CONCLUSIONS

CT with RCE is accurate for diagnosing postoperative colorectal AL. Contrast extravasation is the most reliable sign. RCE should be performed during CT for suspected AL.

KEY POINTS

• CT accurately diagnosed clinically suspected colorectal AL and showed good interobserver agreement • Contrast extravasation was the most sensitive and specific CT sign • Retrograde contrast enema during CT improved positive predictive value • Retrograde contrast enema decreased false-negative or indeterminate original CT interpretations.

CT scan-based modelling of anastomotic leak risk after colorectal surgery

AIM

Prolonged ileus, low-grade fever and abdominal discomfort are common during the first week after colonic resection. Undiagnosed anastomotic leak carries a poor outcome and computed tomography (CT) scan is the best imaging tool for assessing postoperative abdominal complications. We used a CT scan-based model to quantify the risk of anastomotic leak after colorectal surgery.

METHOD

A case-control analysis of 74 patients who underwent clinico-radiological evaluation after colorectal surgery for suspicion of anastomotic leak was undertaken and a multivariable analysis of risk factors for leak was performed. A logistic regression model was used to identify determinant variables and construct a predictive score.

RESULTS

Out of 74 patients with a clinical suspicion of anastomotic leak, 17 (23%) had this complication confirmed following repeat laparotomy. In multivariate analysis, three variables were associated with anastomotic leak: (1) white blood cells count > 9 × 10(9) /l (OR = 14.8); (2) presence of ≥ 500 cm(3) of intra- abdominal fluid (OR = 13.4); and (3) pneumoperitoneum at the site of anastomosis (OR = 9.9). Each of these three parameters contributed one point to the risk score. The observed risk of leak was 0, 6, 31 and 100%, respectively, for patients with scores of 0, 1, 2 and 3. The area under the receiver operating characteristic curve for the score was 0.83 (0.72-0.94).

CONCLUSION

This CT scan-based model seems clinically promising for objective quantification of the risk of a leak after colorectal surgery.

Systematic review on the value of CT scanning in the diagnosis of anastomotic leakage after colorectal surgery

BACKGROUND

Timely diagnosis of anastomotic leakage after colorectal surgery and adequate treatment is important to reduce morbidity and mortality. Abdominal computed tomography (CT) scanning is the diagnostic tool of preference, but its value may be questionable in the early postoperative period. The accuracy of CT scanning for the detection of anastomotic leakage and its role in timing of intervention was evaluated.

METHODS

A systematic literature search was performed. Relevant publications were identified from four electronic databases between 1990 and 2011. Inclusion criteria were human studies, studies published in English or Dutch, colorectal surgery with primary anastomosis, and abdominal CT scan with reported outcome for the detection of anastomotic leakage. Exclusion criteria were cohort of fewer than five patients, other gastrointestinal surgery, no anastomosis, and radiological imaging other than CT.

RESULTS

Eight studies, including 221 abdominal CT scans, fulfilled the inclusion criteria. Overall, the methodological quality of the studies was poor. The overall sensitivity of CT scanning to diagnose leakage was 0.68 (95 % confidence interval 0.59-0.75) for colonic resection. Data on the sequelae of false-negative CT scanning was not available.

CONCLUSION

There is limited good-quality evidence to determine the value of CT scans in the detection of anastomotic leakage. To prevent delay in diagnosis and appropriate treatment of anastomotic leakage, the relatively low sensitivity of CT scanning must be taken into account.

A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review

The post-operative abdomen can be challenging and knowledge of normal post-operative anatomy is important for diagnosing complications. The aim of this pictorial essay is to describe a few selected common, major gastrointestinal surgeries, their clinical indications and depict their normal post-operative computed tomography (CT) appearance. This essay provides some clues to identify the surgeries, which can be helpful especially when surgical history is lacking: recognition of the organ(s) involved, determination of what was resected and familiarity with the type of anastomoses used.

Radiological evaluation of colorectal anastomoses

BACKGROUND AND AIMS

The purpose of this study was to determine the accuracy, interobserver variability, timing and discordance with relaparotomy of postoperative radiological examination of colorectal anastomoses.

PATIENT/METHODS

From 2000 to 2005, 429 patients underwent an ileocolonic, colo-colonic, or colorectal anastomosis. Radiological examination of the anastomosis was not performed routinely, but only when there were clinically signs of leakage. Radiological imaging was reviewed by an independent radiologist and medical records were retrospectively analyzed. Clinical anastomotic leakage was the standard of reference and defined as leakage confirmed during relaparotomy, drainage of pus per anum or as an anastomotic defect identified at digital examination.

RESULTS

Radiological evaluation of the anastomosis was performed in 91 patients (21%): CT in 27 patients, contrast radiography in 40, and both imaging modalities in 24 patients. The interobserver variability of CT and contrast radiography was 10% and 14%, respectively. The sensitivity and negative predictive value of imaging of the anastomosis was 65% and 73%, respectively. Anastomotic leakage was found in 11 of 21 patients (52%) who underwent relaparotomy despite negative imaging. Three of 36 patients (8%) with a diagnosis of anastomotic leakage based on radiological examination had an intact anastomosis at relaparotomy.

CONCLUSION

Radiological imaging of the anastomosis after colorectal surgery should be restrictively applied and interpreted with caution because of the high false-negative rate and the substantial interobserver variability.