Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients

Machine learning-based preoperative analytics for the prediction of anastomotic leakage in colorectal surgery: a swiss pilot study

BACKGROUND

Anastomotic leakage (AL), a severe complication following colorectal surgery, arises from defects at the anastomosis site. This study evaluates the feasibility of predicting AL using machine learning (ML) algorithms based on preoperative data.

METHODS

We retrospectively analyzed data including 21 predictors from patients undergoing colorectal surgery with bowel anastomosis at four Swiss hospitals. Several ML algorithms were applied for binary classification into AL or non-AL groups, utilizing a five-fold cross-validation strategy with a 90% training and 10% validation split. Additionally, a holdout test set from an external hospital was employed to assess the models' robustness in external validation.

RESULTS

Among 1244 patients, 112 (9.0%) suffered from AL. The Random Forest model showed an AUC-ROC of 0.78 (SD: ± 0.01) on the internal test set, which significantly decreased to 0.60 (SD: ± 0.05) on the external holdout test set comprising 198 patients, including 7 (3.5%) with AL. Conversely, the Logistic Regression model demonstrated more consistent AUC-ROC values of 0.69 (SD: ± 0.01) on the internal set and 0.61 (SD: ± 0.05) on the external set. Accuracy measures for Random Forest were 0.82 (SD: ± 0.04) internally and 0.87 (SD: ± 0.08) externally, while Logistic Regression achieved accuracies of 0.81 (SD: ± 0.10) and 0.88 (SD: ± 0.15). F1 Scores for Random Forest moved from 0.58 (SD: ± 0.03) internally to 0.51 (SD: ± 0.03) externally, with Logistic Regression maintaining more stable scores of 0.53 (SD: ± 0.04) and 0.51 (SD: ± 0.02).

CONCLUSION

In this pilot study, we evaluated ML-based prediction models for AL post-colorectal surgery and identified ten patient-related risk factors associated with AL. Highlighting the need for multicenter data, external validation, and larger sample sizes, our findings emphasize the potential of ML in enhancing surgical outcomes and inform future development of a web-based application for broader clinical use.

Presurgical mild anemia is a risk factor for severe postoperative complications of rectal cancer surgery: A Japanese nationwide retrospective cohort study

Background

Anemia has negative effects on long-term outcomes of rectal cancer patients; however, its status as a risk factor for severe complications is disputed. Perioperative risks may differ based on the severity of pre-surgical anemia; nonetheless, no previous study has investigated these differences. This study identified risks of severe postoperative complications in rectal cancer patients based on severity of their pre-surgical anemia.

Materials and Methods

This study enrolled patients who underwent low anterior resection for rectal cancer and were registered in the Japanese National Clinical Database (NCD) between 2017 and 2019. Anemia severity was categorized into three levels: mild, moderate, and severe. A logistic regression model was applied to calculate the risk-adjusted odds ratio (OR) of severe complications after surgery.

Results

This study analyzed a cohort of 51 765 rectal cancer patients who underwent low anterior resection. Results showed that severe complications occurred in 10.9% of patients and were significantly more frequent in patients with anemia (13.6%) than those with normal hemoglobin levels (9.2%). Risk-adjusted ORs of severe complications in the severe, moderate, and mild anemia groups versus the normal group for males were 1.19 (95% confidence interval [CI]: 0.89-1.58), 1.47 (1.34-1.62), and 1.21 (1.12-1.31), respectively. Those for females were 1.39 (0.90-2.15), 1.64 (1.37-1.97), and 1.36 (1.16-1.58), respectively.

Conclusions

According to this large cohort study, pre-surgical anemia significantly increases the risk of severe postoperative complications in rectal cancer patients. Even mild anemia presents a significant risk.

Bowel preparation for elective colorectal resection: multi-treatment machine learning analysis on 6241 cases from a prospective Italian cohort

BACKGROUND

Current evidence concerning bowel preparation before elective colorectal surgery is still controversial. This study aimed to compare the incidence of anastomotic leakage (AL), surgical site infections (SSIs), and overall morbidity (any adverse event, OM) after elective colorectal surgery using four different types of bowel preparation.

METHODS

A prospective database gathered among 78 Italian surgical centers in two prospective studies, including 6241 patients who underwent elective colorectal resection with anastomosis for malignant or benign disease, was re-analyzed through a multi-treatment machine-learning model considering no bowel preparation (NBP; No. = 3742; 60.0%) as the reference treatment arm, compared to oral antibiotics alone (oA; No. = 406; 6.5%), mechanical bowel preparation alone (MBP; No. = 1486; 23.8%), or in combination with oAB (MoABP; No. = 607; 9.7%). Twenty covariates related to biometric data, surgical procedures, perioperative management, and hospital/center data potentially affecting outcomes were included and balanced into the model. The primary endpoints were AL, SSIs, and OM. All the results were reported as odds ratio (OR) with 95% confidence intervals (95% CI).

RESULTS

Compared to NBP, MBP showed significantly higher AL risk (OR 1.82; 95% CI 1.23-2.71; p = .003) and OM risk (OR 1.38; 95% CI 1.10-1.72; p = .005), no significant differences for all the endpoints were recorded in the oA group, whereas MoABP showed a significantly reduced SSI risk (OR 0.45; 95% CI 0.25-0.79; p = .008).

CONCLUSIONS

MoABP significantly reduced the SSI risk after elective colorectal surgery, therefore representing a valid alternative to NBP.

