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Guo MY, Liu J, Balmes P, Yanta C, Motamedi A, Phang PT. Effects of diet and antibiotics on anastomotic healing: A mouse model study with varied dietary fiber and fat, and pre-operative antibiotics. Am J Surg 2024:S0002-9610(24)00274-5. [PMID: 38777716 DOI: 10.1016/j.amjsurg.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/18/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION This study investigated the separate impacts of diet and pre-operative antibiotics on gut microbiome and colonic anastomotic healing using a mouse model. METHODS Male C57BL/6J mice were fed either low-fat-high-fibre (SD) or high-fat-low-fiber (WD) groups for 6 weeks, then further received either pre-operative antibiotics or a control sham before a colonic anastomotic procedure was performed. After 7 days, the anastomosis was assessed and microbiota composition and biodiversity were analyzed in anastomotic tissue and stool. RESULTS WD-fed mice had shorter survival (5.2 ± 2.3 vs. 6.9 ± 2.3 days, p = 0.022), increased weight loss (5.55 ± 3.80g vs. 2.65 ± 2.36g, p = 0.03), and reduced biodiversity compared to SD-fed mice. Pre-operative antibiotics improved anastomotic healing scores (1.33 ± 0.65 vs. 2.08 ± 0.79, p = 0.02) and reduced Enterococcus faecalis growth in tissue and stool (p = 0.02, p = 0.02). Improved anastomotic healing correlated with lower Enterococcus abundance (p = 0.04) and higher collagen III and IV levels (p = 0.01, 0.04) in anastomotic tissue. CONCLUSION SD promotes enhanced post-operative recovery and increased microbiome biodiversity, while pre-operative antibiotics enhance anastomotic healing by suppressing Enterococcus faecalis growth, mitigating collagen III/IV degradation.
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Affiliation(s)
- Michael Y Guo
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
| | - Jerry Liu
- Department of Surgery, Colorectal Surgery, St. Paul's Hospital, Vancouver, Canada
| | - Patricia Balmes
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Christine Yanta
- Sequencing and Bioinformatics Consortium, Department of Bioinformatics, University of British Columbia, Vancouver, Canada
| | - Ali Motamedi
- Department of Surgery, General Surgery, University of Toronto, Toronto, Canada
| | - P Terry Phang
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Department of Surgery, Colorectal Surgery, St. Paul's Hospital, Vancouver, Canada
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2
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Rennie O, Sharma M, Helwa N. Colorectal anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks. Front Surg 2024; 11:1371567. [PMID: 38756356 PMCID: PMC11097957 DOI: 10.3389/fsurg.2024.1371567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
Background Anastomotic leaks (ALs) are a significant and feared postoperative complication, with incidence of up to 30% despite advances in surgical techniques. With implications such as additional interventions, prolonged hospital stays, and hospital readmission, ALs have important impacts at the level of individual patients and healthcare providers, as well as healthcare systems as a whole. Challenges in developing unified definitions and grading systems for leaks have proved problematic, despite acknowledgement that colorectal AL is a critical issue in intestinal surgery with serious consequences. The aim of this study was to construct a narrative review of literature surrounding definitions and grading systems for ALs, and consequences of this postoperative complication. Methods A literature review was conducted by examining databases including PubMed, Web of Science, OVID Embase, Google Scholar, and Cochrane library databases. Searches were performed with the following keywords: anastomosis, anastomotic leak, colorectal, surgery, grading system, complications, risk factors, and consequences. Publications that were retrieved underwent further assessment to ensure other relevant publications were identified and included. Results A universally accepted definition and grading system for ALs continues to be lacking, leading to variability in reported incidence in the literature. Additional factors add to variability in estimates, including differences in the anastomotic site and institutional/individual differences in operative technique. Various groups have worked to publish guidelines for defining and grading AL, with the International Study Group of Rectal Cancer (ISGRC/ISREC) definition the current most recommended universal definition for colorectal AL. The burden of AL on patients, healthcare providers, and hospitals is well documented in evidence from leak consequences, such as increased morbidity and mortality, higher reoperation rates, and increased readmission rates, among others. Conclusions Colorectal AL remains a significant challenge in intestinal surgery, despite medical advancements. Understanding the progress made in defining and grading leaks, as well as the range of negative outcomes that arise from AL, is crucial in improving patient care, reduce surgical mortality, and drive further advancements in earlier detection and treatment of AL.
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Affiliation(s)
- Olivia Rennie
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Manaswi Sharma
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
| | - Nour Helwa
- Department of Clinical Affairs, FluidAI Medical (Formerly NERv Technology Inc.), Kitchener, ON, Canada
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3
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Le KDR, Martin K, Read D. The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis. ANZ J Surg 2024; 94:604-613. [PMID: 38456319 DOI: 10.1111/ans.18925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. METHODS A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. RESULTS Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. DISCUSSION This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.
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Affiliation(s)
- Khang Duy Ricky Le
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
- Department of Surgical Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Katherine Martin
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Read
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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4
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Liu J, Liu N, Xu Y, Wu M, Zhang H, Wang Y, Yan Y, Hill A, Song R, Xu Z, Park M, Wu Y, Ciatti JL, Gu J, Luan H, Zhang Y, Yang T, Ahn HY, Li S, Ray WZ, Franz CK, MacEwan MR, Huang Y, Hammill CW, Wang H, Rogers JA. Bioresorbable shape-adaptive structures for ultrasonic monitoring of deep-tissue homeostasis. Science 2024; 383:1096-1103. [PMID: 38452063 DOI: 10.1126/science.adk9880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/12/2024] [Indexed: 03/09/2024]
Abstract
Monitoring homeostasis is an essential aspect of obtaining pathophysiological insights for treating patients. Accurate, timely assessments of homeostatic dysregulation in deep tissues typically require expensive imaging techniques or invasive biopsies. We introduce a bioresorbable shape-adaptive materials structure that enables real-time monitoring of deep-tissue homeostasis using conventional ultrasound instruments. Collections of small bioresorbable metal disks distributed within thin, pH-responsive hydrogels, deployed by surgical implantation or syringe injection, allow ultrasound-based measurements of spatiotemporal changes in pH for early assessments of anastomotic leaks after gastrointestinal surgeries, and their bioresorption after a recovery period eliminates the need for surgical extraction. Demonstrations in small and large animal models illustrate capabilities in monitoring leakage from the small intestine, the stomach, and the pancreas.
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Affiliation(s)
- Jiaqi Liu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Naijia Liu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Yameng Xu
- The Institute of Materials Science and Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Mingzheng Wu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Haohui Zhang
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Yue Wang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Ying Yan
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Angela Hill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ruihao Song
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Zijie Xu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Minsu Park
- Department of Polymer Science and Engineering, Dankook University, Yongin 16890, Republic of Korea
| | - Yunyun Wu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Joanna L Ciatti
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Jianyu Gu
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Haiwen Luan
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Yamin Zhang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Tianyu Yang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Hak-Young Ahn
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Shupeng Li
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Wilson Z Ray
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Colin K Franz
- Regenerative Neurorehabilitation Laboratory, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- The Ken and Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Matthew R MacEwan
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Yonggang Huang
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Civil and Environmental Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Heling Wang
- Laboratory of Flexible Electronics Technology, Tsinghua University, Beijing 100084, China
- Institute of Flexible Electronics Technology of THU Zhejiang, Jiaxing 314000, China
| | - John A Rogers
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Mechanical Engineering, Northwestern University, Evanston, IL 60208, USA
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Simpson FH, Kulendran K, Yerkovich S, Beatty A, Flynn D, Mao D, Brooks T, Wood P, Chandrasegaram MD. Perioperative Blood Transfusions and Anastomotic Leak After Colorectal Surgery for Cancer in an Australian Hospital. J Gastrointest Cancer 2024; 55:219-226. [PMID: 37335436 PMCID: PMC11096243 DOI: 10.1007/s12029-023-00947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Peri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery. METHODS This retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not. RESULTS A total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001). CONCLUSION Perioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer.
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Affiliation(s)
- Fraser Hugh Simpson
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia.
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Krish Kulendran
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Stephanie Yerkovich
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Andrew Beatty
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - David Flynn
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Derek Mao
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Taylor Brooks
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Phoebe Wood
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
- Northside Clinical School, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Triantafyllou E, Scholer V, Calabrese D, Ribeiro-Parenti L, Msika S, Rebibo L. Is Routine Post-operative Biological Laboratory Assessment Necessary After Sleeve Gastrectomy? Obes Surg 2024; 34:707-715. [PMID: 38273145 DOI: 10.1007/s11695-024-07065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Incidence of post-operative complications after sleeve gastrectomy (SG) is low. However, the early identification of these complications remains crucial. Here, we report the impact of routine laboratory monitoring for the early diagnosis of complications after SG. MATERIAL AND METHODS From January 2018 to December 2019, all consecutive patients who underwent primary SG (n = 457) were included. This was a comparative study of patients undergoing primary SG. Patients were divided into two groups: one group with routine laboratory monitoring performed at postoperative day (POD) 1 and 3 (LAB group) and another group without routine laboratory monitoring (control group). The study's primary endpoint was the overall impact of routine laboratory monitoring. The secondary endpoints were evaluation of patients with complications. RESULTS The population in the two groups were similar in term of demographic and intra-operative data. There was a statistical difference between the two groups in term of length of stay (5.7 days in the LAB group and 3.5 days in the control group (p < 0.001)). There were 19 complications (6.0%) in the LAB group and 5 complications in the control group (3.5%) (p = 0.25). A cut-off C-reactive protein level of 46.3 mg/l was found to be significant (p = 0.006). In the LAB group, 9 patients (2.9%) required readmission vs. three patients (2.0%) in the control group (p = 0.62). CONCLUSION The interest of routine laboratory monitoring after SG seems limited. Routine laboratory monitoring alone is not associated with earlier diagnosis of complications. This routine monitoring is associated with an increase of stay in hospital.
