Complications of colorectal anastomoses: leaks, strictures, and bleeding

A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis

BACKGROUND

Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection.

METHODS

A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort.

RESULTS

72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer.

CONCLUSION

We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.

Outcome variation and the role of caseload in certified colorectal cancer centers - a retrospective cohort analysis of 90 000 cases

BACKGROUND

Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time.

MATERIALS AND METHODS

In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots.

RESULTS

In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed.

CONCLUSION

The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers.

Collagen patch cover facilitates recovery of bowel function after laparoscopic colectomy

BACKGROUND

Numerous factors can influence bowel movement recovery and anastomotic healing in colorectal surgery, and poor healing can lead to severe complications and increased medical expenses. Collagen patch cover (CPC) is a promising biomaterial that has been demonstrated to be safe in animal models and has been successfully applied in various surgical procedures in humans. This study.

METHODS

A retrospective review of medical records from July 2020 to June 2022 was conducted to identify consecutive patients who underwent laparoscopic colectomy. Patients who received CPC at the anastomotic site were assigned to the collagen group, whereas those who did not receive CPC were assigned to the control group.

RESULTS

Data from 241 patients (collagen group, 109; control group, 132) were analyzed. Relative to the control group, the collagen group exhibited a faster recovery of bowel function, including an earlier onset of first flatus (2.93 days vs. 3.43 days, p < 0.01), first defecation (3.73 days vs. 4.18 days, p = 0.01), and oral intake (4.30 days vs. 4.68 days, p = 0.04). CPC use was also associated with lower use of postoperative intravenous analgesics. The complication rates in the two groups did not differ significantly.

CONCLUSIONS

CPCs can be safely and easily applied to the anastomotic site during laparoscopic colectomy, and can accelerate bowel movement recovery. Further studies on the effectiveness of CPCs in colorectal surgery involving larger sample sizes are required.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT05831956 (26/04/2023).

Treatment of benign rectal stricture caused by repeated anal insertion by endoscopy and balloon dilation: A case report

BACKGROUND

Benign rectal strictures can be categorized as primary (disease-related) and secondary (surgical anastomosis-related). Secondary strictures arise from surgical complications, whereas primary strictures have diverse etiologies, including various inflammatory conditions. Benign strictures are usually managed by surgery and endoscopy. We present an unusual etiology of benign rectal stricture caused by the repeated insertion of foreign objects into the rectum for sexual purposes, resulting in rectal injury and subsequent chronic inflammation.

CASE SUMMARY

A 53-year-old man presented to the outpatient clinic of the Colorectal Surgery Department with symptoms of chronic constipation and bloody stools. The patient previously experienced rectal injury due to foreign object insertion for sexual purposes. Colonoscopy revealed benign circumferential narrowing of the rectum. He underwent treatment by endoscopic argon plasma coagulation and balloon dilation and follow-up as an outpatient for 4 months. A colonoscopy at the end of the follow-up period revealed no evidence of rectal stricture relapse.

CONCLUSION

A history of rectal injury, followed by chronic inflammation, should be considered in patients with benign rectal strictures. Management with endoscopic argon plasma coagulation and balloon dilation can prevent the need for surgical resection of benign rectal strictures.

Defunctioning stoma and anastomotic stricture in rectal cancer surgery: a propensity score matching study

BACKGROUND

In cases of rectal cancer surgery, patients at high risk of anastomotic leakage often receive a defunctioning stoma (DS). However, its role in postoperative anastomotic strictures (AS) remains unclear. This study aimed to investigate the correlation between DS and AS and outcomes of transanal endoscopic microsurgery (TEM) in treating rectal AS.

METHODS

This retrospective study was conducted from January 2019 to September 2021 and included patients who underwent rectal cancer surgery. A 1:1 ratio was used for propensity score matching (PSM). Univariate analyses were performed to identify statistically significant variables, and multivariate analyses were conducted to determine the factors affecting AS.

RESULTS

This study included 383 patients. The results of the univariate analysis suggested that surgery time (HR 4.597, 95% CI 1.563-13.525, P=0.006), postoperative anastomotic leakage (HR 11.830, 95% CI 3.773-37.094, P<0.001), and DS (HR 15.475, 95% CI 6.042-39.641, P<0.001) were significantly associated with AS. In the multivariate analysis, postoperative anastomotic leakage (HR 7.596, 95% CI 1.987-29.044, P= 0.003) and DS (HR 11.252, 95% CI 4.113-30.779, P<0.001) were identified as significant risk factors for AS. After matching, the univariate analysis revealed that postoperative anastomotic leakage (HR 8.333, 95% CI 1.541-45.052, P= 0.014) and DS (HR 9.965, 95% CI 2.200-45.142, P= 0.003) were associated with AS. The multivariate analysis indicated that postoperative anastomotic leakage (HR 14.549, 95% CI 1.765-119.913, P= 0.013) and DS (HR 12.450, 95% CI 2.418-64.108, P= 0.003) were significant risk factors for AS.

CONCLUSIONS

This study provides evidence that DS is independently associated with AS, and postoperative anastomotic leakage increases the risk of AS. Furthermore, this study suggests that TEM could be a valuable treatment option for AS.

Transanal formation of anastomosis using C-REX device is feasible and effective in high anterior resection

PURPOSE

C-REX is a novel instrument for creating stapleless colorectal anastomosis by compression. The aim of this study was to evaluate the feasibility and effectiveness of C-REX in open and laparoscopic high anterior resections.

METHODS

A prospective clinical safety study on 21 patients reconstructed with C-REX colorectal anastomosis following high anterior resection of the sigmoid colon using two different devices for intraabdominal (n = 6) or transanal (n = 15) placement of the anastomotic rings. Any signs of complications were prospectively monitored by a predefined protocol. Anastomotic contact pressure (ACP) was measured via a catheter-based system, and time for evacuation of the anastomotic rings by the natural route was noted. Blood samples were collected daily, and flexible endoscopy was performed postoperatively to examine macroscopic appearance of the anastomoses.

RESULTS

One of six patients operated with the intraabdominal anastomosis technique with an ACP of 50 mBar had to be reoperated because of anastomotic leakage. None of the 15 patients operated with the transanal technique (5 open and 10 laparoscopic procedures) had anastomotic complications, and their ACP ranged between 145 and 300 mBar. C-REX rings were uneventfully expelled by the natural route in all patients after a median of 10 days. Flexible endoscopy showed well-healed anastomoses without stenosis in 17 patients and a moderate subclinical stricture in one patient.

