Achieving low anastomotic leak rates utilizing clinical perfusion assessment

Quadruple Assessment of Colorectal Anastomosis after Laparoscopic Rectal Resection: A Retrospective Analysis of a Propensity-Matched Cohort

Background: Anastomotic leakage (AL) is one of the most feared complications in colorectal surgery, with an incidence of 12-39% and associated risk of mortality of 2-24%. The causes of AL and the ways to prevent it are currently under investigation. This study aims to verify if a quadruple assessment of colorectal anastomosis could reduce AL incidence. Methods: A retrospective analysis of prospectively collected data on rectal cancer surgery performed from January 2015 to December 2017 and from January 2021 to December 2023 at a tertiary referral cancer centre was performed. Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. Results: A total of 293 patients were enrolled. AL incidence was lower in the quadruple assessment group than in the control group, reaching a statistically significant result (7.7% vs. 16%; p = 0.001). This result was also confirmed after a propensity score match analysis (PSM), in which the AL rate was lower in the quadruple assessment group (5.4% vs. 12.3%; p = 0.01). Conclusions: This study shows how the systematic implementation of a quadruple assessment when performing a colorectal anastomosis could increase awareness on anastomotic success and reduce the incidence of AL.

Pelvic Floor Peritoneum Closure Reduces Severe Postoperative Complications in Rectal Cancer Patients After Laparoscopic Anterior Rectal Resection

BACKGROUND

Laparoscopic anterior rectal resection (LAR) is a commonly performed surgery for rectal cancer patients. Pelvic floor peritoneum closure (PC), a vital procedure in conventional anterior rectal resection, is not routinely performed in LAR.

STUDY DESIGN

A total of 1118 consecutive patients with rectal cancer receiving LAR were included in this retrospective study. Patients were allocated into the PC group and the non-PC group. The occurrence of postoperative complications was compared between the 2 groups. Influential factors in anastomotic leakage (AL) were explored using univariate and multivariate logistic regression.

RESULTS

There was no difference between the groups in terms of baseline characteristics. The occurrence of postoperative complications was similar between the groups. The PC group had significantly shorter postoperative hospitalization and longer operation duration compared with the non-PC group. The occurrences of Clavien-Dindo (CD) III-IV complications, CD III-IV AL, and reoperation were significantly lower in the PC group than the non-PC group. PC and a protective ileostomy were independent protective factors for CD III-IV AL.

CONCLUSION

PC could reduce the occurrence of CD III-IV complications, especially CD III-IV AL, and the rate of secondary surgery, especially in patients with a lower body mass index and patients who did not receive protective ileostomies.

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Anastomotic Troubleshooting

Anastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Machine learning-based random forest predicts anastomotic leakage after anterior resection for rectal cancer

Background

Anastomotic leakage (AL) is one of the commonest and most serious complications after rectal cancer surgery. The previous analyses on predictors for AL included small-scale patients, and their prediction models performed unsatisfactorily.

Methods

Clinical data of 5,220 patients who underwent anterior resection for rectal cancer were scrutinized to create a prediction model via random forest classifier. Additionally, data of 836 patients served as the test dataset. Patients diagnosed with AL within 6 months' follow-up were recorded. A total of 20 candidate factors were included. Receiver operating characteristic (ROC) curve was conducted to determine the clinical efficacy of our model, and compare the predictive performance of different models.

Results

The incidence of AL was 6.2% (326/5,220). A multivariate logistic regression analysis and the random forest classifier indicated that sex, distance of tumor from the anal verge, bowel stenosis or obstruction, preoperative hemoglobin, surgeon volume, diabetes, neoadjuvant chemoradiotherapy, and surgical approach were significantly associated with AL. After propensity score matching, the temporary stoma was not identified as a protective factor for AL (P=0.58). Contrastingly, the first year of performing laparoscopic surgery was a predictor (P=0.009). We created a predictive random forest classifier based on the above predictors that demonstrated satisfactory prediction efficacy. The area under the curve (AUC) showed that the random forest had higher efficiency (AUC =0.87) than the nomogram (AUC =0.724).

