Managing anastomotic leaks from intestinal anastomoses

Late anastomotic perforation of the ileum 3 years after intestinal resection

Late perforation of the ileum is a rare and potentially life-threatening complication following intestinal resection. We present a unique case of a woman in her 60s with a history of appendiceal carcinoid tumour, who underwent a right hemicolectomy. Positron emission tomography and surveillance CTs showed normal surgical changes and no recurrent malignancy. Three years postoperatively, she presented with severe abdominal pain. CT revealed a perforation along the ileal wall of the ileocolonic anastomosis. She underwent emergent resection and repeat ileocolonic anastomosis. We conclude that the patient had subclinical ischaemia of the anastomosis, which eventually progressed to perforation 3 years later. We discuss a literature review on late small intestinal anastomotic perforations and their associated risk factors. Our case and literature review emphasise the importance of considering delayed anastomotic leak in postoperative patients with a history of intestinal cancer, inflammatory bowel disease, Roux-en-Y enteroenterostomy or side-to-side anastomosis.

Periprocedural Changes of Serum Biomarkers in Predicting Complications Following Bariatric Surgery for Obesity: Systematic Review and Meta-analysis

Bariatric surgery is an effective treatment for severe obesity, but complications and peri-operative monitoring are important considerations. We conducted a comprehensive review of studies assessing pre-operative biomarkers and complications in patients undergoing bariatric surgery. A total of 14 studies were included. Gastric leak, infections, bleeding, obstruction or stenosis, hypoglycemia, and hypoalbuminemia were the most common complications observed. Our analysis showed a significant association between lower pre-operative albumin levels and complications (SMD [95%CI] =  - 0.21 [- 0.38; - 0.04]). However, other biomarkers did not have a significant impact on complication occurrence. Changes in C-reactive protein, neutrophil-lymphocyte ratio, and white blood cell levels were observed in certain peri-operative time points and complication subgroups. These findings suggest the potential use of pre-operative biomarkers and peri-operative changes of biomarker's levels for predicting complications.

Surgical Sealant with Integrated Shape-Morphing Dual Modality Ultrasound and Computed Tomography Sensors for Gastric Leak Detection

Postoperative anastomotic leaks are the most feared complications after gastric surgery. For diagnostics clinicians mostly rely on clinical symptoms such as fever and tachycardia, often developing as a result of an already fully developed, i.e., symptomatic, surgical leak. A gastric fluid responsive, dual modality, electronic-free, leak sensor system integrable into surgical adhesive suture support materials is introduced. Leak sensors contain high atomic number carbonates embedded in a polyacrylamide matrix, that upon exposure to gastric fluid convert into gaseous carbon dioxide (CO2 ). CO2 bubbles remain entrapped in the hydrogel matrix, leading to a distinctly increased echogenic contrast detectable by a low-cost and portable ultrasound transducer, while the dissolution of the carbonate species and the resulting diffusion of the cation produces a markedly reduced contrast in computed tomography imaging. The sensing elements can be patterned into a variety of characteristic shapes and can be combined with nonreactive tantalum oxide reference elements, allowing the design of shape-morphing sensing elements visible to the naked eye as well as artificial intelligence-assisted automated detection. In summary, shape-morphing dual modality sensors for the early and robust detection of postoperative complications at deep tissue sites, opening new routes for postoperative patient surveillance using existing hospital infrastructure is reported.

Implantation of an Impedance Sensor for Early Detection of Gastrointestinal Anastomotic Leaks

INTRODUCTION

Accurate early diagnosis of a gastrointestinal anastomotic leak remains a challenge. When an anastomotic leak develops, the electrical properties of the tissue undergoing inflammatory processes change, resulting from the extravasation of inflammatory fluid and cellular infiltration. The method described here intends to provide a novel early anastomotic leak warning system based upon measurable changes in tissue impedance nearby an acute inflammatory process.