CONCLUSION

These results indicate that the novel transanal C-REX device is a feasible and effective method for colorectal anastomosis following high anterior resections, irrespective of open or laparoscopic approach. Moreover, C-REX allows measurement of intraoperative ACP and thereby a quantitative evaluation of the anastomotic integrity.

Simultaneous Sigmoid Volvulus and Small Bowel Obstruction: A Case Report

Sigmoid volvulus and small bowel obstruction are typically thought to be separate clinical pathologies with distinct clinical features, diagnostic criteria, and treatment strategies. We present a rare case of simultaneous sigmoid volvulus and small bowel obstruction. To our knowledge, this is the first such case in literature and presented a unique set of challenges in regard to treatment and management. This case discusses a different approach to the surgical management of sigmoid volvulus and small bowel obstruction, which is markedly different from the expected and traditional surgical management of isolated sigmoid volvulus and small bowel obstruction.

Clinical efficacy of endoscopic dilation combined with bleomycin injection for benign anastomotic stricture after rectal surgery

Benign anastomotic stricture is a frequent complication after rectal surgery. This study investigated the feasibility of endoscopic dilation combined with bleomycin injection for benign anastomotic stricture after rectal surgery. 31 patients who diagnosed with benign anastomotic stricture after rectal surgery were included in this study. 15 patients received simple endoscopic dilation (dilation group) and 16 patients received endoscopic dilation combined with bleomycin injection (bleomycin group). The clinical effect and adverse events were compared in the 2 groups. The strictures were managed successfully and the obstruction symptoms were relieved immediately. There were 2 minor complications in dilation group and 3 minor complications in bleomycin group. The difference was not significant between the 2 groups (P > .05). During the follow-up, the mean reintervention interval was 4.97 ± 1.00 months in dilation group and 7.60 ± 1.36 months in bleomycin group. The median treatment times was 4 (range 3-5) in dilation group and 2 (range 2-3) in bleomycin group. The differences in the 2 groups were significant (P < .05). Compared with endoscopic dilation, endoscopic dilation combined with bleomycin injection may reduce the treatment times and prolong the reintervention interval, which is a safe and effective endoscopic management for benign anastomotic stricture after rectal surgery.

Transanal endoluminal repair for anastomotic leakage after low anterior resection

BACKGROUND

There is still no consensus on the management of colorectal anastomotic leakage after low anterior resection. The goal was to evaluate the outcomes of patients who underwent transanal endoluminal repair + laparoscopic drainage ± stoma vs. drainage only ± stoma.

METHODS

Retrospective chart review of patients sustaining anastomotic leakage after laparoscopic low anterior resection between January 2013 and September 2020 who required laparoscopic reoperation.

RESULTS

Forty-nine patients were included, 22 patients underwent combined laparoscopy and transanal endoluminal repair and 27 patients had drainage with a stoma (n = 16) or drainage alone (n = 11), without direct anastomotic repair. The overall morbidity rate was 30.6% and the mortality rate was 2%. Combined laparoscopic lavage/drainage and transanal endoluminal repair of anastomotic leakage was associated with a lower complication rate (13.6% vs. 44.4%, p = 0.03) and fewer intraabdominal infections (4.5% vs. 29.6%, p = 0.03) compared with no repair.

CONCLUSIONS

Combined laparoscopic lavage/drainage and transanal endoluminal repair is effective in the management of colorectal anastomosis leakage and was associated with lower morbidity-in particular intraabdominal infection-compared with no repair. However, our results need to be confirmed in larger, and ideally randomized, studies.

Impact of change in the surgical plan based on indocyanine green fluorescence angiography on the rates of colorectal anastomotic leak: a systematic review and meta-analysis

BACKGROUND

In the present study, patients with colorectal anastomoses that were assessed with indocyanine green (ICG) fluorescence angiography (FA) were compared to patients who had only white light visual inspection of their anastomosis. The impact of change in surgical plan guided by ICG-FA on anastomotic leak (AL) rates was assessed.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried for eligible studies. Studies included were comparative cohort studies and randomized trials that compared perfusion assessment of colorectal anastomosis with ICG-FA and inspection under white light. Main outcome measures were change in surgical plan guided by ICG-FA and rates of AL. Risk of bias was assessed using RoB-2 and ROBINS-1 tools. Differences between the two groups in categorical and continuous variables were expressed as odds ratio (OR) with 95% confidence interval (CI) and weighted mean difference.

RESULTS

This systematic review included 27 studies comprising 8786 patients (48.5% males). Using ICG-FA was associated with significantly lower odds of AL (OR 0.452; 95% CI 0.366-0.558) and complications (OR 0.747; 95% CI 0.592-0.943) than the control group. The weighted mean rate of change in surgical plan based on ICG-FA was 9.6% (95% CI 7.3-11.8) and varied from 0.64% to 28.75%. A change in surgical plan was associated with significantly higher odds of AL (OR 2.73; 95% CI 1.54-4.82).

LIMITATIONS

Technical heterogeneity due to using different dosage of ICG and statistical heterogeneity in operative time and complication rates.

CONCLUSION

Assessment of colorectal anastomoses with ICG-FA is likely to be associated with lower odds of anastomotic leak than is traditional white light assessment. Change in plan based on ICG-FA may be associated with higher odds of AL. PROSPERO registration number: CRD42021235644.

Surgical Technique and Considerations about Transanal Transection and Single-Stapled (TTSS) Anastomosis: The Search for a Perfect Anastomosis

The evaluation of preventive measures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review the most recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed.

Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains

Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.

Contrast-enhanced abdominal computed tomography to evaluate anastomotic integrity before ileostomy closure in postoperative colorectal cancer patients

PURPOSE

To investigate the usefulness of contrast-enhanced abdominal computed tomography (CECT) to predict clinically significant anastomotic leakage (CSAL) in patients who received colorectal cancer surgery with diverting ileostomy.

METHODS

In this retrospective cohort study, patients who underwent colorectal cancer surgery with diverting ileostomy from January 2014 to May 2018 and postoperative CECT were included. The performance of significant CECT features, identified using multivariable logistic regression, to predict CSAL was calculated. In subgroup analysis, the areas under the receiver operating characteristic curve (AUROCs) were compared between CECT and water-soluble contrast enema (WSCE) using DeLong's method.