Oral Antibiotics Alone versus Oral Antibiotics Combined with Mechanical Bowel Preparation for Elective Colorectal Surgery: A Propensity Score-Matching Re-Analysis of the iCral 2 and 3 Prospective Cohorts

The evidence regarding the role of oral antibiotics alone (oA) or combined with mechanical bowel preparation (MoABP) for elective colorectal surgery remains controversial. A prospective database of 8359 colorectal resections gathered over a 32-month period from 78 Italian surgical units (the iCral 2 and 3 studies), reporting patient-, disease-, and procedure-related variables together with 60-day adverse events, was re-analyzed to identify a subgroup of 1013 cases (12.1%) that received either oA or MoABP. This dataset was analyzed using a 1:1 propensity score-matching model including 20 covariates. Two well-balanced groups of 243 patients each were obtained: group A (oA) and group B (MoABP). The primary endpoints were anastomotic leakage (AL) and surgical site infection (SSI) rates. Group A vs. group B showed a significantly higher AL risk [14 (5.8%) vs. 6 (2.5%) events; OR: 3.77; 95%CI: 1.22-11.67; p = 0.021], while no significant difference was recorded between the two groups regarding SSIs. These results strongly support the use of MoABP for elective colorectal resections.

Mechanical bowel preparation in elective colorectal surgery: a propensity score-matched analysis of the Italian colorectal anastomotic leakage (iCral) study group prospective cohorts

Retrospective evaluation of the effects of mechanical bowel preparation (MBP) on data derived from two prospective open-label observational multicenter studies in Italy regarding elective colorectal surgery. MBP for elective colorectal surgery remains a controversial issue with contrasting recommendations in current guidelines. The Italian ColoRectal Anastomotic Leakage (iCral) study group, therefore, decided to estimate the effects of no MBP (treatment variable) versus MBP for elective colorectal surgery. A total of 8359 patients who underwent colorectal resection with anastomosis were enrolled in two consecutive prospective studies in 78 surgical centers in Italy from January 2019 to September 2021. A retrospective PSMA was performed on 5455 (65.3%) cases after the application of explicit exclusion criteria to eliminate confounders. The primary endpoints were anastomotic leakage (AL) and surgical site infections (SSI) rates; the secondary endpoints included SSI subgroups, overall and major morbidity, reoperation, and mortality rates. Overall length of postoperative hospital stay (LOS) was also considered. Two well-balanced groups of 1125 patients each were generated: group A (No MBP, true population of interest), and group B (MBP, control population), performing a PSMA considering 21 covariates. Group A vs. group B resulted significantly associated with a lower risk of AL [42 (3.5%) vs. 73 (6.0%) events; OR 0.57; 95% CI 0.38-0.84; p = 0.005]. No difference was recorded between the two groups for SSI [73 (6.0%) vs. 85 (7.0%) events; OR 0.88; 95% CI 0.63-1.22; p = 0.441]. Regarding the secondary endpoints, no MBP resulted significantly associated with a lower risk of reoperation and LOS > 6 days. This study confirms that no MBP before elective colorectal surgery is significantly associated with a lower risk of AL, reoperation rate, and LOS < 6 days when compared with MBP.

Tube Stoma for the Management of Ileocolic Anastomotic Leak in a Patient With Metastatic Colon Cancer

This case involves a 53-year-old male who was diagnosed with stenotic ascending colon cancer and peritoneal metastatic deposits. He was initially planned for cytoreductive surgery and heated intraperitoneal chemotherapy (CRS and HIPEC), along with resection of the primary tumor in the form of right hemicolectomy. Intraoperatively, the disease was found to be more extensive than anticipated. Consequently, the plan was modified to include debulking right hemicolectomy with hand-sewn ileocolic anastomosis and extensive peritoneal procedures. Postoperatively, he experienced an anastomotic leak, leading to another laparotomy. However, due to anatomical challenges, creating a stoma was considered unsafe. Therefore, innovative interventions were performed, including controlling the anastomotic defect with a 30Fr Foley catheter without disrupting the anastomosis. A collaborative effort from various medical teams facilitated the patient's discharge home after an extended stay in the critical care unit (CCU).

Postoperative NSAIDs use and the risk of anastomotic leakage after restorative resection for colorectal cancer

BACKGROUND

Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center.

METHODS

This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011-2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW).

RESULTS

Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76-6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86-6.72; P < 0.001).

CONCLUSION

Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.

Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study

PURPOSE

To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes.

METHODS

Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results.

RESULTS

Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks.

CONCLUSION

AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised.

TRIAL REGISTRATION

Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts

BACKGROUND

Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections.

MATERIALS AND METHODS

A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) - true population of interest, anastomosis performed with a three-row circular stapler; group (B) - control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15-0.73; P =0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17-0.87; P =0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24-0.91; P =0.026).

CONCLUSION

The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage.

Impact of Anastomotic Leak on Long-term Oncological Outcomes After Restorative Surgery for Rectal Cancer: A Retrospective Cohort Study

BACKGROUND

Anastomotic leak after restorative surgery for rectal cancer is a major complication and may lead to worse long-term oncological and survival outcomes.

OBJECTIVE

The purpose of this study was to identify risk factors associated with anastomotic leak and to assess the perioperative and long-term oncological impact of anastomotic leak in our cohort of patients with rectal cancer.

DESIGN

A retrospective analysis was performed on data from the prospectively maintained Cabrini Monash colorectal neoplasia database. Patients who had undergone rectal cancer resection and subsequently received anastomosis between November 2009 and May 2020 were included in this study. Patient and tumor characteristics, technical risk factors, and short-term and perioperative as well as long-term oncological and survival outcomes were assessed.

SETTINGS

The study was conducted in 3 tertiary hospitals.

PATIENTS

A total of 693 patients met the inclusion criteria for this study.

MAIN OUTCOME MEASURES

Univariate analyses were performed to assess the relationship between anastomotic leak and patient and technical risk factors, as well as perioperative and long-term outcomes. Univariate and multivariate proportional HR models of overall and disease-free survival were calculated. Kaplan-Meier survival analyses assessed disease-free and overall survival.

RESULTS

Anastomotic leak rate was 3.75%. Males had an increased risk of anastomotic leak, as did patients with hypertension and ischemic heart disease. Patients who experience an anastomotic leak were more likely to require reoperation and hospital readmission and were more likely to experience an inpatient death. Disease-free and overall survival were also negatively impacted by anastomotic leaks.