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Affiliation(s)
- Evangelia Triantafyllou
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
| | - Vincent Scholer
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Service de Chirurgie, GHI Le Raincy-Montfermeil, 93370, Montfermeil, France
| | - Daniela Calabrese
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Lara Ribeiro-Parenti
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Simon Msika
- Service de Chirurgie Digestive, Oesogastrique Et Bariatrique, Hôpital Bichat Claude Bernard, APHP, 75018, Paris, France
- Université de Paris, Inserm UMR 1149, 75018, Paris, France
| | - Lionel Rebibo
- Université de Paris, Inserm UMR 1149, 75018, Paris, France.
- Service de Chirurgie Digestive Et Oncologique, Hôpital Européen Georges Pompidou, APHP, 75015, Paris, France.
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Montcusí B, Madrid-Gambin F, Pozo ÓJ, Marco S, Marin S, Mayol X, Pascual M, Alonso S, Salvans S, Jiménez-Toscano M, Cascante M, Pera M. Circulating metabolic markers after surgery identify patients at risk for severe postoperative complications: a prospective cohort study in colorectal cancer. Int J Surg 2024; 110:1493-1501. [PMID: 38116682 PMCID: PMC10942180 DOI: 10.1097/js9.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Early detection of postoperative complications after colorectal cancer (CRC) surgery is associated with improved outcomes. The aim was to investigate early metabolomics signatures capable to detect patients at risk for severe postoperative complications after CRC surgery. MATERIALS AND METHODS Prospective cohort study of patients undergoing CRC surgery from 2015 to 2018. Plasma samples were collected before and after surgery, and analyzed by mass spectrometry obtaining 188 metabolites and 21 ratios. Postoperative complications were registered with Clavien-Dindo Classification and Comprehensive Complication Index. RESULTS One hundred forty-six patients were included. Surgery substantially modified metabolome and metabolic changes after surgery were quantitatively associated with the severity of postoperative complications. The strongest positive relationship with both Clavien-Dindo and Comprehensive Complication Index (β=4.09 and 63.05, P <0.001) corresponded to kynurenine/tryptophan, against an inverse relationship with lysophosphatidylcholines (LPCs) and phosphatidylcholines (PCs). Patients with LPC18:2/PCa36:2 below the cut-off 0.084 µM/µM resulted in a sevenfold higher risk of major complications (OR=7.38, 95% CI: 2.82-21.25, P <0.001), while kynurenine/tryptophan above 0.067 µM/µM a ninefold (OR=9.35, 95% CI: 3.03-32.66, P <0.001). Hexadecanoylcarnitine below 0.093 µM displayed a 12-fold higher risk of anastomotic leakage-related complications (OR=11.99, 95% CI: 2.62-80.79, P =0.004). CONCLUSION Surgery-induced phospholipids and amino acid dysregulation is associated with the severity of postoperative complications after CRC surgery, including anastomotic leakage-related outcomes. The authors provide quantitative insight on metabolic markers, measuring vulnerability to postoperative morbidity that might help guide early decision-making and improve surgical outcomes.
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Affiliation(s)
- Blanca Montcusí
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
- Applied Metabolomics Research Group, Hospital del Mar Medical Research Institute (IMIM)
- Department of Surgery, Faculty of Medicine, Universitat de Barcelona (UB)
| | - Francisco Madrid-Gambin
- Applied Metabolomics Research Group, Hospital del Mar Medical Research Institute (IMIM)
- Signal and Information Processing for Sensing Systems, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology
| | - Óscar J Pozo
- Applied Metabolomics Research Group, Hospital del Mar Medical Research Institute (IMIM)
| | - Santiago Marco
- Signal and Information Processing for Sensing Systems, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology
- Department of Electronics and Biomedical Engineering, Faculty of Physics
| | - Silvia Marin
- Department of Biochemistry and Molecular Biomedicine, Faculty of Biology
- Institute of Biomedicine, Universitat de Barcelona (UB)
- CIBER of Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Xavier Mayol
- Colorectal Neoplasms Clinical and Translational Research Group
| | - Marta Pascual
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
| | - Sandra Alonso
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
| | - Silvia Salvans
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
| | - Marta Jiménez-Toscano
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
| | - Marta Cascante
- Department of Biochemistry and Molecular Biomedicine, Faculty of Biology
- Institute of Biomedicine, Universitat de Barcelona (UB)
- CIBER of Hepatic and Digestive Diseases (CIBEREHD), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Miguel Pera
- Department of Surgery, Section of Colon and Rectal Surgery, Hospital del Mar
- Colorectal Neoplasms Clinical and Translational Research Group
- Department of Surgery, Faculty of Medicine, Universitat de Barcelona (UB)
- Department of General and Digestive Surgery, Institut of Digestive and Metabolic Diseases, Hospital Clínic, Barcelona
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8
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Zhao Y, Zhang JY, Ullah S, Zheng QF, Liu D, Wang M, Zhao LX, Shi M, Li DL, Liu BR. Massive continuous irrigation (MCI) and endoscopic debridement as an alternative treatment strategy for refractory abscess-fistula complexes. J Dig Dis 2024; 25:133-139. [PMID: 38511408 DOI: 10.1111/1751-2980.13257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE To evaluate the feasibility, safety, and efficacy of massive continuous irrigation (MCI) and endoscopic debridement for the treatment of refractory abscess-fistula complexes. METHODS This was a retrospective single-center observational study involving 12 patients with refractory abscess-fistula complexes. All patients had experienced long-term treatment failure or had failed multiple treatment modalities. We used over two catheters and inserted them via the gastrointestinal (GI) tract or percutaneously to form a circulation pathway to achieve MCI of normal saline, endoscopic debridement was then performed. The treatment success rate, irrigation volume and treatment duration, time to abscess-fistula complex closure, intra-treatment complications, and recurrence rate were recorded. RESULTS The treatment success rates were 100%. The median time of previous treatment was 32 days (range 7-912 days). The mean time from the use of the novel treatment strategy to abscess-fistula complex healing was 18.8 ± 11.0 days. The mean volume of irrigation was 10 804 ± 1669 mL/24 h. The mean irrigation time was 16.5 ± 9.2 days, and a median of two irrigation tubes (range 2-5) were used. No complications occurred either during or after the procedure. During the follow-up of 23.1 ± 18.1 months, no recurrence or adverse events were noted. CONCLUSIONS MCI and endoscopic debridement may be a feasible, safe, and effective alternative treatment for refractory abscess-fistula complexes. Large prospective studies are needed to validate our results.
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Affiliation(s)
- Yue Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Ji Yu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Qing Fen Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Dan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Meng Wang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Li Xia Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Miao Shi
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - De Liang Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Bing Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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Steyer GE, Puchinger M, Pfeifer J. Successful Clinical Avoidance of Colorectal Anastomotic Leakage through Local Decontamination. Antibiotics (Basel) 2024; 13:79. [PMID: 38247638 PMCID: PMC10812415 DOI: 10.3390/antibiotics13010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
AIM An anastomotic leak is an unpredictable postoperative complication during recovery from colorectal surgery that may require a re-operation. Potentially pathogenic bacteria like Pseudomonas (and Enterococcus) contribute to the pathogenesis of an anastomotic leak through their capacity to degrade collagen and to activate tissue matrix metalloprotease-9 in host intestinal tissues. The microbiome, therefore, is the key to preventing an anastomotic leak after colorectal surgery. The aim of this trial was to investigate whether perioperative selective decontamination with a new mixture of locally acting antibiotics specially designed against Pseudomonas aeruginosa and Enterococcus faecalis can reduce or even stop early symptomatic leakage. METHOD All hospitalized patients in our University Clinic undergoing colorectal surgery with a left-sided anastomosis were included as two groups; patients in the intervention group received polymyxin B, gentamicin and vancomycin every six hours for five postoperative days and those in the control group did not receive such an intervention. An anastomotic leak was defined as a clinically obvious defect of the intestinal wall integrity at the colorectal anastomosis site (including suture) that leads to a communication between the intra- and extraluminal compartments, requiring a re-do surgery within seven postoperative days. RESULTS Between February 2017 and May 2023, a total of 301 patients (median age of 63 years) were analyzed. An anastomotic leak was observed in 11 patients in the control group (n = 152), but in no patients in the intervention group (n = 149); this difference was highly significant. CONCLUSION The antibiotic mixture (with polymyxin B, gentamicin and vancomycin) used for local decontamination in our study stopped the occurrence of anastomotic leaks completely. According to the definition of anastomotic leak, no further surgery was required after local perioperative decontamination.