RESULTS

Of 325 patients (median age, 58 years; 213 men), CECT was routinely performed to evaluate cancer status in 307 (94.5%), and CSAL was observed in 28 (8.6%). After multivariable adjustment, anastomotic mural defect (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.77-15.51; p = 0.003), perianastomotic air (OR 7.28; 95% CI 1.82-29.17; p = 0.007) and ischemic colitis (OR 3.30; 95% CI 1.13-9.61; p = 0.029) were significantly associated with CSAL. The sensitivity, specificity, accuracy, and positive and negative predictive values of significant CECT features were 60.7%, 88.2%, 85.9%, 32.7%, and 96.0%, respectively. In subgroup analysis of 144 patients, the AUROC using significant CECT features (optimal sensitivity/specificity, 50.0%/90.4%) was comparable to that using WSCE (optimal sensitivity/specificity, 12.5%/97.8%) to predict CSAL (0.704 vs. 0.552, p = 0.085).

CONCLUSION

CECT performed after colorectal cancer surgery may be useful to assess anastomotic integrity before ileostomy closure, especially to negatively predict CSAL. In the presence of anastomotic mural defect, perianastomotic air, or ischemic colitis, WSCE may be recommended to exclude CSAL.

Intraoperative surgeon probe inspection compared to leak testing for detecting gaps in canine jejunal continuous anastomoses: A cadaveric study

OBJECTIVE

To compare the detection of gaps in jejunal continuous anastomoses by probing (PT) versus leak testing (LT).

STUDY DESIGN

Experimental study.

ANIMALS

Normal jejunal segments (n = 24) from two fresh canine cadavers.

METHODS

Intestinal segments were randomly selected by four volunteers who created six simple continuous anastomoses: two constructs using standard technique with 2-3 mm suture spacing (ST, 8 total), and four constructs with one 4-mm gap (IG, 16 total). All 24 anastomoses were examined with PT (1 volunteer) prior to LT (3 volunteers). LT was performed within a maximal peristaltic pressure range (34-54 cmH₂ O). The presence and location of anastomotic leaks (L_A ) detected with LT were compared with gaps detected with PT.

RESULTS

Nineteen out of twenty-four (79.2%) samples had at least one probe drop, and four out of twenty-three (17.4%) samples leaked. LT results from one sample were excluded due to iatrogenic suture failure. PT was 100% sensitive (95% CI: 51.01, 100%) with a 100% negative predictive value (95% CI: 56.55, 100%) at detecting gaps compared with LT. The location of all L_A was accurately identified with PT and confirmed during LT.

CONCLUSION

PT was highly sensitive at detecting gaps compared with LT. All L_A were accurately detected by PT. None of the segments negative during PT leaked.

CLINICAL SIGNIFICANCE

The diagnostic value of PT appears adequate to recognize gaps in cadaveric small intestinal anastomoses. PT offers surgeons an alternative to detect suture gaps that may contribute to postoperative dehiscence of intestinal anastomoses.

Does intraoperative flexible endoscopy offer any benefit compared to conventional air leak testing after circular stapled left-sided laparoscopic colon surgery?

BACKGROUND

Anastomotic leakage is still a feared complication after left-sided colonic resections. Various types of "anastomotic leak testing methods" are described in current literature. In this study we evaluated the use of intraoperative flexible endoscopy in comparison to conventional air leak testing after performing a circular stapled anastomosis in left-sided laparoscopic colon surgery.

METHODS

A retrospective database consisting of 130 patients with left sided colonic resections between 01/2015 and 12/2019 at our hospital was evaluated. After performing a circular stapled anastomosis flexible endoscopy was done in 69 cases, 61 patients were controlled with a conventional air leak test. Intraoperative and postoperative complications were recorded and retrospectively evaluated.

RESULTS

In the flexible endoscopy group, we observed complications in 13,04%, in the conventional air leak testing group in 9,83%. Postoperative anastomotic leakage was observed in 10,14% in the flexible endoscopy group and 4,91% in the conventional air leak test group. In 10,14% a positive air leak test was seen in the flexible endoscopy group and 11,47% in the conventional air leak testing group. In those cases, we observed no postoperative complications in the first group, in the conventional group we had two anastomotic leakages and one infected haematoma.

CONCLUSIONS

In the case of a positive air leak, flexible endoscopy offered a more exact detection of the leak. In those cases, no anastomotic leakage was observed postoperatively. In our opinion, flexible endoscopy should be recommended for testing the anastomosis intraoperatively in every left-sided colon surgery.

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.

Endoscopic diagnosis and treatment of complete anastomosis stenosis after colorectal resection without protective ileostomy: report of two cases and literature review

This case report describes a novel procedure for opening the lumen of a completely obstructed anastomosis when open surgery is not an option. Two patients underwent ileocecal or colorectal resection and one-stage anastomosis reconstruction without diverging ileostomy. The patients developed post-surgical abdominal distension and nausea. Emergency imaging indicated complete anastomotic obstruction and distal intestinal anastomosis emptiness. Colonoscopy revealed an anastomosis that was completely discontinued by a membranous structure. Considering that open surgery was not a viable treatment option, a minimally invasive endoscopic approach was adopted to repair the obstruction. A needle knife was used to puncture the linear white scar and contrast agent was injected under endoscopy and fluoroscopic guidance. Fluoroscopically, the proximal bowel was identified and a dual knife-mediated membrane puncture was performed. A guidewire was then passed through the incision into the proximal bowel and progressive pneumatic dilatation was performed successively with a controlled radial expansion balloon dilator until a 1.8 cm diameter dilation was achieved. After conventional balloon dilatation, the endoscope easily passed through the anastomosis without any patient discomfort. There were no postoperative signs of immediate or delayed complications. Overall, endoscopic incision and dilatation was a safe and effective treatment for acute anastomotic obstruction after colorectal surgery.

Fluoroscopy and endoscopy-guided transanastomotic rendezvous: a novel technique for recanalization of a completely obstructed colorectal anastomosis

BACKGROUND

Colorectal anastomotic stricture is a frequent complication that may affect up to 30% of patients. However, a complete obstruction is rare. Endoscopic balloon dilation is the first-line therapy, but it invariably requires being able to cross the stricture with the dilation device. When this is not possible, surgical revision is the alternative, but it is associated with higher morbidity.