LIMITATIONS

This is a retrospective analysis of data from only 3 centers with the usual limitations. However, these effects have been minimized because of the high quality and completeness of the prospective data collection.

CONCLUSIONS

Anastomotic leaks after restorative surgery negatively affect long-term oncological and survival outcomes for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/C81 .

IMPACTO DE LA FUGA ANASTOMTICA EN LOS RESULTADOS ONCOLGICOS A LARGO PLAZO TRAS CIRUGA RESTAURADORA PARA EL CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO

ANTECEDENTES:La fuga anastomótica tras una cirugía restauradora para el cáncer de recto es una complicación mayor y puede conducir a peores resultados oncológicos y de supervivencia a largo plazo.OBJETIVO:El propósito de este estudio fue identificar los factores de riesgo asociados con la fuga anastomótica y evaluar el impacto oncológico perioperatorio y a largo plazo de la fuga anastomótica en nuestra cohorte de pacientes con cáncer de recto.DISEÑO:Se realizó un análisis retrospectivo de datos obtenidos de la base de datos Cabrini Monash sobre neoplasia colorrectal la cual es mantenida prospectivamente. Se incluyeron en este estudio pacientes que fueron sometidos a una resección del cáncer de recto y que posteriormente recibieron una anastomosis entre noviembre de 2009 y mayo de 2020. Se evaluaron las características del paciente y del tumor, los factores de riesgo relacionados a la técnica, los resultados oncológicos y de supervivencia perioperatorio, así como los resultados a corto y largo plazo.AJUSTES:El estudio se realizó en tres hospitales terciarios.PACIENTES:Un total de 693 pacientes cumplieron con los criterios de inclusión para este estudio.PRINCIPALES MEDIDAS DE RESULTADO:Se realizaron análisis univariados para evaluar la relación entre la fuga anastomótica y aquellos factores relacionados al paciente, a la técnica, así como los resultados perioperatorios y a largo plazo. Se calcularon modelos de razón de riesgo proporcional univariante y multivariante de supervivencia global y libre de enfermedad. Los análisis de supervivencia de Kaplan-Meier evaluaron la supervivencia libre de enfermedad y la supervivencia global.RESULTADOS:La tasa de fuga anastomótica fue del 3,75%. Los hombres tenían un mayor riesgo de fuga anastomótica al igual que aquellos pacientes con hipertensión y cardiopatía isquémica. Los pacientes que sufrieron una fuga anastomótica tuvieron mayores probabilidades de requerir una reintervención y reingreso hospitalario, así como también tuvieron mayores probabilidades de sufrir una muerte hospitalaria. La supervivencia libre de enfermedad y general también se vio afectada negativamente por las fugas anastomóticas.LIMITACIONES:Este es un análisis retrospectivo de datos de solo tres centros con las limitaciones habituales. Sin embargo, estos efectos han sido minimizados debido a la alta calidad y la exhaustividad de la recopilación prospectiva de datos.CONCLUSIONES:Las fugas anastomóticas después de una cirugía restauradora afectan negativamente los resultados oncológicos y de supervivencia a largo plazo para los pacientes con cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C81 . (Traducción-Dr. Osvaldo Gauto ).

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Blood Transfusions and Adverse Events after Colorectal Surgery: A Propensity-Score-Matched Analysis of a Hen-Egg Issue

Blood transfusions are considered a risk factor for adverse outcomes after colorectal surgery. However, it is still unclear if they are the cause (the hen) or the consequence (the egg) of adverse events. A prospective database of 4529 colorectal resections gathered over a 12-month period in 76 Italian surgical units (the iCral3 study), reporting patient-, disease-, and procedure-related variables, together with 60-day adverse events, was retrospectively analyzed identifying a subgroup of 304 cases (6.7%) that received intra- and/or postoperative blood transfusions (IPBTs). The endpoints considered were overall and major morbidity (OM and MM, respectively), anastomotic leakage (AL), and mortality (M) rates. After the exclusion of 336 patients who underwent neo-adjuvant treatments, 4193 (92.6%) cases were analyzed through a 1:1 propensity score matching model including 22 covariates. Two well-balanced groups of 275 patients each were obtained: group A, presence of IPBT, and group B, absence of IPBT. Group A vs. group B showed a significantly higher risk of overall morbidity (154 (56%) vs. 84 (31%) events; OR 3.07; 95%CI 2.13-4.43; p = 0.001), major morbidity (59 (21%) vs. 13 (4.7%) events; OR 6.06; 95%CI 3.17-11.6; p = 0.001), and anastomotic leakage (31 (11.3%) vs. 8 (2.9%) events; OR 4.72; 95%CI 2.09-10.66; p = 0.0002). No significant difference was recorded between the two groups concerning the risk of mortality. The original subpopulation of 304 patients that received IPBT was further analyzed considering three variables: appropriateness of BT according to liberal transfusion thresholds, BT following any hemorrhagic and/or major adverse event, and major adverse event following BT without any previous hemorrhagic adverse event. Inappropriate BT was administered in more than a quarter of cases, without any significant influence on any endpoint. The majority of BT was administered after a hemorrhagic or a major adverse event, with significantly higher rates of MM and AL. Finally, a major adverse event followed BT in a minority (4.3%) of cases, with significantly higher MM, AL, and M rates. In conclusion, although the majority of IPBT was administered with the consequence of hemorrhage and/or major adverse events (the egg), after adjustment accounting for 22 covariates, IPBT still resulted in a definite source of a higher risk of major morbidity and anastomotic leakage rates after colorectal surgery (the hen), calling urgent attention to the implementation of patient blood management programs.

The Colorectal Anastomosis: A Timeless Challenge

Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale

BACKGROUND

Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement.

OBJECTIVE

Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons.

DESIGN

Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates.

SETTINGS

The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals.

PATIENTS

Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons.