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Affiliation(s)
- Gerhard Ernst Steyer
- Division of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria;
- Doctoral School of Lifestyle-Related Diseases, Medical University of Graz, Neue Stiftingtalstraße 6, 8010 Graz, Austria
| | - Markus Puchinger
- Medical Engineering and Computing, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria;
| | - Johann Pfeifer
- Division of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria;
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10
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Edmondson J, Hunter J, Bakis G, O’Connor A, Wood S, Qureshi AP. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. J Clin Med 2023; 12:7622. [PMID: 38137691 PMCID: PMC10743498 DOI: 10.3390/jcm12247622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks.
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Affiliation(s)
| | | | | | | | | | - Alia P. Qureshi
- Division of General Surgery, Oregon Health & Science University, Machall 3186, Portland, OR 97239, USA; (J.E.)
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11
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Alanazi KO, Alshammari FA, Alanazi AS, Alrashidi MO, Alrashidi AO, Aldhafeeri YA, Alanazi TH, Alkahtani AS, Alrakhimi AS, Albathali HA. Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e50370. [PMID: 38222119 PMCID: PMC10784652 DOI: 10.7759/cureus.50370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 01/16/2024] Open
Abstract
Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.
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Affiliation(s)
- Khalid O Alanazi
- Department of General Surgery, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Ali Obaid Alrashidi
- Department of Family Medicine, Al-Shifa Primary Health Care Centre, Hafar al-Batin, SAU
| | - Yousif A Aldhafeeri
- Department of Internal Medicine, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Hamdan A Albathali
- Department of Family Medicine, Al-Nozha Primary Health Care Centre, Hafar al-Batin, SAU
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12
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Shin HH, Ryu JH. Bio-Inspired Self-Healing, Shear-Thinning, and Adhesive Gallic Acid-Conjugated Chitosan/Carbon Black Composite Hydrogels as Suture Support Materials. Biomimetics (Basel) 2023; 8:542. [PMID: 37999183 PMCID: PMC10669539 DOI: 10.3390/biomimetics8070542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
The occurrence of leakage from anastomotic sites is a significant issue given its potential undesirable complications. The management of anastomotic leakage after gastrointestinal surgery is particularly crucial because it is directly associated with mortality and morbidity in patients. If adhesive materials could be used to support suturing in surgical procedures, many complications caused by leakage from the anastomosis sites could be prevented. In this study, we have developed self-healing, shear-thinning, tissue-adhesive, carbon-black-containing, gallic acid-conjugated chitosan (CB/Chi-gallol) hydrogels as sealing materials to be used with suturing. The addition of CB into Chi-gallol solution resulted in the formation of a crosslinked hydrogel with instantaneous solidification. In addition, these CB/Chi-gallol hydrogels showed enhancement of the elastic modulus (G') values with increased CB concentration. Furthermore, these hydrogels exhibited excellent self-healing, shear-thinning, and tissue-adhesive properties. Notably, the hydrogels successfully sealed the incision site with suturing, resulting in a significant increase in the bursting pressure. The proposed self-healing and adhesive hydrogels are potentially useful in versatile biomedical applications, particularly as suture support materials for surgical procedures.
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Affiliation(s)
- Hyun Ho Shin
- Department of Chemical Engineering, Wonkwang University, Iksan 54538, Jeonbuk, Republic of Korea;
| | - Ji Hyun Ryu
- Department of Chemical Engineering, Wonkwang University, Iksan 54538, Jeonbuk, Republic of Korea;
- Department of Carbon Convergence Engineering, Wonkwang University, Iksan 54538, Jeonbuk, Republic of Korea
- Smart Convergence Materials Analysis Center, Wonkwang University, Iksan 54538, Jeonbuk, Republic of Korea
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13
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Wang T, Sadowsky M, Blakney R, Coplan P, Petraiuolo W, Soberman M, Tomaszewski J, Rene L, Wood J. Risk of anastomotic leakage with two-row versus three-row manual circular staplers in colorectal anastomosis: a U.S. cohort study. Int J Colorectal Dis 2023; 38:264. [PMID: 37932486 PMCID: PMC10627892 DOI: 10.1007/s00384-023-04552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/08/2023]
Abstract
PURPOSES To compare the risk of anastomotic leak (AL) between Ethicon manual circular staplers (two-row) versus Medtronic EEA™ circular stapler with Tri-Staple™ technology (three-row) and between Medtronic EEA™ circular stapler with DST™ Series technology (two-row) versus Tri-Staple™ technology. METHODS A retrospective cohort study was conducted in adult patients who underwent a left-sided colorectal surgery 2019-2022 in U.S. Premier Healthcare Database to assess the risk of AL within 30 days post-index procedure. The study devices were Ethicon manual circular staplers, Medtronic EEA™ circular stapler with DST™ technology, and Medtronic EEA™ circular stapler with Tri-Staple™ technology. RESULTS Across 447 hospitals, the cumulative incidences (95% confidence intervals [CI]) of AL within 30 days post-index procedure were 7.78% (6.91-8.74%) among 8337 patients in the Ethicon manual circular stapler cohort, 7.54% (6.87-8.27%) among 7928 patients in the Medtronic EEA™ circular stapler with DST™ technology cohort, and 8.19% (6.57-10.07%) among 1306 patients in the Medtronic EEA™ circular stapler with Tri-Staple™ technology cohort. Comparative analyses revealed no difference comparing Ethicon manual circular staplers with Medtronic EEA™ circular staplers with Tri-Staple™ technology (risk ratio [RR], 0.72; 95% CI, 0.52-1.01) or comparing Medtronic EEA™ circular staplers with DST™ technology to Tri-Staple™ technology (RR, 0.75; 95% CI, 0.53-1.06). CONCLUSION In this analysis of a large cohort of patients undergoing a left-sided colorectal surgery from a U.S. hospital database, the risk of AL observed with manual two-row circular staplers was similar to that seen with three-row devices. This study affirms the safety of manual two-row circular staplers in colorectal anastomosis.
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Affiliation(s)
- Tongtong Wang
- Epidemiology & Real-World Data Sciences, MedTech, Johnson & Johnson, New Brunswick, NJ, USA.
| | | | - Rebekah Blakney
- Epidemiology & Real-World Data Sciences, MedTech, Johnson & Johnson, New Brunswick, NJ, USA
| | - Paul Coplan
- Epidemiology & Real-World Data Sciences, MedTech, Johnson & Johnson, New Brunswick, NJ, USA
| | | | - Mark Soberman
- Medical Safety, MedTech, Johnson & Johnson, New Brunswick, NJ, USA
| | | | - Lexi Rene
- Epidemiology & Real-World Data Sciences, MedTech, Johnson & Johnson, New Brunswick, NJ, USA
| | - Jennifer Wood
- Epidemiology & Real-World Data Sciences, MedTech, Johnson & Johnson, New Brunswick, NJ, USA
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14
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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15
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Okafor DK, Katyal G, Kaur G, Ashraf H, Bodapati AP, Hanif A, Khan S. Single-Layer or Double-Layer Intestinal Anastomosis: A Systematic Review of Randomized Controlled Trials. Cureus 2023; 15:e46697. [PMID: 38021792 PMCID: PMC10631554 DOI: 10.7759/cureus.46697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Several malignant and benign indications may necessitate bowel resection. Despite the emergence of newer techniques, the hand-sewn technique remains popular for the reestablishment of intestinal continuity after resection. This method can achieve anastomosis in one or two layers. Some studies have suggested that the single-layer technique has several potential benefits compared to its rivals while simultaneously maintaining a comparable efficacy and safety profile. Previous reviews have failed to recommend either of these methods over the other due to a lack of high-quality evidence. This review aims to establish which technique provides the best outcomes by reviewing recent relevant trials and comparing both methods. We conducted a systematic review of randomized controlled trials (RCTs) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. A database search of PubMed, Google Scholar, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) ultimately returned nine randomized trials published between 2003 and 2023 comparing single-layer intestinal anastomosis (SLIA) and double-layer intestinal anastomosis (DLIA) that fit the inclusion criteria. Overall, results show a dearth of robust trials, and the included studies displayed variable eligibility criteria and materials used for anastomosis. The available evidence, however, does suggest that neither technique is inferior in terms of preventing post-operative complications, but SLIA is less expensive and quicker to perform. The evidence is, however, limited, and further high-quality research is needed.