METHODS

A biodegradable Mg-alloy was compared with a nonabsorbable stainless steel (STS) electrode connected to a wireless recording system for impedance measurement. In vitro measurements were made in physiological solutions and small animal (eight mice) and large animal (eight pigs) models with an anastomotic leak simulated by an open colotomy. Measurements were made at 10 mm intervals from the open colon at baseline and up to 120 min comparing these with a sutured colonic wound and normal tissue.

RESULTS

In-vitro biodegradable magnesium electrode impedance evaluation showed good sensitivity to different media due to its environmental corrosion properties. The impedance of an acidic environment (1.06 ± 0.02 kΩ for citric acid) was twice that of phosphate-buffered saline (PBS) (0.64 ± 0.008 kΩ) with a distinction between Normal Saline (0.42 ± 0.013 kΩ) and PBS (0.64 ± 0.008 kΩ). This was in contrast to the performance characteristics of the control STS electrodes, where impedance in an acidic environment was lower than saline or PBS (citric acid:0.76 ± 0.01 kΩ versus PBS: 1.32 ± 0.014 kΩ). In a mouse model simulating an anastomotic leak, there was a significant increase in impedance after 120 min when compared with controls (99.7% increase versus 9.6% increase, respectively; P < 0.02). This effect was confirmed in a pig model when relative impedance measurements of the leak and control groups were compared (1.86 ± 0.46 versus 1.07 ± 0.02, respectively; P < 0.027).

CONCLUSIONS

Electrophysiological measurement shows diagnostic sensitivity for a gastrointestinal leak with potential clinical utility in the postoperative detection of early intra-abdominal sepsis. Further investigation of biodegradable tissue sensors capable of monitoring an early anastomotic leak is required.

Efficacy and safety of over-the-scope clips for colorectal leaks and fistulas: a pooled analysis

The development of laparoscopic technologies and continuous improvements in intracavitary anastomosis technology have significantly reduced the incidence of anastomotic leak (AL) following colorectal surgery. However, AL incidence can significantly increase the duration of patient hospitalization, patient medical expenses, and incidence of mortality. The recently developed over-the-scope clip (OTSC) system has been of increasing clinical interest owing to its ease of use, low complication rates, and high rates of technical and clinical success. The PubMed/Medline, EMBASE, and Cochrane PubMed Library were systematically searched for all studies of OTSC system-mediated closure of ALs and fistulas published from January 2010 to January 2021. Two reviewers independently identified relevant studies based on appropriate inclusion and exclusion criteria. A total of nine studies were included in the present analysis, incorporating 114 patients of whom 107 were treated with an OTSC system. The technical success rate for these patients was 84% (95%CI, 73.5-94.5%; I² 53%), and the clinical success rate was 74.3% (95%CI, 64.4-84.1%; I² 28%) as calculated via a pooled proportion analysis. Complications occurred in two patients. The endoscopic OTSC system is a safe and effective means of treating ALs and fistulas after colorectal surgery.

Human Oral Mucosal Stem Cells Reduce Anastomotic Leak in an Animal Model of Colonic Surgery

BACKGROUND

Anastomotic leak is regarded as one of the most feared complications of bowel surgery; avoiding leaks is a major priority. Attempts to reduce or eliminate leaks have included alternate anastomotic techniques. Human oral mucosa stem cells (hOMSC) are self-renewing and expandable cells derived from buccal mucosa. Studies have shown that hOMSC can accelerate tissue regeneration and wound healing. The objective of this study was to evaluate whether hOMSC can decrease anastomotic leak rates in a murine model of colon surgery.

METHODS

Two experiments were performed. In the first study, mice underwent colonic anastomosis using five interrupted sutures. hOMSC (n = 7) or normal saline (NS; n = 17) was injected into the colon wall at the site of the anastomosis. To evaluate whether hOMSC can impact anastomotic healing, the model was stressed by repeating the first experiment, reducing the number of sutures used for the construction of the anastomosis from five to four. Either hOMSC (n = 8) or NS (n = 20) was injected at the anastomosis. All mice that survived were sacrificed on postoperative day 7. Anastomotic leak rate, mortality, daily weight, and daily wellness scores were compared.