MAIN OUTCOME MEASURES

Main outcome measures included 30-day risk-adjusted postoperative complications.

RESULTS

The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41).

LIMITATIONS

Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms.

CONCLUSIONS

Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Der erfahrene Chirurg als unabhängiger Risikofaktor für die Morbidität nach Cholezystektomie. Eine multivariate Analyse von 710 Patienten

Einleitung Bei komplexeren chirurgischen Eingriffen wie der Kolonresektion, herzchirurgischen Eingriffen, arteriellen Rekonstruktionen oder Leberresektionen ist der Einfluss des Chirurgen auf die postoperative Morbidität nachgewiesen. Bei Routineeingriffen wie der Cholezystektomie liegen bislang keine Erkenntnisse zum Zusammenhang von Operateur und Morbidität vor. Insbesondere Untersuchungen bei erfahrenen Chirurgen fehlen.

Methoden Es wurden 710 konsekutive Patienten, die zwischen Januar 2014 und Dezember 2018 von erfahrenen Chirurgen (über n = 300 Cholezystektomien vor Beginn der Untersuchung, über 5 Jahre nach bestandener Facharztprüfung) cholezystektomiert wurden, untersucht. In einer univariaten Analyse wurde der Einfluss von Patientenmerkmalen, Laborparametern, chirurgischen Parametern und des Operateurs auf die postoperative Morbidität analysiert. Die Variablen mit statistischer Signifikanzen wurden dann einer multivariaten logistischen Regressionsanalyse unterzogen.

Ergebnisse Die Mortalität lag bei 5 von 710 (0,7%), die Morbidität bei 58 von 710 (8,2%). 37 von 710 Patienten erlitten eine chirurgische Komplikation, 21 von 710 Patienten eine nicht chirurgische Komplikation. Hinsichtlich der Gesamtmorbidität waren in multivariater Analyse der Kreatininwert (OR 1,29; KI 1,01–1,648; p = 0,042), GOT (OR 1,0405; KI 1–1,01; p = 0,03), offene und Konversions-Cholezystektomie (OR 4,134; KI 1,587–10,768; p = 0,004) und der individuelle Chirurg (OR bis 40,675; p = 0,001) ein unabhängiger Risikofaktor. Bei Analyse der chirurgischen Komplikationen blieben offene und Konversions-Cholezystektomie (OR 8,104; KI 3,03–21,68; p < 0,001) sowie der individuelle Chirurg (OR bis 79,69; p = 0,005) ein statistisch signifikanter unabhängiger Risikofaktor.

Schlussfolgerung Der individuelle Chirurg ist auch bei einem Routineeingriff wie der Cholezystektomie ein unabhängiger Risikofaktor für die Morbidität. Dies gilt auch für erfahrene Chirurgen mit Facharztstatus und hoher Caseload. Im Hinblick auf die Patientensicherheit und Verbesserungen der Ergebnisqualität muss daher diskutiert werden, ob eine routinemäßige risikoadjustierte Messung der individuellen Ergebnisse eines jeden Chirurgen als Basis eines gezielten Qualifizierungprogramms sinnvoll ist.

The impact of anastomotic leak on long-term oncological outcomes after low anterior resection for mid-low rectal cancer: extended follow-up of a randomised controlled trial

PURPOSE

The impact of anastomotic leaks (AL) on oncological outcomes after low anterior resection for mid-low rectal cancer is still debated. The aim of this study was to evaluate overall survival (OS), disease-free survival (DFS), and local and distant recurrence in patients with AL following low anterior resection.

METHODS

This is an extension of a multicentre RCT (NCT01110798). Kaplan-Meier method and the log-rank test were used to estimate and compare the 3-, 5-, and 10-year OS and DFS, and local and distant recurrence in patients with and without AL. Predictors of OS and DFS were evaluated using the Cox regression analysis as secondary aim.

RESULTS

Follow-up was available for 311 patients. Of them, 252 (81.0%) underwent neoadjuvant chemoradiotherapy and 138 (44.3%) adjuvant therapy. AL occurred in 63 (20.3%) patients. At a mean follow-up of 69.5 ± 31.9 months, 23 (7.4%) patients experienced local recurrence and 49 (15.8%) distant recurrence. The 3-, 5-, and 10-year OS and DFS were 89.2%, 85.3%, and 70.2%; and 80.7%, 75.1%, and 63.5% in patients with AL, and 88.9%, 79.8% and 72.3%; and 83.7, 74.2 and 62.8%, respectively in patients without (p = 0.89 and p = 0.84, respectively). At multivariable analysis, AL was not an independent predictor of OS (HR 0.65, 95%CI 0.34-1.28) and DFS (HR 0.70, 95%CI 0.39-1.25), whereas positive circumferential resection margins and pathological stage impaired both.

CONCLUSIONS

In the context of modern multimodal rectal cancer treatment, AL does not affect long-term OS, DFS, and local and distant recurrence in patients with mid-low rectal cancer.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detection was initially described in breast cancer surgery, the technique is currently applied in gastric or splenic flexure cancers, as they both present complex and variable lymphatic drainages. FGS allows also to perform intraoperative lymphograms or sentinel lymph node biopsies. New applications of FGS are being developed to assist in the detection of peritoneal metastases or in the evaluation of the tumor resection margins. The present review aims to provide a general overview of the current status of real-time FGS in gastrointestinal oncologic surgery. We put a special focus on the different applications of FGS, discussing the main findings and limitations found in the contemporary literature and also the promising near future applications.

Clinical outcomes of powered and manual staplers in video-assisted thoracic surgery lobectomy for lung cancer

Methods: This retrospective cohort study identified patients who underwent video-assisted thoracic surgery (VATS) lobectomy for lung cancer from January 2016 to December 2018 in a Chinese tertiary general hospital. The electronic hospital medical records associated with the VATS lobectomy for lung cancer were the data sources. Results: Based on the analysis of 433 patients with the utilization of staplers in their VATS lobectomy for lung cancer, using powered stapler was associated with significantly shorter operation time and postsurgery hospital stay length than using the manual stapler in the multivariable generalized linear regression analyses with the adjustment of patient characteristics. However, no other significant differences were observed for other clinical outcomes between the two staplers.