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Affiliation(s)
- Donatus K Okafor
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Gitika Katyal
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Gursharan Kaur
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Hafsa Ashraf
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Adi Prasad Bodapati
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ayesha Hanif
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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16
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Skovsen AP, Burcharth J, Gögenur I, Tolstrup MB. Small bowel anastomosis in peritonitis compared to enterostomy formation: a systematic review. Eur J Trauma Emerg Surg 2023; 49:2047-2055. [PMID: 36526812 DOI: 10.1007/s00068-022-02192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Anastomotic leakage after small bowel resection in emergency laparotomy is a severe complication. A consensus on the risk factors for anastomotic leakage has not been established, and it is still unclear if peritonitis is a risk factor. This systematic review aimed to evaluate if an entero-entero/entero-colonic anastomosis is safe in patients with peritonitis undergoing abdominal acute care surgery. METHODS A systematic literature review based on PRISMA guidelines was performed, searching the databases Pubmed/MEDLINE, Cochrane Library, and Science Direct for studies of anastomosis in peritonitis. Patients with an anastomosis after non-planned small bowel resection (ischemia, perforation, or strangulation), including secondary peritonitis, were included. Elective laparotomies and colo-colonic anastomoses were excluded. Due to the etiology, traumatic perforation, in-vitro, and animal studies were excluded. RESULTS This review identified 26 studies of small-bowel anastomosis in peritonitis with a total of 2807 patients. This population included a total of 889 small-bowel/right colonic resections with anastomoses, and 242 enterostomies. All studies, except two, were retrospective reviews or case series. The overall mortality rates were 0-20% and anastomotic leakage rates 0-36%. After performing a risk of bias evaluation there was no basis for conducting a meta-analysis. The quality of evidence was rated as low. CONCLUSION There was no evidence to refute performing a primary small-bowel anastomosis in acute laparotomy with peritonitis. There is currently insufficient evidence to label peritonitis as a risk factor for anastomotic leakage in acute care laparotomy with small-bowel resection. TRIAL REGISTRATION The review was registered with the PROSPERO register of systematic reviews on 14/07/2020 with the ID: CRD42020168670.
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Affiliation(s)
- Anders Peter Skovsen
- Surgical Department, Hillerød Hospital, University of Copenhagen, Hillerød, Denmark.
| | - Jakob Burcharth
- Surgical Department, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Ismail Gögenur
- Surgical Department, Zealand University Hospital, University of Copenhagen, Køge, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Mai-Britt Tolstrup
- Surgical Department, Hillerød Hospital, University of Copenhagen, Hillerød, Denmark
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17
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Scepanovic M, Randjelovic T, Karamarkovic A, Cuk V, Stanojevic G, Kovacevic B. C‐reactive protein as an early predictor of anastomotic dehiscence in various types of reconstruction in elective abdominal surgery. SURGICAL PRACTICE 2023. [DOI: 10.1111/1744-1633.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/25/2023] [Indexed: 10/20/2023]
Abstract
AbstractObjectiveThe most important factor in abdominal surgery is the successful healing of the intestinal anastomosis performed. This study aims to evaluate the role of C‐reactive protein (CRP) in predicting anastomotic dehiscence in the first week following surgery.MethodsThe study included 100 patients surgically treated over a period of 1 year. Postoperative (p/o) values of CRP, leukocyte (white blood cells [WBCs]) and body temperature (BT) were measured in relation to the development of p/o complications.ResultsCRP p/o values were significantly higher in patients with complications and proved helpful in predicting p/o complications, while WBC and BT were not. For the development of anastomotic leakage, receiver operating characteristic curve shows the earliest diagnostic accuracy on the third p/o day with the cut‐off value of 115.1 mg/L; however, the largest area under the curve was on the fifth p/o day with a cut‐off value of 59.2 mg/L, a sensitivity of 89%, a specificity of 61%, a positive predictive value (PPV) of 21.9 and a negative predictive value (NPV) of 100.ConclusionsMeasurement of p/o CRP values may indicate problematic healing of digestive tract anastomosis before the appearance of clinical signs. High sensitivity and high NPV allow us to rule out p/o complications and anastomotic dehiscence with great certainty and safely discharge these patients from the hospital.
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Affiliation(s)
- Milena Scepanovic
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
- Proktomed Surgery Office Belgrade Serbia
| | | | | | - Vladimir Cuk
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
| | | | - Bojan Kovacevic
- University Clinical Center “Zvezdara” Clinic for Surgery Belgrade Serbia
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18
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Maeda Y, Iwatsuki M, Mitsuura C, Morito A, Ohuchi M, Kosumi K, Eto K, Ogawa K, Baba Y, Iwagami S, Miyamoto Y, Yoshida N, Baba H. Textbook outcome contributes to long-term prognosis in elderly colorectal cancer patients. Langenbecks Arch Surg 2023; 408:245. [PMID: 37354316 DOI: 10.1007/s00423-023-02992-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/16/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Textbook outcome (TO) has been used to define achievement of multiple "ideal" or "optimal" surgical and postoperative quality measures from the patient's perspective. However, TO has not been reported for their impact on survival in elderly, including CRC surgery. This study determined whether TO is associated with long-term outcomes after curative colorectomy in patients with colorectal cancer (CRC). METHODS Patient who underwent curative surgery over 75 years old for CRC between March 2005 and December 2016. TO included five separate parameters: surgery within 6 weeks, radical resection, Lymph node (LN) yield ≥ 12, no stoma, and no adverse outcome. When all 5 short-term quality of care parameters were realized, TO was achieved (TO). If any one of the 5 parameters was not met, the treatment was not considered TO (nTO). RESULTS TO was realized in 80 patients (43.0%). Differences in surgical-related characteristics and pathological characteristics according to TO had no statistically significant differences in baseline characteristics, except for Lymph node dissection. The Kaplan-Meier curves for OS and RFS association between TO and nTO had significantly poor 5-year OS and 5-year RFS compared with the TO groups (OS, 77.8% vs. 60.8%, P < 0.01; RFS, 69.6% vs. 50.8%, P = 0.01). In the multivariate analysis, nTO was an independent predictive factor for worse OS (HR, 2.04; 95% confidence interval (CI), 1.175-3.557; P = 0.01) and RFS (HR, 1.72; 95% CI, 1.043-2.842; P = 0.03). CONCLUSIONS TO can be a useful predictor for postoperative morbidity and prognosis after curative colorectomy for CRC.
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Affiliation(s)
- Yuto Maeda
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan.
| | - Chisho Mitsuura
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Atsushi Morito
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Mayuko Ohuchi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Keisuke Kosumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Katsuhiro Ogawa
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
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19
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Jeong SH, Lee JK, Seo KW, Min JS. Treatment and Prevention of Postoperative Leakage after Gastrectomy for Gastric Cancer. J Clin Med 2023; 12:3880. [PMID: 37373575 DOI: 10.3390/jcm12123880] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Anastomotic leakage is one of the common causes of serious morbidity and death after gastrectomy. The use of surgical treatment for leakage decreased due to the development of nonsurgical management. However, if nonsurgical management fails to control the spread of intra-abdominal infection, emergency surgical treatment is required. The authors wished to determine in which cases surgical treatment is needed for postoperative leakage and to identify treatment and prevention strategies. If a patient's vital signs are stable, local abscesses can be cured by conservative treatment after percutaneous drain insertion; if there is no improvement in anastomotic leakage, endoscopic treatment such as clipping, vacuum, and stent placement can be performed. If a patient's vital signs are unstable or patient shows diffuse peritonitis, surgical treatment should be performed. A surgical plan can be established according to leakage location. The duodenal stump may first require conservative treatment. It is recommended that surgical treatment be attempted first for anastomotic leakage of gastrojejunostomy site and gastric stump in remnant stomach. In conclusion, the need for surgical treatment is determined depending on vital signs and presence of diffuse peritonitis. During surgical treatment, a strategic approach is required according to the patient's condition and the anatomical location of leakage.
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Affiliation(s)
- Sang-Ho Jeong
- Department of Surgery, Gyeongsang National University School of Medicine & Gyoengsang National University Changwon Hospital, Changwon 51471, Republic of Korea
| | - Jin-Kwon Lee
- Department of Surgery, Gyeongsang National University School of Medicine & Gyoengsang National University Changwon Hospital, Changwon 51471, Republic of Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University Gospel Hospital, Busan 49267, Republic of Korea
| | - Jae-Seok Min
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Cancer Center, Busan 46033, Republic of Korea
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20
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Tonini V, Zanni M. Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery. World J Gastrointest Surg 2023; 15:745-756. [PMID: 37342854 PMCID: PMC10277951 DOI: 10.4240/wjgs.v15.i5.745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/21/2023] [Accepted: 04/12/2023] [Indexed: 05/26/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.