CASE PRESENTATION

A 76-year-old male patient underwent an urgent high anterior resection with transverse loop colostomy for an occlusive high rectal tumor. On postoperative day 8, he presented with anastomotic leakage and abscess formation, requiring percutaneous drainage. Ten months after surgery, a colonoscopy revealed a complete stricture of the anastomosis, refractory to negotiation of a guide wire, thus precluding balloon dilation. Hence, a modified rendezvous technique was planned. Simultaneously, a flexible endoscope and a rigid rectoscope were progressed through the distal loop colostomy, and the anus, respectively. A needle device was introduced through the rectoscope and used to pierce the colonic stump. A guide wire was progressed, and the stricture was dilated with a controlled radial expansion balloon catheter. Finally, a 12-Fr Foley catheter was left through the anastomosis. A total of three endoscopic balloon dilation sessions were completed, and successful colostomy reversal was carried out 10 days after the last session.

CONCLUSION

Fluoroscopy-endoscopy-guided recanalization is an effective and safe treatment option for complete colorectal anastomotic stricture.

Human fibrinogen and thrombin patch for extraluminal protection of intestinal anastomosis

In spite of recent advances regarding equipment and surgical techniques in colorectal surgery, rates of anastomotic dehiscence (AD) have remained stable throughout the years. The development of products to protect anastomosis aiming the reduction of AD rates has shown to be promising. Human fibrinogen and thrombin patch (HFTP Tachosil®) have been used in experimental studies in animals and small case series in humans, with promising results. In this study, the authors describe the technique of HFTP use in details, aiming the protection of colorectal anastomosis, and retrospectively demonstrate the preliminary results in a pilot case series. HFTP was used in 4 patients submitted to conventional surgery. The procedures performed were: left colon resection, segmental colectomy (both for colorectal cancer), enteral anastomosis for fistula closure and right ileocolectomy. Anastomotic healing and absence of complications were observed in 3 patients, and the patient submitted to right ileocolectomy developed AD and died after reoperation. The use of HFTP is safe and can be indicated in selected cases. However, AD can occur even after the use of this strategy. Randomized controlled trials with larger samples of patients are needed in order to properly define the real benefits of this strategy in dehiscence prevention

Poly(trimethylene carbonate) flexible intestinal anastomosis scaffolds to reduce the probability of intestinal fistula and obstruction

Biodegradable anastomat play an important role in the reconstruction process of the digestive tract. However, the biocompatibility and organizational compliance of anastomotic tubes still need to be improved. Electrospun tissue engineering scaffolds have excellent biomimetic extracellular matrix properties, biocompatibility and biodegradability. In the present study, electrospun poly(trimethylene carbonate) (PTMC) intestinal anastomosis scaffolds loaded with triclosan (TCS) were reported to reduce the probability of intestinal fistula and obstruction. When the viscosity average molecular weight of PTMC was 157 × 103, the elastic modulus and tensile strength of the anastomosis scaffolds could reach 20.11 MPa and 16.08 MPa, respectively, which indicated that the anastomosis scaffolds exhibited excellent tensile flexibility. The degradation of PTMC was accelerated with the increase of Mw. After 28 days, the weight and length of the anastomosis scaffolds reduced 40% and 50%, respectively. Furthermore, the application of PTMC anastomosis scaffolds could promote intestinal healing and reduce the probability of intestinal fistula and obstruction.

Redo-laparoscopy in the management of complications after laparoscopic colorectal surgery: a systematic review and meta-analysis of surgical outcomes

BACKGROUND

The laparoscopic approach for colorectal surgery has gradually become widely accepted for the treatment of both benign and malignant diseases thanks to its several advantages over the open approach. However, it is associated with the same potential postoperative complications. Some recent studies have analyzed the potential role of laparoscopy in early diagnosis and management of complications following laparoscopic colorectal surgery. The aim of this systematic review was to investigate the outcomes of redo-laparoscopy (RL) for the management of early postoperative complications following laparoscopic colorectal surgery, focusing on length of stay, morbidity and mortality.

METHODS

A systematic review of the literature was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines through MEDLINE (PubMed), Embase and Google Scholar from January 1990 to December 2019. The main outcomes examined were conversion rate, length of hospital stay, postoperative morbidity and mortality rates. A meta-analysis of all eligible studies was then conducted and forest plots were generated.

RESULTS

A total of 19 studies involving 1394 patients who required reoperation after laparoscopic colorectal resection were included. In 539 (38.2%) of these patients, a laparoscopic approach was adopted. The most common indication for returning to the operating theater was anastomotic leakage (64.4% of all redo-surgeries, 67.7% of RL) and the most common type of intervention performed in RL was diverting stoma with or without anastomotic repair/redo (47.1%). Nine studies were included in the pooled analysis. The mean length of stay was significantly shorter in the RL group than in the redo-open one (WMD = - 0.90; 95% CI - 1.04 to - 0.76; Z =  - 12,6; p < 0.001). A significantly lower risk of mortality was observed in the RL cohort (OR =  - 0.91; 95% CI - 1.58 to - 0.23; Z = - 2.62; p = 0.009).

CONCLUSIONS

Laparoscopy is a valid and effective approach for the treatment of complications following laparoscopic primary colorectal surgery thanks to it is well-established advantages over the open approach, which remain noticeable even in redo-surgeries.

Capsule Endoscopy Versus Colonoscopy in Patients With Previous Colorectal Surgery: A Prospective Comparative Study

Background

Colonic capsule endoscopy (CCE) derived from the video capsule endoscopy, initially proposed to explore the small bowel, has demonstrated high sensitivity and specificity for colonic polyp detection. The primary outcome of the study was to assess the safety, feasibility, and reliability of CCE after colorectal surgery. Secondary outcomes were to identify the detection rate of colonic lesions and recognition of the surgical anastomosis as compared to colonoscopy.

Methods

This is a prospective single-center study conducted over a 2-year period. Thirty-seven patients with a history of colorectal surgery were prospectively included in this study. Each patient received both CCE and colonoscopy, performed by different operators blinded to each other’s results.

Results

Thirty-two patients (86.5%) completed the study and were included in the final analysis. All capsules were naturally expelled. In three patients (9.4%), the anal verge was not identified during the CCE recording and the examination of the colon was considered incomplete. Surgical anastomosis was accurately identified by CCE in 78.2% of the patients versus 93.8% for colonoscopy (P = 0.65). Thirty-eight lesions were detected in 14 patients. The sensitivity of CCE to detect colonic polyps was 95.2% (95% confidence interval (CI): 77.3-99.2%), the specificity 82.4% (95% CI: 59.0-93.8%). Positive predictive value (PPV) and negative predictive value (NPV) of CCE to detect colonic polyps were 87.0% and 93.3%, respectively. No complications related to the passage of the capsule through the intestinal anastomosis were detected.

Conclusions

CCE proved to be safe and feasible, reporting a similar detection rate of colonic lesion compared to colonoscopy.