Mucosa plication reinforced colorectal anastomosis and trans-anal vacuum drainage: a pilot study with preliminary results

Dehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019–October 2020. The mean age of patients was 61 years (lower–upper quartiles 54–69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower–upper quartiles 3.00–4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien–Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation.

Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.

Association of certification, improved quality and better oncological outcomes for rectal cancer in a specialized colorectal unit

PURPOSE

Centralization of cancer care is expected to yield superior results. In Germany, the national strategy is based on a voluntary certification process. The effect of centre certification is difficult to prove because quality data are rarely available prior to certification. This observational study aims to assess outcomes for rectal cancer patients before and after implementation of a certified cancer centre.

PATIENTS AND METHODS

All consecutive patients treated for rectal cancer in our certified centre from 2009 to 2017 were retrieved from a prospective database. The dataset was analyzed according to a predefined set of 19 quality indicators comprising 36 quality goals. The results were compared to an identical cohort of patients, treated from 2000 to 2008 just before centre implementation.

RESULTS

In total, 1059 patients were included, 481 in the 2009-2017 interval and 578 in the 2000-2008 interval. From 2009 to 2017, 25 of 36 quality goals were achieved (vs. 19/36). The proportion of anastomotic leaks in low anastomoses was improved (13.5% vs. 22.1%, p = 0.018), as was the local 5-year recurrence rate for stage (y)pIII rectal cancers (7.7% vs. 17.8%, p = 0.085), and quality of mesorectal excision (0.3% incomplete resections vs. 5.5%, p = 0.002). Furthermore, a decrease of abdominoperineal excisions was noted (47.1% vs. 60.0%, p = 0.037). For the 2009-2017 interval, local 5-year recurrence rate in stages (y)p0-III was 4.6% and 5-year overall survival was 80.2%.

CONCLUSIONS

Certification as specialized centre and regular audits were associated with an improvement of various quality parameters. The formal certification process has the potential to enhance quality of care for rectal cancer patients.

Double-layered Nanofibrous Patch for Prevention of Anastomotic Leakage and Peritoneal Adhesions, Experimental Study

BACKGROUND/AIM

Anastomotic leakage is a feared complication in colorectal surgery. Postoperative peritoneal adhesions can also cause life-threatening conditions. Nanofibrous materials showed their pro-healing properties in various studies. The aim of the study was to evaluate the impact of double-layered nanofibrous materials on anastomotic healing and peritoneal adhesions formation.

MATERIALS AND METHODS

Two versions of double-layered materials from polycaprolactone and polyvinyl alcohol were applied on defective anastomosis on the small intestine of healthy pigs. The control group remained with uncovered defect. Tissue specimens were subjected to histological analysis and adhesion scoring after 3 weeks of observation.

RESULTS

The wound healing was inferior in the experimental groups, however, no anastomotic leakage was observed and the applied material always kept covering the defect. The extent of adhesions was larger in the experimental groups.

CONCLUSION

Nanofibrous materials may prevent anastomotic leakage but delay healing.

The influence of diabetes on postoperative complications following colorectal surgery

Background

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.

Methods

Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.

Results

Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837–3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636–2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210–2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349–1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.

Conclusions

This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10151-020-02373-9) contains supplementary material, which is available to authorized users.

Prospective Study Comparing Clinical vs Indocyanine Green Fluorescence-Based Assessment of Line of Transection in Robotic Rectal Cancer Surgery-Indian Study

Anastomotic leakage continues to be the most feared postoperative complications in rectal surgery with negative impact on both short- and long-term outcomes. Fortunately, new surgical strategies have helped to offset this complication and improve surgical outcomes. Traditionally, perfusion is assessed by intraoperative visual judgment by the surgeon. These subjective methods lack predictive accuracy resulting in either excess or insufficient colonic resection. Indocyanine green (ICG) fluorescence has shown promise in identifying the adequacy of perfusion. After injection of ICG, the system projected high-resolution near-infrared real-time images of blood flow in mesentery and bowel wall. This novel imaging method is used intraoperatively for taking real-time informed decisions. We conducted a single institutional prospective study to identify the feasibility of ICG identification of vascularity of anastomotic site and its impact on the change of plan of surgical management in robotic rectal cancer surgery. Between September 2017 and April 2019, fifty patients undergoing robotic rectal cancer surgery were included in the study. The aim was to analyze the feasibility and clinical benefit of intraoperative near-infrared fluorescence imaging in determining the line of transection in comparison with the traditional method. Line of proximal transection of the bowel subjectively assessed by the surgical team was marked point B and that after ICG injection was marked point A if moved proximally and point C if moved distally. The vascular anatomy was clearly identified with no intraoperative or injection-related adverse effects. Of the 50 patients, the line of transaction remained the same in 6 patients (12%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 3 patients (6%) and distally in 41 patients (82%). ICG-based infrared image-guided localization gives a real-time image of colon vascularity possibly affecting anastomotic leak. The ICG fluorescence imaging system is a simple, safe, and useful technique, performed within a short time, and it enables visual evaluation of the blood flow in the intestinal tract prior to anastomosis. Larger studies are needed before this can become the standard of care.

Patient's characteristics, management practices and outcome of re-laparotomies in a tertiary hospital in Tanzania

BACKGROUND

Relaparotomy is an important indicator of the safety and quality of laparotomy in any surgical setting. Despite this, its measure in many low- and middle-income countries is scarce, Tanzania included. Understanding its existence will help curb it and mitigate its adverse outcomes by systematic improvement strategies. This study, therefore, aimed to examine characteristics of patients undergoing on-demand relaparotomy and their management outcomes at a tertiary level hospital in Tanzania.