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Affiliation(s)
- Valeria Tonini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Bologna, Italy
| | - Manuel Zanni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Bologna, Italy
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21
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Salvador-Rosés H, Escartín A, Muriel P, Santamaría M, González M, Jara J, Vela F, Olsina JJ. Robotic versus open approach in total gastrectomy for gastric cancer: a comparative single-center study of perioperative outcomes. J Robot Surg 2023:10.1007/s11701-023-01591-1. [PMID: 37004708 DOI: 10.1007/s11701-023-01591-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/26/2023] [Indexed: 04/04/2023]
Abstract
The robotic approach to gastric cancer has been gaining interest in recent years; however, its benefit over the open procedure in total gastrectomy with D2 lymphadenectomy is still controversial. The aims of the study were to compare postoperative morbidity and mortality, hospital stay, and anatomopathological findings between the robotic and open approaches to oncologic total gastrectomy. We analyzed a prospectively collected database, which included patients who underwent total gastrectomy with D2 lymphadenectomy in our center using a robotic or an open approach between 2014 and 2021. Comparative analysis of clinicopathological, intraoperative, postoperative and anatomopathological variables between the robot-assisted group and the open group was performed. Thirty patients underwent total gastrectomy with D2 lymphadenectomy by a robotic approach and 48 patients by an open procedure. Both groups were comparable. The robot-assisted group presented a lower rate of Clavien-Dindo complications ≥ stage II (20 vs. 48%, p = 0.048), a shorter hospital stay (7 days vs. 9 days, p = 0.003) and had a higher total number of lymph nodes resected (22 nodes vs. 15 nodes, p = 0.001) compared to the open approach. Operative time was longer in the robotic group (325 min vs. 195 min, p < 0.001) compared to the open group. The robotic approach is associated with a longer surgical time, a lower rate of Clavien-Dindo complications ≥ stage II and a shorter hospital stay, and more lymph nodes were resected compared to the open approach.
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Affiliation(s)
- Helena Salvador-Rosés
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain.
| | - Alfredo Escartín
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Pablo Muriel
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Maite Santamaría
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Marta González
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Jimy Jara
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Fulthon Vela
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
| | - Jorge-Juan Olsina
- General Surgery Department, IRBLleida-University Hospital Arnau de Vilanova, Avda Alcalde Rovira Roure 80, 25198, Lérida, Spain
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22
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Koneru S, Reece MM, Goonawardhana D, Chapuis PH, Naidu K, Ng KS, Rickard MJFX. Right hemicolectomy anastomotic leak study: a review of right hemicolectomy in the binational clinical outcomes registry (BCOR). ANZ J Surg 2023. [PMID: 36825639 DOI: 10.1111/ans.18337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/07/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUNDS Surgery remains mainstay management for colon cancer. Post-operative anastomotic leak (AL) carries significant morbidity and mortality. Rates of, and risk factors associated with AL following right hemicolectomy remain poorly documented across Australia and New Zealand. This study examines the Bowel Cancer Outcomes Registry (BCOR) to address this. METHODS A retrospective cohort study was undertaken of consecutive BCOR-registered right hemicolectomy patients undergoing resection for colon cancer (2007-2021). The primary outcome measure was AL incidence. Clinicopathological data were extracted from the BCOR. Factors associated with AL and primary anastomosis were identified using logistic regression. AL-rate trends were assessed by linear regression. RESULTS Of 13 512 patients who had a right hemicolectomy (45.2% male, mean age 72.5 years, SD 12.1), 258 (2.0%) had an AL. On multivariate analysis, male sex (OR 1.33; 95% CI 1.03-1.71) and emergency surgery (OR 1.41; 95% CI 1.04-1.92) were associated with AL. Private health insurance status (OR 0.66; 95% CI 0.50-0.88) and minimally-invasive surgery (OR 0.61; 95% CI 0.47-0.79) were protective for AL. Anastomotic technique (handsewn versus stapled) was not associated with AL (P = 0.84). Patients with higher ASA status (OR 0.47; 95% CI 0.39-0.58), advanced tumour stage (OR 0.56; 95% CI 0.50-0.63), and emergency surgery (OR 0.16; 95% CI 0.13-0.20) were less likely to have a primary anastomosis. AL-rate and year of surgery showed no association (P = 0.521). CONCLUSION The AL rate in Australia and New Zealand following right hemicolectomy is consistent with the published literature and was stable throughout the study period. Sex, emergency surgery, insurance status, and minimally invasive surgery are associated with AL incidence.
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Affiliation(s)
- Sireesha Koneru
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mifanwy M Reece
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dulani Goonawardhana
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Pierre H Chapuis
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Krishanth Naidu
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Matthew J F X Rickard
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Division of Colorectal Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
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23
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Caballero-Herrero MJ, Jumilla E, Buitrago-Ruiz M, Valero-Navarro G, Cuevas S. Role of Damage-Associated Molecular Patterns (DAMPS) in the Postoperative Period after Colorectal Surgery. Int J Mol Sci 2023; 24:ijms24043862. [PMID: 36835273 PMCID: PMC9958549 DOI: 10.3390/ijms24043862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
Anastomotic leakage (AL) is a defect of the intestinal wall at the anastomotic site and is one of the most severe complications in colorectal surgery. Previous studies have shown that the immune system response plays a significant role in the development of AL. In recent years, DAMPs (damage-associated molecular patterns) have been identified as cellular compounds with the ability to activate the immune system. The NLRP3 inflammasome plays an important role in the inflammatory responses which are mediated by DAMPs such as ATP, HSP proteins or uric acid crystals, when found in extracellular environments. Recent publications suggest that systemic concentration of DAMPs in patients with colorectal surgery may determine the inflammatory process and have a role in the occurrence of AL and other post-surgery complications. This review provides valuable knowledge about the current evidence supporting this hypothesis and highlights the possible role of these compounds in postoperative processes, which could open a new path to explore new strategies to prevent possible post-surgical complications.
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Affiliation(s)
- María José Caballero-Herrero
- Molecular Inflammation Group, Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), 30120 Murcia, Spain
| | - Esther Jumilla
- Molecular Inflammation Group, Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), 30120 Murcia, Spain
| | - Manuel Buitrago-Ruiz
- General and Digestive System Surgery, Morales Meseguer University Hospital, 30008 Murcia, Spain
| | - Graciela Valero-Navarro
- General and Digestive System Surgery, Morales Meseguer University Hospital, 30008 Murcia, Spain
- Surgical Research in Health Area, Institute of Biosanitary Research Pascual Parrilla (IMIB), Department of Surgery, Pediatrics, Obstetrics and Gynecology, University of Murcia, 30100 Murcia, Spain
- Correspondence: (G.V.-N.); (S.C.); Tel.: +34-968360900 (ext. 2358) (G.V.-N.); +34-868885039 (S.C.)
| | - Santiago Cuevas
- Molecular Inflammation Group, Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), 30120 Murcia, Spain
- Correspondence: (G.V.-N.); (S.C.); Tel.: +34-968360900 (ext. 2358) (G.V.-N.); +34-868885039 (S.C.)
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24
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El-Sourani N, Miftode S, Troja A, Alfarawan F, Bockhorn M. Changes in diagnosis and management of anastomotic leakage after esophagectomy for underlying malignancy reduce postoperative mortality and improve patient outcome. Eur Surg 2023. [DOI: 10.1007/s10353-022-00790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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25
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Deng S, Liu K, Gu J, Cao Y, Mao F, Xue Y, Jiang Z, Qin L, Wu K, Cai K. Endoscopic fully covered self-expandable metal stent and vacuum-assisted drainage to treat postoperative colorectal cancer anastomotic stenosis with fistula. Surg Endosc 2023; 37:3780-3788. [PMID: 36690896 PMCID: PMC10156781 DOI: 10.1007/s00464-022-09831-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Digestive tract reconstruction is required after the surgical resection of a colorectal malignant tumor. Some patients may have concomitant anastomotic complications, such as anastomotic stenosis with fistula (ASF), postoperatively. Therefore, we evaluated the efficacy and safety of endoscopic fully covered self-expandable metal stent and homemade vacuum sponge-assisted drainage (FSEM-HVSD) for the treatment of ASF following the radical resection of colorectal cancer. METHODS Patients treated with FESM-HVSD were prospectively analyzed and followed up for ASF following colorectal cancer treatment in our medical center from 2017 to 2021 for the observation and evaluation of its safety and efficacy. RESULTS Fifteen patients with a mean age of 55.80 ± 11.08 years were included. Nine patients (60%) underwent protective ileostomy. All 15 patients were treated with endoscopic FSEM-HVSD. The median time from the index operation to the initiation of FSEM-HVSD was 80 ± 20.34 days in patients who underwent protective ileostomy versus 11.4 ± 4.4 days in those who did not. The average number of endoscopic treatments per patient was 5.70 ± 1.25 times. The mean length of hospital stay was 27.60 ± 4.43 days. FSEM-HVSD treatment was successful in 13 patients, and no patients had any complications. The follow-up time was 1 year. Twelve of 15 (80%) patients achieved prolonged clinical success after FSEM-HVSD treatment, 1 experienced anastomotic tumor recurrence and underwent surgery again, and 1 patient required balloon dilation for anastomotic stenosis recurrence. CONCLUSIONS FSEM-HVSD is an effective, safe, and minimally invasive treatment for ASF following colorectal cancer treatment. This technique could be the preferred treatment strategy for patients with ASF.