In vivo performance of a bilayer wrap to prevent abdominal adhesions

There is a high prevalence of intra-abdominal adhesions following bowel resection, which can result in chronic pain, bowel obstruction, and morbidity. Although commercial adhesion barriers have been widely utilized for colonic resections, these barriers do not prevent anastomotic leakage resulting from reduced healing of the anastomosis, which can result in long-term health problems. To address this limitation, we have developed an adhesive bilayer wrap with selective bioactivity to simultaneously prevent intra-abdominal adhesion formation and promote anastomotic healing. Reactive electrospinning was used to generate a crosslinked gelatin mesh to serve as a cell-instructive substrate to improve anastomotic healing. A coating of poly(ethylene glycol) (PEG) foam was applied to the bioactive mesh to generate an antifouling layer and prevent intra-abdominal adhesions. After in vitro confirmation of selective bioactivity, the composite wrap was compared after 2 weeks to a commercial product (Interceed^Ⓡ) in an in vivo rat colonic abrasion model for prevention of intra-abdominal adhesions. The composite bilayer wrap was able to prevent intra-abdominal adhesions when clinical placement was maintained. The composite bilayer wrap was further modified to include tissue adhesive properties for improved efficacy. Preliminary studies indicated that the adhesive composite bilayer wrap maintained a maximum shear strength comparable to Interceed^Ⓡ and greater than fibrin glue. Overall, this work resulted in an initial proof-of-concept device that was shown to effectively prevent intra-abdominal adhesion formation in vivo. The composite bilayer wrap studied here could lead to an improved technology for improved healing of intestinal anastomoses.

A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial

AIM

Our aim was to evaluate the efficacy of indocyanine green (ICG) fluorescence angiography (FA) in reducing the incidence of anastomotic leakage (AL) following colorectal anastomosis.

METHOD

A single-centre randomized trial was undertaken between 2018 and 2019. Those patients who underwent a stapled colorectal anastomosis were randomized 1:1 for ICG FA versus visual clinical assessment of blood perfusion of the anastomosed colon and rectal stump (non-ICG FA group). The primary end-point was to assess whether ICG FA was associated with a reduction in the incidence of AL. Secondary outcomes were the rate of postoperative complications and change in the level of bowel resection.

RESULTS

A total of 380 patients undergoing sigmoid and rectal resection were enrolled. After randomization, three patients were excluded. The results of 377 cases were available for analysis; 187 had ICG FA and 190 were in the non-ICG FA group. ICG FA identified impaired blood perfusion of the colon in 36 (19%) cases. An AL (grade A, B or C) developed in 48 patients: 17 (9.1%) in the ICG FA group and 31 (16.3%) in the non-ICG FA group (P = 0.04). ICG FA did not decrease the rate of AL of high anastomoses (9-15 cm from the anal verge), at 1.3% vs 4.6% in the non-ICG FA group (P = 0.37). In contrast, a decrease in AL rate was found for low (4-8 cm) colorectal anastomoses (14.4% in ICG FA vs 25.7% in the non-ICG FA group; P = 0.04).

CONCLUSION

ICG FA is associated with a reduction in AL following low anterior resection.

Protective ileostomy does not prevent anastomotic leakage after anterior resection of rectal cancer

OBJECTIVE

To explore whether protective ileostomy is beneficial in preventing anastomotic leakage after anterior resection of rectal cancer.

METHODS

A total of 347 patients underwent anterior resection of rectal cancer in our hospital. Ninety-five patients were treated with protective ileostomy (treatment group), and 252 patients were not (control group). The incidences of anastomotic leakage and permanent stoma were compared between the two groups.

RESULTS

The overall incidences of anastomotic leakage were 6.32% (6/95) and 8.73% (22/252) in the treatment group and control group, respectively. In the cohort of patients who underwent neoadjuvant radiotherapy, the incidence of anastomotic leakage was 5.88% (2/34) and 12.0% (3/25) in the treatment group and control group, respectively. Logistic regression showed that the incidence of anastomotic leakage was not statistically significant. However, diabetes and the anastomotic height significantly affected the occurrence of anastomotic leakage. The permanent stoma rate was 6.42% (6/95) and 5.95% (15/252) in the treatment group and control group, respectively.

CONCLUSION

Protective ileostomy did not show a significant advantage in reducing the incidence of postoperative anastomotic leakage in patients with rectal cancer, and it may lead to a permanent stoma.

High versus low ligation of inferior mesenteric artery during laparoscopic radical resection of rectal cancer: A retrospective cohort study

Laparoscopic radical resection is standard treatment for resectable rectal cancer. However, whether high or low inferior mesenteric artery (IMA) ligation should be performed remains controversial. This retrospective cohort study compared the advantages and disadvantages of low vs high IMA ligation in patients undergoing laparoscopic total mesorectal excision for rectal cancer.Rectal cancer patients (n = 322) undergoing total mesorectal excision at our institution in 2010 to 17 were enrolled; 174 underwent high IMA ligation group and 148 low IMA ligation (LIMAL group). Baseline data on patients, operative indices, economic indices, pathology findings, perioperative complications, and survival in the 2 groups were analyzed retrospectively.The low IMA ligation group had significantly higher anus retention ratio (P = .022), shorter hospital stay (P = .025), lower medical expenses (P = .032), fewer cases of anastomotic leakage (P = .023) and anastomotic stricture (P < .001), and lower incidence of postoperative genitourinary dysfunction (P = .003). Cox regression analysis indicated that local recurrence, distant metastasis, tumor differentiation, and tumor-node-metastasis stage were independently associated with survival.Low ligation of the IMA during laparoscopic radical resection of rectal cancer appears to be associated with a lower risks for anastomotic leakage, anastomotic stricture, and genitourinary dysfunction, a shorter hospital stay, and lower costs. In contrast, the rate of lymph node harvest, tumor recurrence rate, metastasis, or mortality was not found to be related with the level of IMA ligation.

Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis

AIM

Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity.

METHODS

PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates.

RESULTS

Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB.

CONCLUSION

This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.

Mechanotechnical faults and particular issues of anastomotic complications following robot-assisted anterior resection in 968 rectal cancer patients

BACKGROUND

As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine-green fluorescence imaging (IFI) and robot-stapled anastomosis have yet been undetermined.

METHODS

This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot-assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed.

RESULTS

AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease-free survival (P = .02) and local recurrence (P = .03), respectively.

CONCLUSIONS

AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.

