Anastomotic leaks after bowel resection: what does peer review teach us about the relationship to postoperative mortality?

Replogle Modified Endoscopic Vacuum-Assisted Closure (EVAC) Therapy: A New Strategy to Treat Anastomotic Leakage and Esophageal Perforation

BACKGROUND

Anastomotic leakage (AL) and esophageal perforation are life-threatening complications following surgery or endoscopic dilations. "Replogle modified EVAC therapy" consists of placing a Replogle tube directly into the lumen or within an abscess cavity and remove by suction all intra-cavity fluids and secretion with a continuous low-pressure suction, promoting granulation tissue proliferation, thereby gradually decreasing the cavity size. The aim of our study was to evaluate the technical feasibility, safety, and efficacy of this technique in pediatric patients.

METHODS

A retrospective review charts of consecutive pediatric patients that were treated with "Replogle modified EVAC therapy" at our pediatric referral center between 2013 and 2022 was conducted. The clinical, endoscopic, radiological, and surgical information and data of patients were collected and revised as well as their follow-up and outcomes.

RESULTS

Ten patients (6/10 male; mean age: 7.8 y.o., range: 1.1-18 y.o.) were treated using the "Replogle modified EVAC therapy". Four out of ten patients developed esophageal perforations after endoscopic procedures. Six out of the ten enrolled patients had AL complications after surgical operations. All patients were successfully treated. There were no technical failures or complications with device placement. Mean treatment duration was 16 days (range 7-41 days). No additional treatment was needed for complete leak resolution.

CONCLUSIONS

"Replogle modified EVAC therapy" represents a promising and mini-invasive method to treat esophageal perforations and post-surgical leak in the paediatric age group. In our experience, the use of this technique was safe, effective, and particularly well suited also in complex paediatric patients.

LEVEL OF EVIDENCE

IV.

Safety profile of a multimodal fail-safe model to minimize postoperative complications in oncologic colorectal resections-a cohort study

BACKGROUND

Despite innovations in surgical techniques, major complications following colorectal surgery still lead to a significant morbidity and mortality. There is no standard protocol for perioperative management of patients with colorectal cancer. This study evaluates the effectiveness of a multimodal fail-safe model in minimizing severe surgical complications following colorectal resections.

METHODS

We compared major complications in patients with colorectal cancers who underwent surgical resections with anastomosis during 2013-2014 (control group) with patients treated during 2015-2019 (fail-safe group). The fail-safe group had preoperative bowel preparation and a perioperative single dose of antibiotics, on-table bowel irrigation and early sigmoidoscopic assessment of anastomosis in rectal resections. A standard surgical technique for tension-free anastomosis was adapted in the fail-safe approach. The chi-square test measured relationships between categorical variables, t-test estimated the probability of differences, and the multivariate regression analysis determined the linear correlation among independent and dependent variables.

RESULTS

A total of 924 patients underwent colorectal operations during the study period; however, 696 patients had surgical resections with primary anastomoses. There were 427 (61.4%) laparoscopic and 230 (33.0%) open operations, while 39 (5.6%) laparoscopic procedures were converted. Overall, the rate of major complications (Dindo-Clavien grade IIIb-V) significantly reduced from 22.6% for the control group to 9.8% for the fail-safe group (p < 0.0001). Major complications mainly occurred due to non-surgical reasons such as pneumonia, heart failure, or renal dysfunction. The rates of anastomotic leakage (AL) were 11.8% (22/186) and 3.7% (n = 19/510) for the control and fail-safe groups, respectively (p < 0.0001).

CONCLUSION

We report an effective multimodal fail-safe protocol for colorectal cancer during the pre-, peri-, and postoperative period. The fail-safe model showed less postoperative complications even for low rectal anastomosis. This approach can be adapted as a structured protocol during the perioperative care of patients for colorectal surgery.

TRIAL REGISTRATION

This study was registered in the German Clinical Trial Register (Study ID: DRKS00023804 ).