METHODS

A cross-sectional descriptive study was carried out in the department of surgery of Muhimbili National Hospital for one year in 2017-2018. All patients (of all ages and sex) who required an on-demand relaparotomy within 60 days of their index laparotomy were identified for inclusion into the study. Data were collected regarding patient's demography, clinical characteristics, index surgical procedure, indication for relaparotomy, number of re-laparotomies, complications during re-laparotomy, ICU admission, and mortality. Data were entered into SPSS version 23 for analysis where continuous variables were summarized as means with standard deviations and categorical variables summarized as the frequency with proportions. Ethical approval for the audit was obtained from the Muhimbili University of Health IRB.

RESULTS

A total of 101 patients had undergone relaparotomy, with a relaparotomy rate among those primarily operated at our hospital of 7.6%. Their mean age was 37 years with equal sex distribution. The leading primary procedure had involved bowel resection and anastomosis (47.5%) with anastomotic leak being the leading reason for relaparotomy (37.6%) followed by intra-abdominal collection (29.7%), bowel fistula (19.8%) and wound dehiscence (18.8%). Electrolyte imbalance was the leading complication among the patients (22.9%) followed by anemia (21.5%), wound infection (18.9%) and Septicemia (11%). The overall mortality of rate was 39.6%.

CONCLUSION

On-demand relaparotomy carries a high mortality and morbidity at Muhimbili National Hospital in Tanzania. Addressing predictors and improving post-operative services are urgently needed.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques

INTRODUCTION

There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn).

MATERIALS AND METHODS

This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed.

RESULTS

We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified.

CONCLUSION

Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Incisional hernia recurrence after open elective repair: expertise in abdominal wall surgery matters

BACKGROUND

Recurrence after incisional hernia repair is one of the major problems related with this operation. Our objective is to analyze the influence of abdominal wall surgery expertise in the results of the open elective repair of incisional hernia.

METHODS

We have compiled the data of a cohort of patients who received surgery for an incisional hernia from July 2012 to December 2015 in a University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). The short- and long-term complications between the groups of patients operated on by the Abdominal Wall Surgery (AWS) unit and groups operated on by surgeons outside of the specialized abdominal wall group (GS) were compared.

RESULTS

During the study period, a total of 237 patients were operated on by the open approach (114 AWS; 123 GS). One hundred seventy-five patients completed a median follow-up of 36.6 months [standard deviation (SD) = 6]. Groups were comparable in terms of age, sex, body mass index (BMI), comorbidities, and complexity of hernia. Complications were similar in both groups. Patients in the AWS group presented fewer recurrences (12.0% vs. 28.9%; P = 0.005). The cumulative incidence of recurrence was higher in the GS group [log rank 13.370; P < 0.001; odds ratio (OR) = 37.8; 95% confidence interval (CI) = 30.3-45.4]. In the multivariate analysis, surgery performed by the AWS unit was related to fewer recurrences (OR = 0.19; 95%CI = 0.07-0.58; P < 0.001).

CONCLUSION

Incisional hernia surgery is associated with better results in terms of recurrence when it is performed in a specialized abdominal wall unit.

Intraoperative intraperitoneal chemotherapy increases the incidence of anastomotic leakage after anterior resection of rectal tumors

BACKGROUND

Intraoperative intraperitoneal chemotherapy is an emerging treatment modality for locally advanced rectal neoplasms. However, its impacts on postoperative complications remain unknown. Anastomotic leakage (AL) is one of the most common and serious complications associated with the anterior resection of rectal tumors. Therefore, we designed this study to determine the effects of intraoperative intraperitoneal chemotherapy on AL.

AIM

To investigate whether intraoperative intraperitoneal chemotherapy increases the incidence of AL after the anterior resection of rectal neoplasms.

METHODS

This retrospective cohort study collected information from 477 consecutive patients who underwent an anterior resection of rectal carcinoma using the double stapling technique at our institution from September 2016 to September 2017. Based on the administration of intraoperative intraperitoneal chemotherapy or not, the patients were divided into a chemotherapy group (171 cases with intraperitoneal implantation of chemotherapy agents during the operation) or a control group (306 cases without intraoperative intraperitoneal chemotherapy). Clinicopathologic features, intraoperative treatment, and postoperative complications were recorded and analyzed to determine the effects of intraoperative intraperitoneal chemotherapy on the incidence of AL. The clinical outcomes of the two groups were also compared through survival analysis.

RESULTS

The univariate analysis showed a significantly higher incidence of AL in the patients who received intraoperative intraperitoneal chemotherapy, with 13 (7.6%) cases in the chemotherapy group and 5 (1.6%) cases in the control group (P = 0.001). As for the severity of AL, the AL patients who underwent intraoperative intraperitoneal chemotherapy tended to be more severe cases, and 12 (92.3%) out of 13 AL patients in the chemotherapy group and 2 (40.0%) out of 5 AL patients in the control group required a secondary operation (P = 0.044). A multivariate analysis was subsequently performed to adjust for the confounding factors and also showed that intraoperative intraperitoneal chemotherapy increased the incidence of AL (odds ratio = 5.386; 95%CI: 1.808-16.042; P = 0.002). However, the survival analysis demonstrated that intraoperative intraperitoneal chemotherapy could also improve the disease-free survival rates for patients with locally advanced rectal cancer.

CONCLUSION

Intraoperative intraperitoneal chemotherapy can improve the prognosis of patients with locally advanced rectal carcinoma, but it also increases the risk of AL following the anterior resection of rectal neoplasms.

The Clinical and Economic Burden of Colorectal Anastomotic Leaks: Middle-Income Country Perspective

Purpose

Anastomotic leaks (AL) present a significant source of clinical and economic burden on patients undergoing colorectal surgeries. This study was aimed at evaluating the clinical and economic consequences of AL and its risk factors.