Conclusions

Our findings suggest that eight factors may affect the incidence of AL. Our random forest classifier is an innovative and practical model to effectively predict AL, and could provide rational advice on whether to perform a temporary stoma, which might reduce the rate of stoma and avoid the ensuing complications.

Dynamic Serosal Perfusion Assessment during Colorectal Resection Using Visible Light Spectroscopy

INTRODUCTION

Anastomotic leakage (AL) in colorectal surgery occurs with an incidence of up to 20%. Bowel perfusion is deemed to be one of the most important factors for anastomotic healing. However, not much is known about its variability during colorectal surgery and its impact on the outcome. Therefore, this study aims to evaluate serosal oxygen saturation patterns during colorectal resections with visible light spectroscopy (VLS).

MATERIALS AND METHODS

Bowel perfusion in patients undergoing left-sided colorectal resections was assessed at different timepoints during surgery using VLS on the colonic serosa. The primary outcome parameter was serosal oxygen saturation (StO2) at the anastomosis during different timepoints of surgery.

RESULTS

We included 50 patients who underwent colorectal resection for bowel cancer (58%) and diverticular disease (34%). StO2 at the proximal site of the anastomosis increased significantly throughout the surgery (mean difference 3.61%; 95% CI -6.22 to -1.00; p = 0.008). However, aberrancy from this identified perfusion pattern had no impact on the postoperative outcome.

CONCLUSION

During colorectal resections, we could demonstrate an increase of the colonic StO2 throughout surgery. Appearance of AL was not associated with lower StO2, underlining the multifactorial genesis of developing AL.

Intra-operative assessment of left-sided colorectal anastomotic integrity: a systematic review of available techniques

AIM

Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer-related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought.

METHOD

A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990-2020. Additional papers were detected by scanning references of relevant papers.

RESULTS

A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air-leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra-operatively provides the opportunity for either suture reinforcement or formal takedown with or without re-do of the anastomosis and consideration of diversion. Suture repair alone of a positive air-leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future.

CONCLUSION

Although over reliance on any assessment tool should be avoided, intra-operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra-operatively for mechanical failure, particularly distal anastomoses.

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.

Complicated Diverticular Disease

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

Short-term outcomes of pelvic floor peritoneum closure in endoscopic low anterior resection of rectal cancer: A propensity score matching analysis

BACKGROUND

The efficacy of pelvic floor peritoneum closure (PC) during endoscopic low anterior resection (E-LAR) of rectal cancer remains unclear. This study aimed to clarify whether pelvic floor PC affected short-term outcomes.

METHODS

The study group comprised patients with the pathologically confirmed diagnosis of rectal cancer who underwent E-LAR with pelvic floor PC or with no PC (NPC) between January 2013 and December 2018 in Southwest Hospital. After propensity score matching (PSM), 584 patients (292 who underwent PC and 292 who underwent NPC) were evaluated. Postoperative indicators, including the rates of complications, anastomotic leakage (AL), reoperation, and inflammation, were observed in the two groups.

RESULTS

No significant difference was observed in the rates of postoperative complications between the PC and NPC groups. The rates of AL were similar (11.3% vs. 9.2%, p = .414). However, the reoperation rate of patients in the PC group was significantly lower than that of patients in the NPC group after AL (36.4% vs. 11.1%, p = .025). The hospital costs were higher in the NPC leakage subgroup (p = .001). Additionally, the serum C-reactive protein levels were lower in the PC group on postoperative days (PODs) 1, 3, and 5, whereas procalcitonin levels on POD 1 and 3 were lower in the PC group but did not differ significantly on POD 5.

CONCLUSION

Pelvic peritonization did not affect the rate of complications, especially AL; however, it effectively reduced the reoperation and inflammation rates and reduced hospitalization costs. Other short-term outcomes were similar, which warrant the increased use of pelvic peritonization in endoscopic surgery.