RESULTS

In the five-suture anastomosis, there were no differences in anastomotic leak rate, mortality, or daily weight. Mice that received hOMSC had significantly higher wellness scores on postoperative day 2 (p < 0.05). In the four-suture anastomosis, there was a significant decrease in leak rate (70% [NS] vs. 25% [hOMSC], p = 0.029) and higher wellness scores in mice that received hOMSC (p < 0.05).

CONCLUSION

Our study suggests that injecting hOMSC at the colonic anastomosis can potentially reduce anastomotic leak and improve postoperative wellness in a murine model of colon surgery.

Endoscopic repair of delayed stomach perforation caused by penetrating trauma: A case report

BACKGROUND

Primary endoscopic closure of a perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are very few studies on the efficacy of endoscopic management of delayed traumatic gastric perforation. Herein, we report a novel case of a patient who was successfully treated for delayed traumatic stomach perforation using an alternative endoscopic modality.

CASE SUMMARY

A 39-year-old woman presented with multiple penetrating traumas in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suturing of the lacerated lung was performed; however, delayed free perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for the primary repair of the gastric wall, re-perforation was noted 15 d postoperatively. The high risk associated with re-surgery prompted an endoscopic intervention using 2 endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.

CONCLUSION

Endoscopic closure with endoloops and clips can be a useful therapeutic alternative to re-surgery for delayed traumatic gastric perforation.

Single-incision laparoscopic ileostomy is a safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection

Purpose

Currently, many operations are performed using the single-incision laparoscopic method. Although there have been recent reports on single-incision laparoscopic ileostomy, none have compared this method to conventional laparoscopic ileostomy. This study aimed to assess the safety and feasibility of single-incision laparoscopic ileostomy for anastomotic leakage following laparoscopic low anterior resections.

Methods

From April 2012 to April 2017, 38 patients underwent laparoscopic ileostomy (single-incision; 19 patients referred to as group A, conventional laparoscopy; 19 patients referred to as group B) for anastomotic leakage following laparoscopic low anterior resection. We analyzed surgical and clinical outcomes between the 2 groups. Patients in whom a protective ileostomy was carried out during the initial laparoscopic low anterior resection were excluded from this study.

Results

No significant differences were observed between the 2 groups in terms of patient demographics and initial operation details. Incisional surgical site infections occurred less in group A than in group B (2 of 19 vs. 9 of 19, P = 0.029). The median ileostomy operation time, amount of intraoperative bleeding, parastomal hernia ratio, hospital stay duration after ileostomy, postoperative pain score were not significantly different between the 2 groups.

Conclusion

Single-incision laparoscopic ileostomy is safe and feasible method of fecal diversion for anastomotic leakage following laparoscopic low anterior resection.

Risk Factors and Oncologic Outcomes of Anastomosis Leakage After Laparoscopic Right Colectomy

PURPOSE

We estimated the incidence of anastomosis leakage and explore possible risk factors and oncologic outcomes following laparoscopic right-side colon resection among colon cancer patients.

MATERIALS AND METHODS

We retrospectively analyzed 423 patients who were diagnosed with appendiceal, cecal, ascending, or hepatic flexure colon cancer who underwent laparoscopic colonic resection and anastomosis between September 2006 and July 2014. We compared short-term and long-term outcomes between no-leakage and leakage groups.

RESULTS

There were 16 cases of right-side anastomosis leakage in a total 423 colon cancer cases (3.78%). The risk of leakage was increased in smokers (odds ratio=6.592, P=0.007) and with a longer operating time (odds ratio=1.024, P<0.001). There were no significant differences between the groups in local recurrence (P=0.106), overall survival (P=0.055), or cancer-specific survival (P=0.235).

CONCLUSIONS

Smoking and long operating time are risk factors for right-side colon anastomosis. There were no significant differences in oncologic outcomes.