The Risk Factors of Anastomotic Leakage After Rectal Cancer Surgery

Background: Anastomotic leakage is a significant complication after colorectal anastomosis. The aim of this study was to evaluate the risk factors and preventive measures for anastomotic leakage after rectal cancer surgery. Methods: A total of 171 patients who had undergone laparoscopic and open rectal cancer resection with a double stapling participated in this study. Twelve independent variables include age, sex, obesity, smoking, ASA grading, medical diseases, preoperative radiotherapy, preoperative chemotherapy, splenic flexure mobilization, diverting ileostomy, and the number of stapler firing were analyzed. Results: The anastomotic leakage rate was 2.33% (4 of 171). The mean age of the patients was 58.33 years old while their mean body mass index (BMI) was calculated as 24.10 kg/m2. In our study, 16.3% of patients were cigarette smokers. Of the 171 rectal surgeries, 69.0% of patients were diverted by loop ileostomy and 1.16% were supported by ghost ileostomy. Of 171 patients included in this study, 17.5 % of patients required a single staple firing for rectal division. In contrast, 47.9% of patients required 2 linear staplers, others, 24.5% of patients required 3 cartridges for rectal division, and 9.9% of patients required 4 cartridges in their surgeries. There were significant differences between men and women in the number of cartridges used (P = 0.023). Conclusions: All our leakage cases were men and the higher number of stapler firings for rectal division, history of smoking; male gender, and level of anastomosis were independent risk factors for the anastomotic leak.

Lactate Level as a Prediction Factor of Reperforation after Repairing Gastric Perforation

Reperforation after gastric perforation repair is a complication which increases the rate of morbidity and mortality in gastric perforation. The lack of ability of the tissue to use oxygen in septic condition causes anaerobic cellular metabolism and furthermore it will cause failure in closing the perforation. The production of anaerobic metabolism is lactic acid which can be measured from the blood. The aim of this study is to determine the cut-off point of blood lactate level as a predictor of reperforation after repairing gastric perforation. Forty-six patients diagnosed as gastric perforation, who were repaired in Dr Soetomo Hospital from October 2014 to October 2015 were recruited as samples. Serum lactate was taken one hour before repairing the perforation. After being repaired, the patients were observed until the 14th day to evaluate whether any reperforation would occur or not . The design of this research was cross-sectional, analytic observational. The data was analyzed using independent t-test and ROC for obtaining the cut-off point as a predictor of the reperforation after the gastric perforation was repaired. There was a significant difference in the mean of lactate level in the group with reperforation compared with that of the non-reperforation group, that is as big as 3.74±0.59 mmol/L and 2.60±0.76 mmol/L. Using ROC curve analysis, there was the cut-off point of lactate level for reperforation 3.35 mmol/L, with sensitivity 92.9%, specificity 84.4%, positive predictive value 72% and negative predictive Value 96.4%, accuracy 87.0% and in the AUC value 0.902.

The assessment of perioperative risk factors of anastomotic leakage after intestinal surgeries; a prospective study

Background

Anastomotic leaks (AL) are among the most serious complications due to the substantial impact on the quality of life and mortality. Inspite of the advance in diagnostic tools such as laboratory tests and radiological adjuncts, only moderate improvement has been recorded in the rate of detected leaks. The purpose of the research was to assess the perioperative risk factors for AL.

Methods

This study was achieved at MUH and MIH/Egypt within the period between January 2016 and January 2019 for the candidates who underwent bowel anastomosis for small intestinal (except duodenal one) and colorectal pathology. The collected data were analyzed using SPSS of V-26.

Results

This study included 315 cases, among them, 27 cases (8.57%) developed AL. The percentage of covering stoma was significantly higher in the non-leakage group vs leakage one (24.3% vs 11.1% respectively). lower albumin, operative timing, perforation, and covering stoma were shown as significant risk factors for leakage, but with multivariate analysis for these factors, the emergency operation, and serum albumin level was the only independent risk factors that revealed the significance consequently (p = 0.043, p = 0.015). The analysis of different predictors of AL on the third day showed that the cut-off point in RR was 29 with 83% sensitivity and 92% specificity in prediction of leakage, the cut-off point in RR was 118 with 74% sensitivity and 87% specificity in prediction of leakage and the cut-off point in CRP was 184.7 with 82% sensitivity and 88% specificity in prediction of AL and all had statistically significant value.

Conclusions

The preoperative serum albumin level and the emergency operations are independent risk factors for anastomotic leakage. Moreover, leakage should be highly suspected in cases with rising respiratory rate, heart rate, and CRP levels.