Lower GI Bleeding: An Update on Incidences and Causes

Bleeding from the lower gastrointestinal tract represents a significant source of morbidity and mortality. The colon represents the vast majority of the location of bleeding with only a much smaller incidence occurring in the small intestine. The major causes of lower gastrointestinal bleeding (LGIB) are from diverticulosis, vascular malformations, and cancer. We discuss the incidence and causes of LGIB.

Incidence and risk factors for anastomotic bleeding in lower gastrointestinal surgery

Objective

Although major anastomotic bleeding after lower gastrointestinal surgery is considered rare, it can be life-threatening if not properly managed. The objective of this study was to assess the incidence of postoperative lower gastrointestinal intraluminal bleeding and to identify its potential risk factors. This retrospective cohort study used data from charts of 314 patients who underwent digestive surgery of the colon or small intestine. Details are reported for their sociodemographic data, surgical approach, comorbidities, timing and presentation of intraluminal bleeding events, bleeding diagnosis, treatment strategies, hospital length of stay, and clinical complications.

Results

A total of 7 patients (2.3%) experienced intraluminal bleeding in the postoperative period. The average length of hospital stay before discharge was 12 days (median = 13 days). Patients with intraluminal bleeding had a significantly higher percentage of coronary artery diseases compared to patients without intraluminal bleeding (P value = .04), as well as having a cancer diagnosis (P value = .02). The clinical complications that were more likely in patients with intraluminal bleeding included requiring blood transfusions (P value = .01), reduction in hemoglobin (P value = .001), cardiac ischemia (P value = .02), and atrial fibrillations (P value = .02).

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4403-0) contains supplementary material, which is available to authorized users.

Nomogram for Predicting Risk of Intestinal Complications After Colorectal Cancer Surgery

Background

Intestinal complications are a major cause of morbidity after colorectal cancer surgery. This study aimed to develop an effective nomogram for predicting risk of intestinal complications following colorectal cancer surgery.

Material/Methods

We retrospectively analyzed 1876 patients who underwent colorectal cancer surgery at Yangpu and Zhuji hospitals from January 2013 to October 2018. Intestinal complications were defined as intestinal obstruction, leakage or bleeding, or peritonitis within 30 days after surgery. A logistic regression model was used to identify the risk factors associated with postoperative intestinal complications, and a nomogram for intestinal complications was established. The predictive accuracy of the nomogram was assessed using area under the receiver operating characteristic curve (AUC) and calibration plot.

Results

A total of 164 patients (8.7%) developed intestinal complications after colorectal cancer surgery; 35 (21.3%) of whom died in the postoperative period. Multivariate logistic analysis showed that male gender, history of abdominal surgery, preoperative intestinal obstruction/perforation, metastatic cancer, and lower level of hemoglobin and prognostic nutrition index were independent risk factors (P<0.05 for all). A nomogram was then constructed, and it displayed good accuracy in predicting postoperative intestinal complications with an AUC of 0.76. The calibration plot also showed an excellent agreement between the predicted and observed probabilities.

Conclusions

We constructed a nomogram based on clinical variables, which could provide individual prediction of postoperative intestinal complications with good accuracy.

Retrospective multicenter study of post-operative stenosis after stapled colorectal anastomosis

Anastomotic stenosis after colorectal surgery is usually considered low-rate complication and often is under-reported in most studies. Few data are available on management strategies. The aim of the study was to assess the prevalence of stenosis after stapled colorectal anastomosis, performed either in elective or emergent setting, for benign or malignant disease, and to evaluate treatment profiles. This retrospective study was a survey conducted in a large Italian North-Eastern area including three regions (Triveneto), over a 12-month period (January-December 2015). Patients' characteristics and surgical technique details were recorded, along with data on the prevalence of stenosis and its treatment. Patients with mid or low rectal resection and/or neoadjuvant chemo-radio therapy and/or diverting stoma were excluded. The study was promoted by the Italian Association of Hospital Surgeons (ACOI) and the Society of Surgeons of the Triveneto Region. Twenty-eight surgical units were enrolled in the survey, accounting for over 1400 patients studied. Fifty percent of the units performed laparoscopically > 70% of the colorectal resections and 7.5% of the procedures were emergent. Less than 60% of the units planned regular endoscopic follow-up after colorectal resection. Anastomotic stricture was recorded in 2% of the patients; 88% of the stenoses were diagnosed within 6 months from surgery. Only one anastomotic stricture required re-do surgery. The CANSAS study confirms that colorectal anastomotic stenosis is low-rate-but still present-complication. Treatment strategies vary according to surgeons' and endoscopists' preferences. Commonly endoscopic dilatation is preferred, but re-do surgery is required in some cases.

Endoscopic therapy of colorectal anastomotic hematoma with hypertonic dextrose

Anastomotic dehiscence and leak are dreaded complications after a colorectal resection and can often present with rectal bleeding and pelvic abscess or sepsis. Although most cases of bleeding after gastrointestinal anastomoses are minor and self-limited, major bleeding, as defined by hemodynamic instability or the need for blood transfusions, poses a significant challenge for management. Here we report a case in which a patient presenting with profuse rectal bleeding and pelvic hematoma secondary to a colorectal anastomotic leak was treated endoscopically with 50% dextrose spray then enema.

Which Is the Safer Anastomotic Method for Colon Surgery? - Ten-year Results

BACKGROUND/AIM

In colon surgery, the anastomotic method is generally selected by surgeon's preferences or by local conditions. In this study, we retrospectively analyzed anastomotic complications to assess safe methods of anastomosis in colonic resection.

PATIENTS AND METHODS

We retrospectively analyzed a total of 684 cases, performed between July 2003 and June 2013 in our Hospital. Anastomosis complications, such as leakage, stricture and bleeding, were analyzed in relation to the three methods of anastomosis, hand-sewn (HS), functional end-to-end (FEEA) and triangulating anastomosis (TRI).

RESULTS

Univariate analysis indicated that the incidence of leakage was significantly lower in laparoscopic surgeries (p=0.034) and TRI (p=0.047). The results of the multivariable analysis indicated that anastomotic leakage was significantly less with TRI (p=0.029).

CONCLUSION

In colon surgery, TRI seems to be associated with a low risk of anastomotic leakage compared to HS and FEEA.