The effects of optical sensor-tissue separation in endocavitary photoplethysmography

OBJECTIVE

Intestinal anastomotic failure that occurs mainly due to ischaemia is a serious risk in colorectal cancer patients undergoing surgery. Surgeons continue to rely on subjective methods such as visual inspection to assess intestinal viability during surgery and there are no clinical tools to directly monitor viability postoperatively. A dual-wavelength reflectance optical sensor has been developed for continuous and dynamic monitoring of intestinal viability via the intestinal lumen. Maintaining direct contact between the sensor and the inner intestinal wall can be difficult in an intraluminal design, therefore impacting on signal acquisition and quality. This paper investigates the effect of direct contact versus variable distances between the sensor and the tissue surface of the buccal mucosa as a surrogate.

APPROACH

The in vivo study involved 20 healthy volunteers to measure the effect of optical sensor-tissue distances on the ability to acquire photoplethysmography signals and their quality. Signals were acquired from the buccal mucosa at five optical sensor-tissue distances.

MAIN RESULTS

Distances between 0 mm (contact) to 5 mm were the most optimal, producing signals of high quality and signal-to-noise ratio, resulting in reliable estimations of the blood oxygen saturation. Distances exceeding 5 mm compromised the acquired signals, and were of poor quality, thereby unreliably estimating the blood oxygen saturation.

SIGNIFICANCE

The developed optical sensor proved to be reliable for acquiring photoplethysmography signals for cases where distances between the optical sensor-tissue may arise during the assessment of intraluminal intestinal viability.

Development of an intraluminal intestinal photoplethysmography sensor

Intestinal ischemia is a serious medical condition and can lead to life threatening sepsis. Currently, there are no reliable techniques available for directly monitoring intestinal viability for prolonged periods of time, and intraoperatively, the majority of the surgeons still rely on subjective methods, such as visual inspection to assess viability of the intestine. The development of an intraluminal optical sensor for monitoring intestinal viability is being proposed. The sensor will continuously monitor changes in blood volume and oxygen saturation. The developed reflectance photoplethysmography/pulse oximetry sensor comprises of two emitters (red and infrared) and a photodiode. A photoplethysmography processing and data acquisition system was also utilized. The prototype sensor was evaluated in a pilot study in the buccal mucosa of 12 healthy volunteers, given the locations similarity to the intestinal mucosa and its easy accessibility. Good quality photoplethysmography signals with high signal-to-noise ratio were acquired from the buccal mucosa in all the volunteers. Preliminary blood oxygen saturation values from the intraluminal sensor were in broad agreement with the standard finger pulse oximeter probes.

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed

INTRODUCTION

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application.

METHODS

Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another.

RESULTS

All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2 months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously.

CONCLUSION

OTSC provided safe and successful closure in a number of settings.

Endoscopic management of patients with post-surgical leaks involving the gastrointestinal tract: A large case series

BACKGROUND

Post-surgical anastomotic leaks often require a re-intervention, are associated with a definite morbidity and mortality, and with relevant costs. We described a large series of patients with different post-surgical leaks involving the gastrointestinal tract managed with endoscopy as initial approach.

METHODS

This was a retrospective analysis of prospectively collected cases with anastomotic leaks managed with different endoscopic approaches (with surgical or radiological drainage when needed) in two endoscopic centres during 5 years. Interventions included: (1) over-the-scope clip (OTSC) positioning; (2) placement of a covered self-expanding metal stent (SEMS); (3) fibrin glue injection (Tissucol); and (4) endo-sponge application, according to both the endoscopic feature and patient's status.

RESULTS

A total of 76 patients underwent endoscopic treatment for a leak either in the upper (47 cases) or lower (29 cases) gastrointestinal tract, and the approach was successful in 39 (83%) and 22 (75.9%) patients, respectively, accounting for an overall 80.3% success rate. Leak closure was achieved in 84.9% and 78.3% of patients managed by using a single or a combination of endoscopic devices. Overall, leak closure failed in 15 (19.7%) patients, and the surgical approach was successful in all 14 patients who underwent re-intervention, whilst one patient died due to sepsis at 7 days.