Resuturing Without Enterostomy for the Treatment of Early-Stage Anastomotic Leaks After Laparoscopic Soave Procedure in Hirschsprung's Disease

Background: Anastomotic leak (AL) rates gradually decreased with surgical skills and perioperative management progression, but it is still inevitable. As the traditional management of AL after the pull-through procedure of Hirschsprung's disease (HD), enterostomy could lead to multiple surgeries, repeated hospitalizations, increased costs, and enterostomy-associated complications. This study aimed to explore the safety and feasibility of resuturing without enterostomy treating early AL after the laparoscopic Soave procedure. Methods: From October 2014 to June 2019, 10 patients who had AL after the laparoscopic Soave procedure were included. Six patients underwent simply resuturing with presacral drainage; the reoperation time was 1-5 days after primary surgery. Four patients who had diffused peritonitis or severe inflammations received resuturing with an ileostomy, and the reoperation time was 6-11 days. Results: Common early symptoms of AL included persistent fever, sacrococcygeal pain, and abdominal pain. The median delay to reoperation was 1.0 (0-2.25) day. Five patients had leaks at the 3-6 o'clock position, two had leaks at the 6-9 o'clock, and the other three had leaks at the 6 o'clock. The median postoperative fever durations were similar in patients without or with an ileostomy, and the median length of intensive care unit (ICU) stays, duration of antibiotic use, and postoperative length of stay were significantly longer in patients with ileostomy. The mean follow-up time was 38.5 ± 16.7 months (15-69 m). As of the time of writing, no reoccurrence was identified. Conclusion: For patients without diffuse peritonitis, severe inflammations, early diagnosis and timely resuturing of AL within 5 days after the laparoscopic Soave procedure of HD could be a safe, effective, and pleasing treatment.

Predictors of complications from stoma closure in elective colorectal surgery: an assessment from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP)

BACKGROUND

There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure.

METHODS

The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling.

RESULTS

We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p = 0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p = 0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p = 0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p = 0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p = 0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p = 0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p = 0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p = 0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p = 0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p = 0.015) were associated with increased odds of readmission.

CONCLUSIONS

Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.

PulseCam: a camera-based, motion-robust and highly sensitive blood perfusion imaging modality

Blood carries oxygen and nutrients to the trillions of cells in our body to sustain vital life processes. Lack of blood perfusion can cause irreversible cell damage. Therefore, blood perfusion measurement has widespread clinical applications. In this paper, we develop PulseCam - a new camera-based, motion-robust, and highly sensitive blood perfusion imaging modality with 1 mm spatial resolution and 1 frame-per-second temporal resolution. Existing camera-only blood perfusion imaging modality suffers from two core challenges: (i) motion artifact, and (ii) small signal recovery in the presence of large surface reflection and measurement noise. PulseCam addresses these challenges by robustly combining the video recording from the camera with a pulse waveform measured using a conventional pulse oximeter to obtain reliable blood perfusion maps in the presence of motion artifacts and outliers in the video recordings. For video stabilization, we adopt a novel brightness-invariant optical flow algorithm that helps us reduce error in blood perfusion estimate below 10% in different motion scenarios compared to 20-30% error when using current approaches. PulseCam can detect subtle changes in blood perfusion below the skin with at least two times better sensitivity, three times better response time, and is significantly cheaper compared to infrared thermography. PulseCam can also detect venous or partial blood flow occlusion that is difficult to identify using existing modalities such as the perfusion index measured using a pulse oximeter. With the help of a pilot clinical study, we also demonstrate that PulseCam is robust and reliable in an operationally challenging surgery room setting. We anticipate that PulseCam will be used both at the bedside as well as a point-of-care blood perfusion imaging device to visualize and analyze blood perfusion in an easy-to-use and cost-effective manner.

Incidence and Risk Factors for Anastomotic Failure in 1594 Patients Treated by Transanal Total Mesorectal Excision: Results From the International TaTME Registry

OBJECTIVE

To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal Excision (TaTME) and identify independent risk factors for failure.

BACKGROUND

Anastomotic leak and its sequelae are dreaded complications following gastrointestinal surgery. TaTME is a recent technique for rectal resection, which includes novel anastomotic techniques.

METHODS

Prospective study of consecutive reconstructed TaTME cases recorded over 30 months in 107 surgical centers across 29 countries. Primary endpoint was "anastomotic failure," defined as a composite endpoint of early or delayed leak, pelvic abscess, anastomotic fistula, chronic sinus, or anastomotic stricture. Multivariate regression analysis performed identifying independent risk factors of anastomotic failure and an observed risk score developed.