Development of a Risk Score to Predict Anastomotic Leak After Left-Sided Colectomy: Which Patients Warrant Diversion?

BACKGROUND

Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated.

RESULTS

38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%.

CONCLUSION

A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution

BACKGROUND

Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique.

METHODS

This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis.

RESULTS

A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO₂ retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities.

CONCLUSIONS

Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Clinical Significance of Pelvic Peritonization in Laparoscopic Dixon Surgery

Background:

Pelvic floor peritoneum reconstruction is a key step in various standard resections for open radical rectal cancer. However, during endoscopic surgery, most surgeons do not close the pelvic floor peritoneum. This study aims to evaluate the efficacy of pelvic peritonization during laparoscopic Dixon surgery using an observational study.

Methods:

A total of 189 patients, who underwent laparoscopic Dixon surgery at Tianjin Union Medical Center, China, were analyzed retrospectively. All of the cases were divided into two groups according to the differences of surgical procedure. The 92 patients in Group A (observation group) underwent pelvic peritonization and the 97 patients in Group B (control group) did not undergo this procedure. Postoperative complications were observed in the two groups, compared, and analyzed using the Chi-square or Fisher's exact test.

Results:

The incidence of anastomotic leakage was significantly lower in Group A than in Group B (P = 0.014). A significant difference was found in the postoperative short-term (P = 0.029) and long-term (P = 0.029) ileus rates between the two groups, with Group A exhibiting a lower rate than Group B. Patients in Group A had significantly lower rates of postoperative infections than those in Group B (χ² = 7.606, P = 0.006; χ² = 4.464, P = 0.035). Patients in Group A had significantly lower rates of deep venous thrombosis than those in Group B (χ² = 8.531, P = 0.003).

Conclusions:

Pelvic peritonization effectively reduces postoperative complications, such as anastomotic leakage, which warrants its increased use in laparoscopic surgery.

IntAct: intra-operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial

AIM

Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10-15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near-infrared laparoscopy can minimize the rate of AL leak compared with conventional white-light laparoscopy. Two mechanistic sub-studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies.

METHOD

IntAct is a prospective, unblinded, parallel-group, multicentre, European, randomized controlled trial comparing surgery with intra-operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end-point is rate of clinical AL at 90 days following surgery. Secondary end-points include all AL (clinical and radiological), change in planned anastomosis, complications and re-interventions, use of stoma, cost-effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days.

DISCUSSION

IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning.

Patient Acuity and Operative Technique Associated with Post-Colectomy Mortality Across New York State: an Analysis of 160,792 Patients over 20 years

This study sought to characterize in-hospital post-colectomy mortality in New York State. One hundred sixty thousand seven hundred ninety-two patients who underwent colectomy from 1995 to 2014 were analyzed from the all-payer New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear trends of in-hospital mortality rate over 20 years were calculated using log-linear regression models. Chi-square tests were used to compare categorical variables between patients. Multivariable regression models were further used to calculate risk of in-hospital mortality associated with specific demographics, co-morbidities, and perioperative complications. From 1995 to 2014, 7308 (4.5%) in-hospital mortalities occurred within 30 days of surgery. Over this time period, the rate of overall in-hospital post-colectomy mortality decreased by 3.3% (6.3 to 3%, p < 0.0001). The risk of in-hospital mortality for patients receiving emergent and elective surgery decreased by 1% (RR 0.99 [0.98-1.00], p = 0.0005) and 5% (RR 0.95 [0.94-0.96], p < 0.0001) each year, respectively. Patients who underwent open surgeries were more likely to experience in-hospital mortality (adjusted OR 3.65 [3.16-4.21], p < 0.0001), with an increased risk of in-hospital mortality each year (RR 1.01 [1.00-1.03], p = 0.0387). Numerous other risk factors were identified. In-hospital post-colectomy mortality decreased at a slower rate in emergent versus elective surgeries. The risk of in-hospital mortality has increased in open colectomies.