Methods

A retrospective cohort study was conducted between 2012 and 2013 based on the billing information of 337 patients who underwent low anterior resection (LAR). The outcomes evaluated were the development of AL, use of antibiotics, 30-day readmission and mortality, and total hospital costs, including readmissions and length of stay (LOS). The risk factors for AL, as well as the relationship between AL and clinical outcomes, were analyzed using multivariable Poisson regression. Generalized linear models (GLM) were employed to evaluate the association between AL and continuous outcomes (LOS and costs).

Results

AL was detected in 6.8% of the patients. Emergency surgery (aRR 2.56; 95% CI: 1.15-5.71, p = 0.021), blood transfusion (aRR 4.44; 95% CI: 1.86-10.64, p = 0.001), and cancer diagnosis (aRR 2.51; 95% CI: 1.27-4.98, p = 0.008) were found to be independent predictors of AL. Patients with AL showed higher antibiotic usage (aRR 1.69; 95% CI: 1.37-2.09, p < 0.001), 30-day readmission (aRR 3.34; 95% CI: 1.53-7.32, p = 0.003) and mortality (aRR 13.49; 95% CI: 4.10-44.35, p < 0.001), and longer LOS (39.6 days, as opposed to 7.5 days for patients without AL, p < 0.001). Total hospital costs amounted to R$210,105 for patients with AL in comparison with R$34,270 for patients without AL (p < 0.001). In multivariable GLM, the total hospital costs for AL patients were 4.66 (95% CI: 3.38-6.23, p < 0.001) times higher than those for patients without AL.

Conclusions

AL leads to worse clinical outcomes and increases hospital costs by 4.66 times. The risk factors for AL were found to be emergency surgery, blood transfusion, and cancer diagnosis.

Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study

BACKGROUND

Data on anastomotic leak rates after stapled versus handsewn ileocolic anastomosis are conflicting. In a Cochrane review, the combined estimate favored the stapled technique, but recent cohort studies demonstrated a 2-fold increase in anastomotic leak with the stapled approach.

OBJECTIVE

The purpose of this study was to investigate anastomotic leak rates following stapled versus handsewn ileocolic anastomosis.

DESIGN

This was a nationwide, retrospective cohort study.

SETTING

Data were obtained from the Danish Colorectal Cancer Group and National Patient Registry databases.

PATIENTS

Danish patients, ≥18 years of age, undergoing right hemicolectomy for a first-time diagnosis of adenocarcinoma in the right colon with primary anastomosis between October 2014 and December 2015 were included.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic leak rate. Secondary outcomes included 30-day mortality. Covariates included demographics, comorbidity, tumor stage, and surgical variables. Multivariable logistic regression and propensity score matching were used to adjust for confounding.

RESULTS

The 1414 patients included 391 (28%) in the stapled group and 1023 (72%) in the handsewn group. Forty-five patients (3.2%) developed anastomotic leak: 21 of 391 (5.4%) and 24 of 1023 (2.4%) in the stapled and handsewn group (p = 0.004). This difference was confirmed in multivariable analysis (adjusted OR, 2.91; 95% CI, 1.53-5.53; p < 0.001), and after propensity score matching (OR, 2.41; 95% CI, 1.24-4.67; p = 0.009). Thirty-day mortality was 15.6% (7/45) and 2.1% (29/1369) in patients with and without anastomotic leak (p < 0.001), with no difference between the stapled and handsewn approach.

LIMITATIONS

The study's design was retrospective, with no information on allocation to the stapled or handsewn approach.

CONCLUSIONS

The present study demonstrated a 2-fold increase in anastomotic leak after stapled versus handsewn ileocolic anastomoses. Previous opinions on the optimal anastomosis technique for colon cancer should be scrutinized given the devastating short-term outcome of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A819.

Power of Judgment: The Significance of Kant's Philosophy for the Medical System Today

The ways of thinking in the manufacturing sciences are increasingly determining the rationality within medicine as a practical or action-based science. This "technological paradigm" infiltrates the field of medicine with the promise of increasing efficiency while simultaneously improving quality at various points in the system. Simple linear causal relationships generally need to be taken into account when manufacturing products. Even complex manufacturing processes can be broken down into the smallest units and, therefore, also be automated. The situation in complex systems such as the human body, however, is completely different. In order for doctors to be able to carry out their actions within this complex system, medicine as a science provides the physician with rules on the means that should be used to decide which remedy should be used, when and how. This judgment of which remedy should be used, when and how, what is known as the indication, is a central medical moment. This requires a power of judgment sharpened by experience. The indication, in turn, essentially determines the course of a disease and thus the quality of the treatment or the quality of result so often referred to these days.

Pelvic exenterations for primary rectal cancer: Analysis from a 10-year national prospective database

AIM

To identify short-term and oncologic outcomes of pelvic exenterations (PE) for locally advanced primary rectal cancer (LAPRC) in patients included in a national prospective database.

METHODS

Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Española de Cirujanos (AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence (LR), disease-free survival (DFS) and overall survival (OS). A propensity-matched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint.

RESULTS

Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication (abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio (HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival (HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS.

CONCLUSION

PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Indocyanine Green Fluorescence Angiography and the Incidence of Anastomotic Leak After Colorectal Resection for Colorectal Cancer: A Meta-analysis

BACKGROUND

Anastomotic leak is a life-threatening complication of colorectal surgery. Recent studies showed that indocyanine green fluorescence angiography might be a method to prevent anastomotic leak.

OBJECTIVE

The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak.

DATA SOURCES

Potential relevant studies were identified from the following databases: PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure.

STUDY SELECTION

This meta-analysis included comparative studies investigating the association between indocyanine green fluorescence angiography and anastomotic leak in patients undergoing surgery for colorectal cancer where the diagnosis of anastomotic leak was confirmed by CT and the outcomes of the indocyanine green group were compared with a control group.

INTERVENTION

Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis.