RESULTS

One thousand five hundred ninety-four cases with anastomotic reconstruction were analyzed; 96.6% performed for cancer. Median anastomotic height from anal verge was 3.0 ± 2.0 cm with stapled techniques accounting for 66.0%. The overall anastomotic failure rate was 15.7%. This included early (7.8%) and delayed leak (2.0%), pelvic abscess (4.7%), anastomotic fistula (0.8%), chronic sinus (0.9%), and anastomotic stricture in 3.6% of cases. Independent risk factors of anastomotic failure were: male sex, obesity, smoking, diabetes mellitus, tumors >25 mm, excessive intraoperative blood loss, manual anastomosis, and prolonged perineal operative time. A scoring system for preoperative risk factors was associated with observed rates of anastomotic failure between 6.3% to 50% based on the cumulative score.

CONCLUSIONS

Large tumors in obese, diabetic male patients who smoke have the highest risk of anastomotic failure. Acknowledging such risk factors can guide appropriate consent and clinical decision-making that may reduce anastomotic-related morbidity.

Reduced rate of dehiscence after implementation of a novel technique for creating colonic anastomosis in pediatric patients undergoing intestinal anastomosis in a single institute

We aimed to investigate the new continuous horizontal mattress anastomosis for pediatric patients who underwent emergency or electively laparotomy.From June 2012 to June 2017, 858 patients undergoing intestinal anastomosis were reviewed retrospectively, including 369 patients with the new continuous horizontal mattress anastomosis and 489 patients with traditional 2 layer interrupted anastomosis, served as control. Propensity score matching was performed to adjust for selected baseline variables. The primary outcome, anastomosis complications and clinical outcomes, including postoperative gastrointestinal function recovery, overall expenditure, and postoperative hospital stay were compared between the 2 groups.Patients with the new manual anastomosis had advantageous postoperative outcomes than those with the traditional 2 layer interrupted anastomosis. A mean of 11.4 minutes was required to construct the new manual single-layer anastomosis versus 18.5 minutes for the traditional anastomosis (P < .001). A reduction trend for postoperative anastomotic complications was indicated in patients receiving horizontal mattress anastomosis (odds ratio [OD] (95% confidence interval [CI]), 0.56 (0.37-0.84); P = .004), including peritonitis or abscess (OD [95% CI], 0.56 (0.32-0.98); P = .026), anastomotic leakage (OD [95% CI], 0.39 [0.12-1.27]; P = .088), and anastomotic strictures (P = .26). Mean length of stay was 10.9 ± 2.9 days for the new manual anastomosis group and 11.3 ± 3.5 days for traditional 2-layer anastomosis patients (P = .12).Beneficial effects of the new manual anastomosis were demonstrated in terms of anastomotic complications, and length of hospital stay in the pediatric patients. Furthermore, it is a novel, feasible and safe method that may simplify the surgical procedure in anastomoses.

Transanal Total Mesorectal Excision: Is There a Real Advantage? The Baltic View

Background

The novel surgical procedure transanal total mesorectal excision (taTME) has rapidly become an interest of research in order to overcome the shortcomings of laparoscopic surgery in the treatment of middle and low rectal cancer. taTME is a new natural orifice transluminal endoscopic surgery modality combining three rectal surgery techniques.

Methods

A retrospective clinical study was conducted in a single centre for a period of 3 years, and herein we report on our first 25 taTME procedures in patients with middle and lower third rectal adenocarcinoma.

Results

The main demographics were evaluated. The mean age of patients was 64 ± 12 years. There were predominantly males (72%) and 7 female patients (28%) with an average body mass index of 29 ± 4.8 kg/m². High blood pressure, obesity, chronic heart insufficiency, chronic atrial fibrillation, and diabetes mellitus were commonly diagnosed in all patients. A circumferential resection margin >1 mm was achieved in 16% (n = 4), >2 mm in 40% (n = 10), and >3 mm in 44% (n = 11) of operated patients. The average CRM was 1.8 ± 0.9 cm. In 24% of cases, the distance of a tumour from the mesorectal fascia (MRF) was <1 mm; meanwhile, for 76% of patients, the tumour margin was >1 mm from the MRF. Recovery to flatus was 3 ± 1 days. The average length of hospital stay was 11 ± 3 days. The overall postoperative morbidity was 8%, i.e. one (4%) complication classified as Clavien-Dindo degree I and one (4%) major (IIIb) complication. Subsequently, all patients successfully recovered and were discharged from hospital. During the follow-up period no cancer recurrence was observed.

Conclusion

Our results nicely demonstrate that taTME can be safely performed with acceptable perioperative complications in patients with middle or lower third rectal cancer. In addition, the perioperative morbidity is also acceptable. However, taTME remains a technically highly demanding operation but is feasible and safe after the appropriate experience is gained. Nevertheless, larger multi-centre prospective randomised studies are ongoing to confirm the safety and to verify oncological results when compared to laparoscopic rectal surgery.

Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients

AIM

Reports detailing the morbidity-mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies.

METHOD

We undertook a STROBE-compliant analysis of left colectomies included in a national prospective online database. Forty-two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the 'least absolute shrinkage and selection operator' (LASSO) method.

RESULTS

We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00-7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58-8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18-0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03-8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8-40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001).

CONCLUSION

Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy.

Green indocyanine fluorescence in robotic abdominal surgery

Fluorescent imaging with indocyanine green (ICG) is an emerging technology that is gaining acceptance for being a valid tool in surgeons' decision making. ICG binds to plasma lipoproteins if injected intravenously and, when excited by near-infrared light, provides anatomic information about organs vascularization and tissues perfusion. If injected in tissues, it migrates in the lymphatic system, therefore enabling the identification of lymphatic draining pathways of different organs. In this paper we address specific applications of ICG fluorescence in robotic general surgery.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats

INTRODUCTION

This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy.

METHODS

32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1β) plasma levels.

RESULTS

Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1β plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU.

CONCLUSION

Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

Multicenter analysis of transanal tube placement for prevention of anastomotic leak after low anterior resection

BACKGROUND

Anastomotic leak (AL) is a serious complication of low anterior resection (LAR). This study aimed to evaluate the effect of transanal tube placement for prevention of AL.

METHODS

This multicenter retrospective cohort study enrolled 328 consecutive patients who underwent LAR for rectal cancer at participating hospitals from 2009 to 2014. Multivariate logistic regression was used to adjust for confounding factors.

RESULTS

A transanal tube was placed in 205 patients (TA group) and not placed in 123 patients (non-TA group). Symptomatic AL occurred in 36 cases (11%), with significantly higher incidence of symptomatic AL in the non-TA group than in the TA group (15% vs 8.3%, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.01-4.06). After adjusting for confounding factors, multivariate analysis revealed that placement of a transanal tube could decrease the incidence of symptomatic AL (adjusted OR 0.37, 95%CI 0.15-0.91). There was no significant difference in postoperative morbidity, mortality, length of hospital stay, or local recurrence rate between the two groups. Local recurrence rate tended to be higher in patients with symptomatic AL (3/36) than in those without it (10/292).

CONCLUSIONS

Transanal tube placement is effective for decreasing the incidence of symptomatic AL after LAR.

Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation

BACKGROUND

Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.

METHODS

We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.

RESULTS

Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 109/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.

CONCLUSION

This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.

Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage

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.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery.

METHOD

This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage.

RESULTS

A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001).

CONCLUSION

In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors

PURPOSE

To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage.

METHODS

The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution.

RESULTS

The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator.

CONCLUSIONS

The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

Is the routine use of a water-soluble contrast enema prior to closure of a loop ileostomy necessary? A review of a single institution experience

Background

The aims of the study were to determine the radiological leak rate in those patients who had undergone a resection for left-sided colorectal cancer and to see if the presence of a leak can be related with the postoperative clinical period. We also aimed to identify any common factors between patients with leak.

Methods

A retrospective analysis of prospectively collected data of all patients who underwent a left-sided colorectal cancer resection with formation of a defunctioning ileostomy was undertaken. Between 2005 and 2010, 418 such patients were identified.

Results

A water-soluble contrast enema was performed in 339 patients (81.1 %). Of these, 24 (7.1 %) were reported to show an anastomotic leak. Data for these 24 patients is presented in this study.

Twenty-three (95.8 %) of the leaks occurred in patients who had undergone an anterior resection; 95.8 % of the patients with a leak were male. Fifteen (62.5 %) patients underwent neo-adjuvant radiation. The mean length of stay in those patients shown to have a subsequent radiological leak was 18.8 days (median), compared with the overall unit figures of 12 days. Only 29.2 % of the patients who had a leak identified had an uncomplicated postoperative period. Overall 87.5 % of the patients had a reversal of the ileostomy.

Conclusions

Radiological leakage is not uncommon. The majority of patients, who were shown to have a radiological leak in this study, were male, had undergone an anterior resection, had received neo-adjuvant radiation, had a longer initial length of stay and had postoperative complications. Water-soluble contrast enemas could be selectively used in patients with these characteristics.