Preoperative radiotherapy for patients with rectal cancer: a risk factor for non-reversal of ileostomy caused by stenosis or stiffness proximal to colorectal anastomosis

The influence of radiotherapy on permanent stoma and the bowel proximal to anastomosis was not well investigated. The current study aimed to analyze the effect of preoperative radiotherapy on colorectal anastomosis and incidence of non-reversal ileostomy. A total of 184 eligible patients with rectal cancer undergoing loop ileostomy were included. Patients were well selected by excluding some confounding factors and divided into two groups according to whether they received preoperative radiotherapy. Patients with preoperative radiotherapy had higher incidence of non-reversal stoma (12.8%, P = 0.004) and stenosis or stiffness around anastomosis (21.1%, P < 0.01) including 13 patients with stenosis or stiffness proximal to anastomosis. Stenosis proximal to anastomosis was different from anastomotic stricture caused by surgery and could be described by imaging findings. Preoperative radiotherapy prolonged the interval to closure (P = 0.008) and was defined as a significant risk factor for permanent stoma (HR, 0.627; 95% CI, 0.405-0.973; P = 0.04) by multivariate Cox regression analysis. In conclusion, Preoperative radiotherapy increased incidence of non-reversal ileostomy and stenosis or stiffness proximal to anastomosis in rectal cancer patients with radical resection and diverting ileostomy.

Endometriosis: A Rare Cause of Large Bowel Obstruction

Large bowel obstruction can result in significant morbidity and mortality, especially in cases of acute complete obstruction. There are many possible causes, the most common in adults being colorectal cancer. Endometriosis is a benign disease, and the most affected extragenital location is the bowel, especially the rectosigmoid junction. However, transmural involvement and acute occlusion are very rare events. We report an exceptional case of acute large bowel obstruction as the initial presentation of endometriosis. The differential diagnosis of colorectal carcinoma may be challenging, and this case emphasizes the need to consider intestinal endometriosis in females at a fertile age presenting with gastrointestinal symptoms and an intestinal mass causing complete large bowel obstruction.

Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy

BACKGROUND

Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery.

METHODS

From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes.

RESULTS

One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P < 0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95-24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P < 0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29-3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR = 0.36; 95 % CI 0.08-1.66).

CONCLUSIONS

Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.

Does bowel preparation for inflammatory bowel disease surgery matter?

AIM

The purpose of this study was to determine if bowel preparation influences outcomes in patients with inflammatory bowel disease undergoing surgery.

METHODS

The database of the American College of Surgeons National Surgical Quality Improvement Program, Procedure Targeted Colectomy, from 2012 to 2014 was analyzed. Inflammatory bowel disease patients undergoing colorectal resection with or without bowel preparation were included in the study.

RESULTS

In all, 3679 patients with inflammatory bowel disease were identified. 42.5% had no bowel preparation, 21.5% had mechanical bowel preparation only, 8.8% had oral antibiotic bowel preparation only and 27.2% had combined mechanical and oral antibiotic preparation. Combined mechanical and oral antibiotic preparation is associated with lower rates of anastomotic leak, ileus, surgical site infection, organ space infection, wound dehiscence and sepsis/septic shock.

CONCLUSION

Combined mechanical and oral antibiotic preparation for inflammatory bowel disease patients undergoing colectomy is associated with decreased rates of surgical site infection, anastomotic leak, ileus. Combined bowel preparation should be the standard of care for inflammatory bowel disease patients undergoing colorectal resection.

Early anastomotic stricture occurring after colectomy that responded well to Transanal decompression and local steroid therapy: A case report

•

Very few studies have reported anastomotic strictures occurring soon after colectomy. No established treatment is available.

•

We describe our experience with a patient who had bowel obstruction due to an anastomotic stricture 12 days after colectomy.

•

Steroid local therapy has been reported to be effective when combined with gastrointestinal endoscopic treatment. However, few studies have reported on anastomotic strictures of the colorectum.

•

Transanal decompression therapy and local steroid therapy promptly improved symptoms in a patient with an anastomotic stricture of the colon.

•

Transanal decompression therapy combined with local steroid therapy may improve anastomotic strictures occurring soon after colectomy.

Introduction

Anastomotic strictures occurring after colectomy are a most challenging postoperative complication for gastroenterological surgeons. Reports documenting anastomotic strictures developing in the early postoperative phase are scant, and no established treatment is available.

Presentation of case

A 78-year-old man who had undergone a laparoscopic left hemicolectomy for lower colon cancer presented on postoperative day 12 because of abdominal pain and no bowel movement. Endoluminal decompression was performed with a transanal decompression tube, and local steroid treatment was administered by concurrent intralesional steroid injection (ILe-SI) and intraluminal steroid instillation (ILu- SI). The anastomotic stricture promptly improved. The patient recovered uneventfully, with no recurrence of anastomotic stricture.

Discussion

A transanal decompression tube should be inserted and placed in a cautious manner within a short period of time. ILe-SI in the large intestine requires an understanding of potential adverse events and complications, as well as fully informed consent from the patient. ILu-SI has been reported to be an effective treatment for the management of strictures in various regions. To the best of our knowledge, however, this is the first report to document the treatment of an anastomotic stricture of the colorectum by ILu-SI.

Conclusion

Transanal decompression therapy combined with local steroid local treatment might promptly improve anastomotic strictures occurring after colectomy.

The Role of Laparoscopy in the Treatment of Anastomotic Leaks After Minimally Invasive Colorectal Resections for Cancer

AIM OF THE STUDY

The aim of this study was to describe the role of laparoscopy in the treatment of leaks occurring after minimally invasive colorectal resections.

MATERIALS AND METHODS

Thirty-four of 566 consecutive patients who underwent minimally invasive colorectal resection for cancer between January 2004 and December 2012 and who showed signs of anastomotic leakage (6%) requiring reoperation were studied using a prospectively maintained database. Patient characteristics, clinical signs, the surgical approach, the role of laparoscopy, operative and postoperative results, and the rate of permanent stoma were analyzed.

RESULTS

The median time to diagnosis of an anastomotic leak after surgery was 5.5 days. The median time to reoperation from the diagnosis of leakage was 2 days. Leaks were treated laparoscopically in 21 of 34 (61.8%) patients. Anastomoses were dismantled in 14 patients (41.2%) and the procedure was performed laparoscopically in 28.6% of the cases. The postoperative morbidity was 55.9%, the perioperative mortality 5.7%, and the rate of permanent stoma was 8.8%.

CONCLUSIONS

Laparoscopic reoperation can be performed in most cases of anastomotic leaks occurring after minimally invasive colorectal resection for cancer. Anastomosis can be dismantled laparoscopically in 28.6% of the cases. A permanent stoma was necessary only in patients with terminal stomas.