MAIN OUTCOME MEASURES

The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies. ORs and 95% CIs were used to assess the association between indocyanine green and anastomotic leak.

RESULTS

In 4 studies with a total sample size of 1177, comparing the number of anastomotic leaks in the indocyanine green and control groups, the ORs were 0.45 (95% CI, 0.18-1.12), 0.30 (95% CI, 0.03-2.98), 0.17 (95% CI, 0.01-3.69), and 0.12 (95% CI, 0.03-0.52). The combined OR was 0.27 (95% CI, 0.13-0.53). The difference was statistically significant (p < 0.001), and there was no significant heterogeneity (p = 0.48; I = 0).

LIMITATIONS

Data could not be pooled because of the small number of studies; some differences between studies may influence the results. Also, the pooled data were not randomized.

CONCLUSIONS

The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.

Outcomes of transanal tube placement in anterior resection: A meta-analysis and systematic review

BACKGROUND

In recent years, transanal tube placement was reported to be an effective procedure preventing anastomotic leakage after anterior resection of rectal cancer. However, this procedure is still controversial owing to inconsistent results found in previous studies.

METHODS

A comprehensive literature search was performed using Pubmed, Embase, Cochrane library from the databases inception up until June 21, 2018. The methodological quality of randomized controlled trials and cohort studies were evaluated by Cochrane Collaboration's tool for assessing risk of bias and Newcastle-Ottawa Scale, respectively. Statistical analysis was performed using the RevMan 5.3 software.

RESULTS

1 randomized controlled trial and 9 cohort studies were included in our meta-analysis. The randomized controlled trial was proven to be low risk according to the Cochrane Collaboration's tool for assessing risk of bias. All of the cohort studies proved a high quality according to the Newcastle-Ottawa Scale. Patients in transanal tube group had more disadvantageous preoperative demographic characteristics than patients in non-transanal tube group. The anastomotic leak rate was lower in the transanal tube group. Patients in the transanal tube group tended to have lower reoperation rates and shorter hospital stays compared with patients in the non-transanal tube group.

CONCLUSION

Despite various unfavorable preoperative characteristics, anastomotic leakage after anterior resection was lower in patients who received transanal tube placement compared with the control group. Transanal tube placement may be an alternative procedure of defunctioning stoma. A large sample size, multicenter RCT was needed to prove our results.

Morbidity after transanal endoscopic microsurgery: risk factors for postoperative complications and the design of a 1-day surgery program

BACKGROUND

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid.

METHODS

This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien-Dindo (Cl-D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out.

RESULTS

Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl-D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3-7.8), anti-platelet medication (OR 2.3, 95% CI 1.1-5.1), and surgeon's experience < 150 procedures (OR 2.0, 95% CI 1-4.1).

CONCLUSIONS

TEM is a safe procedure. The low rates of morbidity, re-hospitalization, and postoperative complications in the first 2 days after surgery make the procedure suitable for A-OdS.

Male sex and history of ischemic heart disease are major risk factors for anastomotic leakage after laparoscopic anterior resection in patients with rectal cancer

Background

Anastomotic leakage (AL) is the most serious and common complication of surgery for rectal cancer, and associated risk factors remain unknown despite developments in laparoscopic surgery. The present study aimed to determine risk factors for AL after laparoscopic anterior resection (AR) of rectal cancer.

Methods

This retrospective cohort study extracted information from a prospective database of all consecutive colorectal resections that proceeded at Nippon Medical School Hospital between January 2011 and December 2015 (n = 865). We identified 154 patients with rectal cancer treated by elective laparoscopic AR with anastomosis using primary double-stapling. Clinical variables and comorbidity, habits, and surgery-related variables were assessed by univariate and multivariate analyses to determine preoperative risk factors for clinical AL.

Results

The overall rate of clinical AL was 11.7% (18 of 154 patients), and 5 (27.8%) of 18 patients required revised laparotomy. Data from males were analyzed because AL occurred only in males. Univariate analysis of male patients (n = 100) significantly associated preoperative creatinine values (p = 0.03) and a history of ischemic heart disease (IHD) (p = 0.012) with AL. The frequency of AL tended to increase (p = 0.06) when patients had low AR (p = 0.06) and transanal drainage. Having AL significantly prolonged hospital stays compared with patients without leakage (36.2 vs. 11.1 days; p <  0.01). Multivariate analysis identified a history of IHD (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.27–17.5; p = 0.025] as an independent risk factor for AL.

Conclusions

Male sex and a history of IHD are possible risk factors for AL after elective laparoscopic rectal cancer surgery.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Risk factors for bad outcomes in incisional hernia repair: Lessons learned from the National Registry of Incisional Hernia (EVEREG)

INTRODUCTION

Registries are powerful tools for identifying factors predicting bad results. Our objective was to analyse data from the Spanish Registry of Incisional Hernia (EVEREG) to detect risk situations for the development of complications and recurrences.

METHODS

We have analysed data of the cohort of hernias registered during the period from July 2012 to June 2014. We have compared the data between complicated and non-complicated patients in the short and long term follow-up. Data compared were: patient demographics, comorbid condition, hernia defect characteristics and surgical technique to determine which of them may be predictors of poor outcomes.

RESULTS

During the period of study, we collected data from 1,336 hernias (43.7% males; 56.3% females) with a mean age of 63.6 years (SD 12.4) and BMI of 30.4 (SD 5.4). In the multivariate analysis, factors associated with complications were: age >70 years, previous neoplasm, diameter greater than 10cm, previous repair and bowel resection. Factors related with recurrences were: parastomal hernia, previous repair, emergency repair, postoperative complications and reoperation. A separation of components was the only protective factor for this type of analysis (OR 0.438; CI 0.27-0.71; p=0.0001).

CONCLUSIONS

Risk factors for the development of complications and recurrences must be considered for promoting preoperative patient prehabilitation, planning the surgical technique and referring patients to specialized abdominal wall units.