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Affiliation(s)
- Shenghe Deng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Ke Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Junnan Gu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Fuwei Mao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yifan Xue
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Zhenxing Jiang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Le Qin
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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26
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Xu K, Wu X, Zhang X, Xing M. Bridging wounds: tissue adhesives' essential mechanisms, synthesis and characterization, bioinspired adhesives and future perspectives. BURNS & TRAUMA 2022; 10:tkac033. [PMID: 36225327 PMCID: PMC9548443 DOI: 10.1093/burnst/tkac033] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/29/2022] [Indexed: 11/05/2022]
Abstract
Bioadhesives act as a bridge in wound closure by forming an effective interface to protect against liquid and gas leakage and aid the stoppage of bleeding. To their credit, tissue adhesives have made an indelible impact on almost all wound-related surgeries. Their unique properties include minimal damage to tissues, low chance of infection, ease of use and short wound-closure time. In contrast, classic closures, like suturing and stapling, exhibit potential additional complications with long operation times and undesirable inflammatory responses. Although tremendous progress has been made in the development of tissue adhesives, they are not yet ideal. Therefore, highlighting and summarizing existing adhesive designs and synthesis, and comparing the different products will contribute to future development. This review first provides a summary of current commercial traditional tissue adhesives. Then, based on adhesion interaction mechanisms, the tissue adhesives are categorized into three main types: adhesive patches that bind molecularly with tissue, tissue-stitching adhesives based on pre-polymer or precursor solutions, and bioinspired or biomimetic tissue adhesives. Their specific adhesion mechanisms, properties and related applications are discussed. The adhesion mechanisms of commercial traditional adhesives as well as their limitations and shortcomings are also reviewed. Finally, we also discuss the future perspectives of tissue adhesives.
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Affiliation(s)
- Kaige Xu
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada
| | - Xiaozhuo Wu
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada
| | - Xingying Zhang
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada
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27
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Lazarus E, Jesudason MR, Varghese G, Raghunath R, Mittal R, Prakash JAJ. Association of a Single Post-Operative Day Three C-Reactive Protein Value with Anastomotic Complications after Colorectal Surgery: A Prospective Observational Study. Surg Infect (Larchmt) 2022; 23:576-582. [PMID: 35867007 DOI: 10.1089/sur.2022.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Early detection and treatment of a colorectal anastomotic leak reduces leak-associated morbidity. The primary objective of this study was to assess the role of C-reactive protein (CRP) as a tool to facilitate the early diagnosis of large bowel anastomotic leak. Patients and Methods: We conducted a prospective observational study at a specialized colorectal unit of a tertiary referral teaching center where we recorded CRP levels pre-operatively and on day three for 113 patients undergoing a large bowel anastomosis. The primary outcome measure was the occurrence of anastomotic leak and its association with post-operative day three CRP levels (day one considered as 24 hours after surgery). The area under the curve of the receiver operating characteristic (ROC) curve analysis for the day three CRP value with the anastomotic leak was calculated and optimal cutoffs derived. Definitions and diagnostic criteria for a leak were established before commencing the study. Demographic, operative, diagnostic, and interventional procedure data were also recorded. Results: Twenty-two patients had an anastomotic leak (19.4%), and 14 (12.3%) required re-exploration or drain placement. The cutoff value of day three CRP with the greatest area under the ROC curve in the ROC curve analysis was 166 mg/L (area under the curve [AUC], 0.853) for open and laparoscopic procedures (sensitivity and specificity of 81.81% and 82.42%, respectively) with a negative predictive value of 93.8%. There was no difference in mean day three CRP levels between open and laparoscopic surgery (116.57 mg/L vs. 108.94 mg/L) Conclusions: A CRP value of more than 166 mg/L on day three should raise suspicion of an anastomotic leak.
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Affiliation(s)
- Emmanuel Lazarus
- Department of Surgery Unit-2, Christian Medical College, Vellore, India
| | | | - Gigi Varghese
- Department of Surgery Unit-2, Christian Medical College, Vellore, India
| | - Rajat Raghunath
- Department of Surgery Unit-2, Christian Medical College, Vellore, India
| | - Rohin Mittal
- Department of Surgery Unit-2, Christian Medical College, Vellore, India
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28
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van den Beukel BAW, de Ree R, van Goor H, van der Wal SEI, Ten Broek RPG. Analgesia in patients with adhesion-related chronic abdominal and pelvic pain after surgery: a systematic review. Acta Chir Belg 2022; 122:303-311. [PMID: 33899669 DOI: 10.1080/00015458.2021.1881336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Adhesions are the most common cause of chronic abdominal pain after surgery. Surgical adhesiolysis can relieve symptoms in selected patients, but many require other treatments. The aim of this study is to evaluate analgesic treatments other than abdominal surgery in chronic pain related to adhesions. DATABASE AND DATA TREATMENT A search was conducted in PubMed, Embase, and Central. Studies with patients suffering from chronic postoperative pain related to adhesions and undergoing all types' analgesic treatment were included. The primary outcome was the number of patients who improved in pain at long-term follow-up (at least 1 year). Secondary outcomes included improvement in pain at 3 months follow-up, quality of life, and physical functioning. RESULTS Searches identified 3022 citations. Four studies were included, one trial, one cohort study, and two case reports. The primary outcome was not reported. In a small trial (n = 18) pregabalin tended to have a benefit over placebo improving pain at 3 months. In the cohort study, 17 patients with chronic pelvic pain underwent a trial of sacral nerve stimulation. Eight patients who responded positively received an implanted device for continuous modulation, reporting sustainable improvement during follow-up (range: 6-36 months). One case report described improved pain at 6 months with trans-abdominis plane stimulation. The second report described improvement of physical function with manual therapy at long-term follow-up. CONCLUSIONS Low level of evidence is available regarding analgesic treatments of chronic abdominal and pelvic pain related to adhesions. The benefit of pregabalin is doubtful; nerve modulation is promising in a selected group.HighlightsAdhesions are a frequent cause of chronic abdominal and pelvic pain after surgery.Many patients are not good candidates for surgery (Adhesiolysis) or have relapses of pain.There is an important knowledge gap regarding non-surgical analgesic treatment.Analgesia in adhesion-related chronic abdominal pain after surgery.
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Affiliation(s)
- B A W van den Beukel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R de Ree
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S E I van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R P G Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Mazaki J, Katsumata K, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Ishizaki T, Nagakawa Y, Tsuchida A. Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study. Medicine (Baltimore) 2022; 101:e29600. [PMID: 35839009 PMCID: PMC11132375 DOI: 10.1097/md.0000000000029600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Anastomotic leak after gastrointestinal anastomosis is a serious complication. Anastomotic failure depends on various parameters. The aim of our study was to evaluate the pressure resistance of a new device, EEA™ circular stapler with Tri-Staple™ technology 28 mm Medium/Thick (Triple-rows circular stapler; TCS) compared with EEA™ circular stapler with DST series™ technology 28 mm, 4.8 mm staples (double-rows circular stapler; DCS). PATIENTS AND METHODS We performed 30 anastomoses (DSC: 15, TCS: 15) of DST with porcine colon model in vitro. We performed following 3 comparative experiences; Experiment 1: observation of staple shape with a colonoscopy, Experiment 2: comparison of the pressure resistance, Experiment 3: comparison of leakage points. RESULTS There was no hypoplasia of staples and the shapes were well-formed by colonoscopy. The leakage pressure of DCS was 19.6 ± 4.4 mm Hg (mean ± standard deviation) and that of TCS was 38.6 ± 10.2 mm Hg (mean ± standard deviation). There was a significantly difference between 2 groups (P < .001). 12 cases of DCS (80%) and 10 cases of TCS (66.7%) had leakages from Circular stapler point. 2 cases of DCS (13.3%) and 5 cases of TCS (33.3%) had leakages from Crossing points. Only 1 case of DCS had leakages from Dog ear point (6.7%). There was no significantly difference in leakage site between 2 groups (P = .195). CONCLUSIONS TSC showed high pressure resistance during DST compared with that of DCS. It was suggested that TCS may contribute to the reduction of anastomotic leakage rate.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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30
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Mazaki J, Katsumata K, Ishizaki T, Fukushima N, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Nagakawa Y, Tsuchida A. Effectiveness of a new triple-row circular stapler in reducing the risk of colorectal anastomotic leakage: A historical control and propensity score-matched study. Medicine (Baltimore) 2022; 101:e29325. [PMID: 35801763 PMCID: PMC9259104 DOI: 10.1097/md.0000000000029325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Anastomotic leakage (AL) after colorectal surgery is a serious complication. This study aimed to evaluate the effectiveness of the EEA™ circular stapler, a new triple-row circular stapler (TCS), relative to a conventional, double-row circular stapler (DCS). A total of 285 patients who underwent anastomosis with the double stapling technique at the Tokyo Medical University Hospital between 2017 and 2021 were included in this nonrandomized clinical trial with historical controls using a propensity score (PS) analysis. The primary endpoint was the risk of AL. We performed a 1:2 PS matching analysis. Before case matching, AL occurred in 15 (7.4%) and 2 (2.4%) patients in the DCS and TCS groups, respectively, with no significant difference (P = .17). After case matching, AL occurred in 13 patients (11.6%) and 1 patient (1.8%) in the DCS and TCS groups, respectively, revealing a significant difference (P = .04). Cox models were created by applying PS to adjust for group differences via regression adjustment. Odds ratios for AL in the DCS group versus the TCS group were 0.31 (95% confidence interval [CI]: 0.07-1.38) in the entire cohort, 0.15 (95% CI: 0.02-0.64) in the regression adjustment cohort, and 0.14 (95% CI: 0.02-1.09) in the 1:2 PS-matched cohort. PS analysis of clinical data suggested that the use of TCS contributes to a reduced risk of AL after colorectal anastomosis CTwith the double stapling technique.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
- *Correspondence: Junichi Mazaki, Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan (e-mail: )
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Noritoshi Fukushima
- Department of Preventive Medicine and Public Health, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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Angeramo CA, Schlottmann F, Laporte M, Bun ME, Rotholtz NA. Re-laparoscopy to Treat Early Complications After Colorectal Surgery: Is There a Learning Curve? Surg Laparosc Endosc Percutan Tech 2022; 32:362-367. [PMID: 35583576 DOI: 10.1097/sle.0000000000001052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Laparoscopy for treating complications after laparoscopic colorectal surgery (LCS) is still controversial. Moreover, its learning curve has not been evaluated yet. The aim of this study was to analyze whether operative outcomes were influenced by the learning curve of re-laparoscopy. METHODS A retrospective analysis of patients undergoing LCS and reoperated by a laparoscopic approach during the period 2000-2019 was performed. A cumulative sum analysis was done to determine the number of operations that must be performed to achieve a stable operative time. Based on this analysis, the cohort was divided in 3 groups. Demographics and operative variables were compared between groups. RESULTS From a total of 1911 patients undergoing LCS, 132 (7%) were included. Based on the cumulative sum analysis, the cohort was divided into the first 50 (G1), the following 52 (G2), and the last 30 (G3) patients. Less computed tomography scans were performed in G3 (G1: 72% vs. G2: 63% vs. G3: 43%; P=0.03). There were no differences in the type of operation performed between the groups. The conversion rate (G1: 18% vs. G2: 4% vs. G3: 3%; P=0.02) and the mean operative time (G1: 104 min vs. G2: 80 min vs. G3: 78 min; P=0.003) were higher in G1. Overall morbidity was lower in G3 (G1: 46% vs. G2: 63% vs. G3: 33%; P=0.01). Major morbidity, mortality, and mean length of stay remained similar in all groups. CONCLUSIONS A total of 50 laparoscopic reoperations might be needed to achieve an appropriate learning curve with reduced operative time and lower conversion rates. Further research is needed to determine the learning process of re-laparoscopy for treating complications after colorectal surgery.