Interpretative Guidelines and Possible Indications for Indocyanine Green Fluorescence Imaging in Robot-Assisted Sphincter-Saving Operations

BACKGROUND

Since the introduction of indocyanine green angiography more than 25 years ago, few studies have presented interpretative guidelines for indocyanine green fluorescent imaging.

OBJECTIVE

We aimed to provide interpretative guidelines for indocyanine green fluorescent imaging through quantitative analysis and to suggest possible indications for indocyanine green fluorescent imaging during robot-assisted sphincter-saving operations.

DESIGN

This is a retrospective observational study.

SETTINGS

This study was conducted at a single center.

PATIENTS

A cohort of 657 patients with rectal cancer who consecutively underwent curative robot-assisted sphincter-saving operations was enrolled between 2010 and 2016, including 310 patients with indocyanine green imaging (indocyanine green fluorescent imaging+ group) and 347 patients without indocyanine green imaging (indocyanine green fluorescent imaging- group).

MAIN OUTCOME MEASURES

We tried to quantitatively define the indocyanine green fluorescent imaging findings based on perfusion (mesocolic and colic) time and perfusion intensity (5 grades) to provide probable indications.

RESULTS

The anastomotic leakage rate was significantly lower in the indocyanine green fluorescent imaging+ group than in the indocyanine green fluorescent imaging- group (0.6% vs 5.2%) (OR, 0.123; 95% CI, 0.028-0.544; p = 0.006). Anastomotic stricture was closely correlated with anastomotic leakage (p = 0.002) and a short descending mesocolon (p = 0.003). Delayed perfusion (>60 s) and low perfusion intensity (1-2) were more frequently detected in patients with anastomotic stricture and marginal artery defects than in those without these factors (p ≤ 0.001). In addition, perfusion times greater than the mean were more frequently observed in patients aged >58 years, whereas low perfusion intensity was seen more in patients with short descending mesocolon and high ASA classes (≥3).

LIMITATIONS

The 300 patients in the indocyanine green fluorescent imaging- group underwent operations 3 years before indocyanine green fluorescent imaging.

CONCLUSIONS

Quantitative analysis of indocyanine green fluorescent imaging may help prevent anastomotic complications during robot-assisted sphincter-saving operations, and may be of particular value in high-class ASA patients, older patients, and patients with a short descending mesocolon.

Impact of Preoperative Radiotherapy on Anastomotic Leakage and Stenosis After Rectal Cancer Resection: Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Evidence regarding the effect of preoperative radiotherapy on anastomotic integrity remains conflicting in rectal cancer surgery. Prospective comparisons with appropriate controls are needed.

OBJECTIVE

This study aimed to assess the impact of preoperative radiotherapy on anastomotic leakage and stenosis after rectal cancer resection.

DESIGN

This was a post hoc analysis of a randomized controlled trial (NCT01211210).

SETTINGS

Data were retrieved from the leading center of the trial, which is a tertiary hospital.

PATIENTS

The full analysis population of 318 patients was included.

INTERVENTIONS

Patients were randomly assigned to receive preoperative radiation (50 Gy per 25 fractions) and 5-fluorouracil infusion, alone (arm A) or combined with oxaliplatin (arm B), or preoperative chemotherapy with 5-fluorouracil and oxaliplatin without radiation (arm C).

MAIN OUTCOME MEASURES

The rates of anastomotic leakage and stenosis were calculated for each treatment arm. Multivariate analysis was used to verify the effect of preoperative radiotherapy.

RESULTS

The treatment arms were comparable in terms of most baseline characteristics, but more diversions were used in the chemoradiotherapy arms. Anastomotic leakage occurred in 20.2% of patients in arm A, 23.6% of patients in arm B, and 8.5% of patients in arm C (p = 0.007). The corresponding rates of stenosis were 17.0%, 18.9%, and 6.8% (p = 0.02). Multivariate analysis confirmed the correlation between preoperative radiotherapy and clinical leakage (p = 0.02), which was associated with delayed stenosis (p < 0.001). For patients undergoing chemoradiotherapy, radiation proctitis was identified as an independent risk factor for clinical leakage (p = 0.01) and stenosis (p < 0.001).

LIMITATIONS

The main limitations were discrepancies in stoma creation and chemotherapy regimen among the treatment arms.

CONCLUSIONS

Preoperative radiotherapy increases the risk of anastomotic leakage and stenosis after rectal cancer resection. Clinical leakage independently contributes to the development of stenosis.

Large-scale implementation of enhanced recovery programs after surgery. A francophone experience

INTRODUCTION

Enhanced recovery after surgery program (ERP) has now surpassed the stage of clinical research in certain specialties and currently poses the problematic of large-scale implementation. The goal of this study was to report the experience during the first year of implementation in three French-speaking countries.

MATERIAL AND METHODS

This is a prospective study in which 67 healthcare centers, all registered in the Grace-Audit databank, participated. Included were patients undergoing colorectal (CRS), bariatric (BS) and orthopedic hip and knee surgery (OS), performed within an ERP. The main endpoints were duration of hospital stay, postoperative morbidity, the degree of compliance with the elements of the ERP, the relation between the extent of application of the elements and postoperative hospital stay, and finally the completeness of data inclusions in the databank.

RESULTS

A total of 1904 patients were included in the Grace-Audit databank between January 1, 2015 and January 31, 2016, undergoing CRS (n=490), BS (n=431), and OS (n=983). The mean implementation rate was 83.7±10.0% for CRS, 75.0±23.7% for BS, and 83.5±14.9% for OS. The duration of hospital stay was 6.5 days for CRS, 2.6 days for BS and 3.4 days for OS. Overall postoperative morbidity (onset of postoperative undesirable event), surgical morbidity (superficial or deep organ space surgical site complications such as bleeding, infection or defective healing) and readmission rates were 20.6%, 7.5%, and 5.7% for CRS; 2.5%, 1.4%, and 1.6% for BS and 2.9%, 0.2%, and 2% for OS, respectively. A statistically significant relationship was found between the degree of compliance of the elements of ERP and the duration of hospital stay for CRS and BS; hospital stay was reduced when at least 15 of the 22 elements of the program were applied (P<0.001). The patients included in the Grace-Audit databank represented less than 20% of the patients undergoing operation in the same establishments during the study period for all three specialties.

CONCLUSIONS

This study shows that large-scale ERPs are feasible and safe in French-speaking countries. Nonetheless, although encouraging, these preliminary results highlight that implementation must be improved in specialties such as bariatric surgery and that more complete data collection is needed.