CONCLUSIONS

Our data suggest that an endoscopic approach, with surgical or radiological drainage when needed, is successful and safe in the majority of patients with anastomotic gastrointestinal leaks. Therefore, an endoscopic treatment could be attempted before resorting to more invasive, costly and risky re-intervention.

The marker C-reactive protein is helpful in monitoring the integrity of anastomosis: plasma calprotectin

BACKGROUND

Despite improved surgical techniques and materials, anastomotic leakage is a big problem for surgeons. The most frequently used laboratory parameters is leukocyte (white blood cell) and C-reactive protein (CRP). Availability of plasma calprotectin with CRP to detect anastomotic leakage was studied.

METHODS

In this prospective study of 41 (male/female 18/23) patients in the anastomosis group, 30 (male/female 20/10) patients were included in the control group. The anastomosis groups viewed in preoperatively day and postoperatively 1st, 3rd, and 5th day of CRP, white blood cell, and plasma calprotectin values.

RESULTS

Anastomosis group with complications and without complications were studied. Statistically significant similarities between plasma calprotectin and CRP levels in the postoperative period were observed.

CONCLUSION

Plasma calprotectin in monitoring the integrity of the anastomosis can be used with a marker CRP.

Contrast medium at the site of the anastomosis is crucial in detecting anastomotic leakage with CT imaging after colorectal surgery

PURPOSE

The use of computed tomography (CT) to detect anastomotic leakage (AL) is becoming the standard of care. Accurate detection of AL is crucial. The aim of this study was to define CT criteria that are most predictive for AL.

METHODS

From January 2006 to December 2012, all consecutive patients who had undergone CT imaging because of clinical suspicion of anastomotic leakage after colorectal surgery were analysed. All CT scans were re-evaluated by two independent abdominal radiologists blinded for clinical outcome. The images were scored with a set of criteria and a conclusion whether or not AL was present was drawn. Each separate criterion was analysed for its value in predicting AL by uni- and multivariable logistic regression

RESULTS

Of 668 patients with colorectal surgery, 108 had undergone CT imaging within 16 days postoperatively. According to our standard of reference, 34 (31%) of the patients had AL. Univariable analysis showed that "fluid near anastomosis" (radiologist 1 (rad 1), p < 0.001; radiologist 2 (rad 2), p < 0.001) and "air near anastomosis" (rad 1, p < 0.001; rad 2, p < 0.001), "air intra-abdominally" (rad 1, p = 0.019; rad 2, p = 0.004) and "contrast leakage" (rad 1, p < 0.001; rad 2, p < 0.001) were associated with AL. Contrast leakage was the only independent predictor for AL in multivariable analysis for both radiologists (rad 1, OR 5.43 (95% CI 1.18-25.02); rad 2, OR 8.51 (95% CI 2.21-32.83)).

CONCLUSION

The only independent variable predicting AL is leakage of contrast medium. To improve the accuracy of CT imaging, optimal contrast administration near the anastomosis appears to be crucial.

Malpractice in colorectal surgery: a review of 122 medicolegal cases

BACKGROUND

Medical malpractice has become a rising concern for physicians, affecting the cost and delivery of health care. Colorectal procedures account for 24% of all general surgery cases, a high-risk specialty, with 15% of its physicians facing malpractice suit annually.

METHODS

The Westlaw legal database was used to identify colorectal malpractice cases.

RESULTS

In all, 122 of 230 lawsuits were included in this study. A majority of 65.6% were physician verdicts, 19.7% plaintiff verdicts, and 14.8% reached a settlement. Plaintiff payments were found to be significantly higher than settlement awards. The most common cause of alleged malpractice was failure to recognize a complication in a timely manner (45.1%), followed by damage to surrounding tissues (36.1%).