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Affiliation(s)
| | | | - Mariano Laporte
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Maximiliano E Bun
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Nicolas A Rotholtz
- Department of Surgery
- Division of Colorectal Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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Hof S, Truse R, Weber L, Herminghaus A, Schulz J, Weber APM, Maleckova E, Bauer I, Picker O, Vollmer C. Local Mucosal CO 2 but Not O 2 Insufflation Improves Gastric and Oral Microcirculatory Oxygenation in a Canine Model of Mild Hemorrhagic Shock. Front Med (Lausanne) 2022; 9:867298. [PMID: 35573010 PMCID: PMC9096873 DOI: 10.3389/fmed.2022.867298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Acute hemorrhage results in perfusion deficit and regional hypoxia. Since failure of intestinal integrity seem to be the linking element between hemorrhage, delayed multi organ failure, and mortality, it is crucial to maintain intestinal microcirculation in acute hemorrhage. During critical bleeding physicians increase FiO2 to raise total blood oxygen content. Likewise, a systemic hypercapnia was reported to maintain microvascular oxygenation (μHbO2). Both, O2 and CO2, may have adverse effects when applied systemically that might be prevented by local application. Therefore, we investigated the effects of local hyperoxia and hypercapnia on the gastric and oral microcirculation. Methods Six female foxhounds were anaesthetized, randomized into eight groups and tested in a cross-over design. The dogs received a local CO2-, O2-, or N2-administration to their oral and gastric mucosa. Hemorrhagic shock was induced through a withdrawal of 20% of estimated blood volume followed by retransfusion 60 min later. In control groups no shock was induced. Reflectance spectrophotometry and laser Doppler were performed at the gastric and oral surface. Oral microcirculation was visualized by incident dark field imaging. Systemic hemodynamic parameters were recorded continuously. Statistics were performed using a two-way-ANOVA for repeated measurements and post hoc analysis was conducted by Bonferroni testing (p < 0.05). Results The gastric μHbO2 decreased from 76 ± 3% to 38 ± 4% during hemorrhage in normocapnic animals. Local hypercapnia ameliorated the decrease of μHbO2 from 78 ± 4% to 51 ± 8%. Similarly, the oral μHbO2 decreased from 81 ± 1% to 36 ± 4% under hemorrhagic conditions and was diminished by local hypercapnia (54 ± 4%). The oral microvascular flow quality but not the total microvascular blood flow was significantly improved by local hypercapnia. Local O2-application failed to change microvascular oxygenation, perfusion or flow quality. Neither CO2 nor O2 changed microcirculatory parameters and macrocirculatory hemodynamics under physiological conditions. Discussion Local hypercapnia improved microvascular oxygenation and was associated with a continuous blood flow in hypercapnic individuals undergoing hemorrhagic shock. Local O2 application did not change microvascular oxygenation, perfusion and blood flow profiles in hemorrhage. Local gas application and change of microcirculation has no side effects on macrocirculatory parameters.
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Affiliation(s)
- Stefan Hof
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Lea Weber
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jan Schulz
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Andreas P M Weber
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Eva Maleckova
- Institute of Plant Biochemistry, Cluster of Excellence on Plant Sciences (CEPLAS), Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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33
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Degiuli M, Elmore U, De Luca R, De Nardi P, Tomatis M, Biondi A, Persiani R, Solaini L, Rizzo G, Soriero D, Cianflocca D, Milone M, Turri G, Rega D, Delrio P, Pedrazzani C, De Palma GD, Borghi F, Scabini S, Coco C, Cavaliere D, Simone M, Rosati R, Reddavid R. Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group. Colorectal Dis 2022; 24:264-276. [PMID: 34816571 PMCID: PMC9300066 DOI: 10.1111/codi.15997] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/07/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022]
Abstract
AIM Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage. METHODS The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured. RESULTS A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection. CONCLUSIONS While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.
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Affiliation(s)
- Maurizio Degiuli
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
| | - Ugo Elmore
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | - Raffaele De Luca
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Paola De Nardi
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | | | - Alberto Biondi
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Roberto Persiani
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Leonardo Solaini
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Gianluca Rizzo
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusRomeItaly
| | - Domenico Soriero
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | | | - Marco Milone
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Giulia Turri
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Daniela Rega
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Paolo Delrio
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Giovanni D. De Palma
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Felice Borghi
- Department of SurgeryS. Croce e Carle HospitalCuneoItaly
| | - Stefano Scabini
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | - Claudio Coco
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusUniversità Cattolica del Sacro CuoreRomeItaly
| | - Davide Cavaliere
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Michele Simone
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Riccardo Rosati
- Division of Gastrointestinal SurgerySan Raffaele HospitalVita Salute UniversityMilanItaly
| | - Rossella Reddavid
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Aiolfi A, Gagner M, Zappa MA, Lastraioli C, Lombardo F, Panizzo V, Bonitta G, Cavalli M, Campanelli G, Bona D. Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Obes Surg 2022; 32:1466-1478. [PMID: 35169954 PMCID: PMC8986671 DOI: 10.1007/s11695-022-05950-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
Purpose Staple line reinforcement (SLR) during laparoscopic sleeve gastrectomy (LSG) is controversial. The purpose of this study was to perform a comprehensive evaluation of the most commonly utilized techniques for SLR. Materials and Methods Network meta-analysis of randomized controlled trials (RCTs) to compare no reinforcement (NR), suture oversewing (SR), glue reinforcement (GR), bioabsorbable staple line reinforcement (Gore® Seamguard®) (GoR), and clips reinforcement (CR). Risk Ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrI) were used as pooled effect size measures. Results Overall, 3994 patients (17 RCTs) were included. Of those, 1641 (41.1%) underwent NR, 1507 (37.7%) SR, 689 (17.2%) GR, 107 (2.7%) GoR, and 50 (1.3%) CR. SR was associated with a significantly reduced risk of bleeding (RR=0.51; 95% CrI 0.31–0.88), staple line leak (RR=0.56; 95% CrI 0.32–0.99), and overall complications (RR=0.50; 95% CrI 0.30–0.88) compared to NR while no differences were found vs. GR, GoR, and CR. Operative time was significantly longer for SR (WMD=16.2; 95% CrI 10.8–21.7), GR (WMD=15.0; 95% CrI 7.7–22.4), and GoR (WMD=15.5; 95% CrI 5.6–25.4) compared to NR. Among treatments, there were no significant differences for surgical site infection (SSI), sleeve stenosis, reoperation, hospital length of stay, and 30-day mortality. Conclusions SR seems associated with a reduced risk of bleeding, leak, and overall complications compared to NR while no differences were found vs. GR, GoR, and CR. Data regarding GoR and CR are limited while further trials reporting outcomes for these techniques are warranted. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-022-05950-z.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy.
| | | | - Marco Antonio Zappa
- UOC Chirurgia Generale Ospedale Fatebenefratelli, Asst Fatebenefratelli-Sacco Milano, Milan, Italy
| | - Caterina Lastraioli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Francesca Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Valerio Panizzo
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Marta Cavalli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Giampiero Campanelli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, n16, 20149, Milan, Italy
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El Zaher HA, Ghareeb WM, Fouad AM, Madbouly K, Fathy H, Vedin T, Edelhamre M, Emile SH, Faisal M. Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections. World J Surg Oncol 2022; 20:33. [PMID: 35151339 PMCID: PMC8840033 DOI: 10.1186/s12957-022-02506-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/05/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery. Method Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation. Results This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively). Conclusion The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.