Proximal intestinal diversion is associated with increased morbidity in patients undergoing elective colectomy for diverticular disease: an ACS-NSQIP study

BACKGROUND

Elective colectomy for diverticular disease is common. Some patients undergo primary resection with proximal diversion in an effort to limit morbidity associated with potential anastomotic leak.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried. All patients undergoing a single, elective resection for diverticular disease from 2005 to 2011 were analyzed. Thirty-day outcomes were reviewed. Factors predictive of undergoing diversion and the risk-adjusted odds of postoperative morbidity with and without proximal diversion were determined by multivariable logistic regression models.

RESULTS

Fifteen thousand six hundred two patients undergoing non-emergent, elective resection were identified, of whom 348 (2.2 %) underwent proximal diversion. Variables predictive for undergoing proximal diversion included age ≥65 years, BMI ≥30, current smoking status, corticosteroid use, and serum albumin <3.0 g/dL. Multivariable analysis demonstrated that diversion was associated with significantly increased risk of surgical site infection (OR = 1.68), deep venous thrombosis (OR = 5.27), acute renal failure (OR = 5.83), sepsis or septic shock (OR = 1.75), readmission (OR = 2.57), and prolonged length of stay (OR = 3.35).

CONCLUSIONS

Proximal diversion in the setting of elective segmental colectomy for diverticular disease is uncommon. A combination of preoperative factors and intraoperative factors drives the decision for diversion. Patients who undergo diversion experience increased postoperative morbidity. Surgeons should have a low index of suspicion for postoperative complications and be prepared to mitigate their effect on the patient's outcome.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Surgeon, not disease severity, often determines the operation for acute complicated diverticulitis

BACKGROUND

The "best" operation in the setting of acute complicated diverticulitis has been debated for decades. Multiple studies, including a recent prospective randomized trial, have reported improved outcomes with primary anastomosis. The aim of this study was to determine whether surgeon or patient-specific factors drives the choice of operative procedure.

STUDY DESIGN

Consecutive adult patients with sigmoid diverticulitis, requiring emergent operative treatment for acute complicated diverticulitis, from 1997 to 2012 at an academic medical center, were identified from a prospectively maintained complications database. Patient characteristics, surgeon, choice of operation, and outcomes including postoperative complications and stoma reversal were noted. The use of primary anastomosis and associated outcomes between colorectal and noncolorectal surgeons were compared.

RESULTS

There were 151 patients who underwent urgent resection during the study period, and 136 met inclusion criteria. Eighty-two resections (65.1%) were performed by noncolorectal surgeons and 44 by colorectal surgeons (34.9%). Noncolorectal surgeons performed more Hartmann procedures (68.3% vs 40.9%, p = 0.01) despite similar demographics, American Society of Anesthesiologists (ASA) classification, and Hinchey stage. Length of stay, time to stoma reversal, ICU days, and postoperative complications were lower in the colorectal group (43.2% vs 16.7, p = 0.02).

CONCLUSIONS

Although patient-specific factors are important, surgeon is a potent predictor of operation performed in the setting of severe acute diverticulitis. A more aggressive approach to primary anastomosis may lower the complication rate after surgical treatment for severe acute diverticulitis.

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute

Background:

Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes.

Objective:

The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery.

Design:

Retrospective, audit.

Materials and Methods:

The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group).

Results:

The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks.

Conclusion:

Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.

Establishing quality in colorectal surgery

AIM

The review aimed to offer a contemporary perspective of the quality of current colorectal surgery.

METHOD

A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language.

RESULTS

Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework.

CONCLUSION

A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.

Intestinal anastomoses in small children: is there a higher risk?

AIM

The aim of the retrospective study was to evaluate complications and outcome of children in whom an intestinal anastomosis had been performed at age younger than 1 year.

PATIENTS AND METHODS

Data were collected both retrospectively and by interviewing the parents. For the retrospective analysis, the underlying disease, biometric data, technical information about the anastomoses, associated illnesses, and complications were evaluated. In the parent interviews, the present quality of life and the state of health of the children were evaluated.

RESULTS

From 1997 to 2007, intestinal anatomoses had been performed in 131 children for various reasons. There were no complications in 81.7% of the patients; 17 children received reoperation. In only 5 cases were anastomotic complications the reasons for the reoperation. Only 7.3% of the 77 interviewed families believe that their child has severe or relevant restrictions in daily life.

CONCLUSIONS

Among 131 children in whom an intestinal bowel anastomosis procedure was performed at age younger than 1 year, only 5 (3.2%) experienced complications associated with the anastomosis. The children are in good physical condition and have an excellent quality of life.