CONCLUSIONS

The most common cause of alleged malpractice was failure to recognize a complication in a timely manner, followed by damage to surrounding tissue. Plaintiff awards were significantly higher than settlement payments. It is important to understand the mechanism of malpractice allegations to better prevent litigation and improve patient care.

Tissue sealants in endoscopic applications for anastomotic leakage during a 25-year period

BACKGROUND

Anastomotic leakage after gastrointestinal operation is a complication difficult to manage because conservative therapy and/or reoperation may be unsuccessful and carry the risk of increased morbidity and mortality. The endoscopic use of tissue sealants appears to be a promising alternative to avoid operation.

METHOD

We present conclusively our 25-year experience with tissue sealing in a series of 63 patients referred after gastrointestinal anastomosis leakage; 48 of the upper and 15 of the lower gastrointestinal tract, experiencing a drainage volume ranging 50-2,400 mL.

RESULTS

Tissue glue was applied orally in 37, anally in 10, through the fistula tract in 8, and through a combination of approximation routes in another 8 cases. Biological glue (fibrin) was used in 47, cyanoacrylate in 8, and both glue types in another 8 patients. The total volume of fibrin applied was 2-36 mL, in a median of four sessions, 0.5-4 mL for cyanoacrylate, in a median of two sessions, and, whenever a combination of glues was used, a volume of 12-40 mL of fibrin plus 1-4 mL of cyanoacrylate, in a median of nine sessions. The median hospital stay after initiation of gluing was 14 days (range 8-32). The clinical and technical success rate was 96.8% (61 of 63 patients).

CONCLUSION

Tissue glue appears to be a valuable clinical tool that would prevent further operative interventions and the associated morbidity and mortality after a gastrointestinal anastomosis dehiscence. However, it must be borne in mind that repeated sessions and large volumes of sealants are necessary in many cases.

The use of TachoSil as sealant in an experimental model of colonic perforation

BACKGROUND

The suture dehiscence has traditionally represented a major surgical problem that has not fully resolved. Surgeons should perform sutures in nonoptimal conditions using different methods of sealing and/or reinforcement of suture. The aim is to assess the effectiveness of TachoSil in an experimental model of colon perforations in a simulated precarious situation.

METHODS

Forty Wistar rats of both genders (14-24 weeks old) were equally divided in 2 groups; study group was submitted to extended starvation and segmental ischemia. The surgical complications analyzed were animal death, colonic leaks, or intra-abdominal infection, either as local abscesses or diffuse peritonitis. The burst pressure was measured in millimeters of mercury. The histological analysis was performed according to Ehrlich and Hunt numerical scale modified by Phillips.

RESULTS

Only 1 animal belonging to the study group died as a consequence of the colonic ischemia. The eventual colonic leak or diffuse peritonitis was reported. Three local abscesses were observed in the study group and one in the control group, and numerous microscopic abscesses in histological analysis (12 vs. 11) were detected. The average burst pressure in the study group was 209.47 ± 50.274 versus 203 ± 51.514 mm Hg in the control group. No differences were observed in any of the variables analyzed in the histological activity.

CONCLUSION

TachoSil has proven useful as a sealant of colonic perforations in our experimental study. We therefore conclude that its use in situations of insecurity may be adequate, even in optimal conditions in which reinforcement of previous suture is not strictly required.

Abnormal vital signs are common after bowel resection and do not predict anastomotic leak

BACKGROUND

Anastomotic leak is a serious complication of gastrointestinal surgery. Abnormal vital signs are often cited in retrospective peer review and medicolegal settings as evidence of negligence in the failure to make an early diagnosis. We aimed to profile the postoperative courses of patients who undergo intestinal anastomosis and determine how reliably abnormal vital signs predict anastomotic leaks.

STUDY DESIGN

Consecutive patients undergoing bowel resection with anastomosis at an academic medical center from July 2009 through July 2011 were identified from a prospective complication database. The electronic medical record was queried for postoperative vital signs and laboratory studies, which were digitally abstracted. Abnormal values were defined as temperature >38°C, white blood cell count ≤4,000 or ≥12,000 cells/uL, systolic blood pressure ≤80 mmHg or diastolic blood pressure ≤50 mmHg, pulse ≥100 beats per minute, and respiratory rate ≥20 breaths per minute. Patients who developed an anastomotic leak were compared with those with an uncomplicated postoperative course.

RESULTS

Of the 452 patients, 141 (31.2%) suffered a total of 271 complications, including 19 anastomotic leaks. Even in "uncomplicated" recoveries, tachycardia and tachypnea were almost routine, occurring in more than half of the patients frequently throughout the postoperative period. Hypotension, fever, and leukocytosis were also remarkably common. The positive predictive value of any aberrant vital sign or white blood cell count ranged between 4% and 11%.

CONCLUSIONS

Abnormal vital signs are extremely common after bowel resection with anastomosis. Even sustained aberrant vital signs and/or leukocytosis are not necessarily suggestive of a leak or other postoperative complication.

Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery

AIM

Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage.

METHOD

A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing.

RESULTS

Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications.

CONCLUSION

Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.

Early predictors for tissue healing deficit and leakage in geriatric critically ill patients receiving emergent abdominal surgery: a case control study

BACKGROUND

As our world ages and the elderly population grows. Surgery on the aged critically ill tend to result in additional morbidity and mortality. We sought to determine early predicting factors that were associated with postoperative leakage and tissue healing deficiency after emergent abdominal surgery in geriatric critically ill patients.

MATERIAL AND METHOD

Retrospectively, geriatric critically ill patients received anticipated, single-stage emergent abdominal surgery via emergency room were enrolled. Patients who received only one definitive surgery during their hospital course were labeled as group A, patients received anticipated one-stage surgery and eventually with postoperative leakage and tissue healing deficiency were labeled as group B. The demographics and parameters were obtained for comparison.

RESULT

There were 45 patients in group A, and 34 patients in group B. The mean age is 77.4 ± 6.1 years in Group A and 76.9 ± 8.5 years in Group B, the mean APACHE score was 20.3 ± 7.5 vs. 21.6 ± 7.7. There were no significances in age, gender, comorbidities, and physiological scores. There were significances in the persistent post-operative use of vasopressors and hypoalbuminemia. The 30-day mortality rate was 0% in group A and 38.2% in group B.

CONCLUSION

Persistent post operative vasopressor use and hypoalbuminemia are associated with higher rate of morbidity and mortality after emergent abdominal surgery in geriatric critically ill patients. Early recognition is essential for proper management. Further studies are required for a better understanding in identifying risk factors.

Endoscopic repair of post-surgical gastrointestinal complications

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

Efficacy of transanal drainage for anastomotic leakage after laparoscopic low anterior resection of the rectum

INTRODUCTION

Anastomotic leakage remains a devastating complication following low anterior resection of the rectum. Our aim was to retrospectively assess the efficacy of transanal drainage.

METHODS

Twenty-five patients with anastomotic leakage after laparoscopic low anterior resection (using the double-stapling technique) were reviewed. Transanal drainage was performed when an abscess was localized within the pelvic cavity, and any leakage was detected through radiological study and digital examination. In each patient, the fistula was dilated with a forefinger, and the abscess was drained into the rectum. A suction drain tube was indwelled transanally when the abscess cavity was large or unstable. Clinical outcomes of patients after transanal drainage were then analyzed.

RESULTS

Nine of the 25 patients required an emergency operation. The remaining 16 cases with localized disease were treated conservatively as an initial treatment. This included 12 patients treated by transanal drainage, 10 of whom were successfully cured. Two eventually required a defunctioning ileostomy because of fistula formation with other organs (treatment success rate: 83.3%). The median duration of drain placement, fasting and postoperative hospitalization were 10, 10 and 45 days, respectively.

CONCLUSIONS

Transanal drainage may be a viable option for the treatment of anastomotic leakage after low anterior resection of the rectum.