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Meyer J, Joshi H, Davies J. Should Prophylactic Transanal Tube Drainage Be Continued in Colorectal Surgery? JAMA Surg 2022; 157:546-547. [PMID: 35138339 DOI: 10.1001/jamasurg.2021.7561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jeremy Meyer
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Division of Digestive Surgery, University Hospitals of Geneva, Genève, Switzerland.,Medical School, University of Geneva, Genève, Switzerland
| | - Heman Joshi
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Martínez Hernández A, Beltrán Herrera H, Martínez García V, Ibáñez Belenguer M, Queralt Martín R, Maiocchi Segredo AK, Aliaga Hilario E, Laguna Sastre JM. Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:1034-1048. [PMID: 35132569 DOI: 10.1007/s11695-022-05890-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results. METHODS We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality. RESULTS A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement. CONCLUSIONS Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.
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Affiliation(s)
| | | | | | | | | | | | | | - José Manuel Laguna Sastre
- Department of General Surgery, University General Hospital, Castellon, Spain.,Jaume I Univeristy, Castellon, Spain
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Campos FG, Pandini RV, Bustamante-Lopez LA, Nahas SC. Surgical Technique and Considerations about Transanal Transection and Single-Stapled (TTSS) Anastomosis: The Search for a Perfect Anastomosis. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractThe evaluation of preventive measures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review the most recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed.
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Affiliation(s)
- Fábio Guilherme Campos
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rafael Vaz Pandini
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Sérgio Carlos Nahas
- Colorectal Surgery Division, Gastroenterology Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Ellis CT, Maykel JA. Defining Anastomotic Leak and the Clinical Relevance of Leaks. Clin Colon Rectal Surg 2021; 34:359-365. [PMID: 34853555 DOI: 10.1055/s-0041-1735265] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.
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Affiliation(s)
- Clayton Tyler Ellis
- Division of Colorectal Surgery, Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Worcester, Massachusetts
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Burke JR, Helliwell J, Wong J, Quyn A, Herrick S, Jayne D. The use of mesenchymal stem cells in animal models for gastrointestinal anastomotic leak: A systematic review. Colorectal Dis 2021; 23:3123-3140. [PMID: 34363723 DOI: 10.1111/codi.15864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/29/2021] [Accepted: 07/29/2021] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leak is the most feared complication of gastrointestinal surgery. Mesenchymal stem cell technology is used clinically to promote wound healing; however, the safety and efficacy of this technology on anastomotic healing has yet to be defined. The aim of this study was to investigate whether mesenchymal stem cells confer any benefit when applied to animal models for gastrointestinal anastomotic leak, identify the methodology and how efficacy is assessed. METHODS The MEDLINE, EMBASE, WebofScience and Cochrane Library databases were interrogated between 1 January1947 to 1 May 2020. All studies where mesenchymal stem cells were applied to laboratory animal leak models to demonstrate a healing effect were considered. All experimental and histological outcomes were examined. Compliance to ARRIVE and current International Consensus was assessed. RESULTS A total of 1205 studies were screened. Twelve studies reported on 438 gastrointestinal anastomoses in four species using 11 models; seven in the colon. No studies utilised a model with a known leak rate. Significant variance was observed in histological outcomes with efficacy demonstrated in five out of 12 studies. One study demonstrated a benefit in leak rate. Colorectal studies had a greater median ARRIVE compliance, 60.8% (IQR 63.2-64.5) compared to noncolorectal 45.4% (IQR 43.8-49.0). CONCLUSIONS Mesenchymal stem cell delivery to an animal anastomosis is safe and feasible. Use may confer benefit but findings are currently limited to surrogate histological outcomes. There is consistency in outcome measures reported but variance in how this is assessed. Poor compliance to ARRIVE but good compliance to current international consensus in leak models of the colon was observed.
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Affiliation(s)
- Joshua Richard Burke
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Jack Helliwell
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Jason Wong
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Aaron Quyn
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
| | - Sarah Herrick
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - David Jayne
- The John Goligher Colorectal Surgery Unit, St. James's University Hospital, Leeds Teaching Hospital Trust, Leeds, UK
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Mu Y, Zhao L, He H, Zhao H, Li J. The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis. World J Surg Oncol 2021; 19:318. [PMID: 34732226 PMCID: PMC8567543 DOI: 10.1186/s12957-021-02432-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/24/2021] [Indexed: 01/30/2023] Open
Abstract
Background Protective ileostomy is always applied to avoid clinically significant anastomotic leakage and other postoperative complications for patients receiving laparoscopic rectal cancer surgery. However, whether it is necessary to perform the ileostomy is still controversial. This meta-analysis aims to analyze the efficacy of ileostomy on laparoscopic rectal cancer surgery. Methods Cochrane Library, EMBASE, Web of Science, and PubMed were applied for systematic search of all relevant literature, updated to May 07, 2021. Studies compared patients with and without ileostomy for laparoscopic rectal cancer surgery. We applied Review Manager software to perform this meta-analysis. The quality of the non-randomized controlled trials was assessed using the Newcastle-Ottawa scale (NOS), and the randomized studies were assessed using the Jadad scale. Results We collected a total of 1203 references, and seven studies were included using the research methods. The clinically significant anastomotic leakage rate was significantly lower in ileostomy group (27/567, 4.76%) than that in non-ileostomy group (54/525, 10.29%) (RR = 0.47, 95% CI 0.30–0.73, P for overall effect = 0.0009, P for heterogeneity = 0.18, I2 = 32%). However, the postoperative hospital stay, reoperation, wound infection, and operation time showed no significant difference between the ileostomy and non-ileostomy groups. Conclusion The results demonstrated that protective ileostomy could decrease the clinically significant anastomotic leakage rate for patients undergoing laparoscopic rectal cancer surgery. However, ileostomy has no effect on postoperative hospital stay, reoperation, wound infection, and operation time. The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02432-x.
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Affiliation(s)
- Yu Mu
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China
| | - Linxian Zhao
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China
| | - Hongyu He
- Operating Theater and Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China
| | - Huimin Zhao
- Operating Theater and Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China
| | - Jiannan Li
- Department of General Surgery, The Second Hospital of Jilin University, Changchun, 130041, Jilin, China.
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Boney O, Moonesinghe SR, Myles PS, Grocott MPW. Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC): a modified Delphi process to develop a core outcome set for trials in perioperative care and anaesthesia. Br J Anaesth 2021; 128:174-185. [PMID: 34740438 DOI: 10.1016/j.bja.2021.09.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/20/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Outcome selection underpins clinical trial interpretation. Inconsistency in outcome selection and reporting hinders comparison of different trials' results, reducing the utility of research findings. METHODS We conducted an iterative consensus process to develop a set of Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC), following the established Core Outcome Measures for Effectiveness Trials (COMET) methodology. First, we undertook a systematic review of RCTs in high-impact journals to describe current outcome reporting trends. We then surveyed patients, carers, researchers, and perioperative clinicians about important outcomes after surgery. Finally, a purposive stakeholder sample participated in a modified Delphi process to develop a core outcome set for perioperative and anaesthesia trials. RESULTS Our systematic review revealed widespread inconsistency in outcome reporting, with variable or absent definitions, levels of detail, and temporal criteria. In the survey, almost all patients, carers, and clinicians rated clinical outcome measures critically important, but clinicians rated patient-centred outcomes less highly than patients and carers. The final core outcome set was: (i) mortality/survival (postoperative mortality, long-term survival); (ii) perioperative complications (major postoperative complications/adverse events; complications/adverse events causing permanent harm); (iii) resource use (length of hospital stay, unplanned readmission within 30 days); (iv) short-term recovery (discharge destination, level of dependence, or both); and (v) longer-term recovery (overall health-related quality of life). CONCLUSIONS This core set, incorporating important outcomes for both clinicians and patients, should guide outcome selection in future perioperative medicine or anaesthesia trials. Mapping these alongside standardised endpoint definitions will yield a comprehensive perioperative outcome framework.
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Affiliation(s)
- Oliver Boney
- Surgical Outcomes Research Centre, University College Hospital, London, UK; Health Services Research Centre, National Institute of Academic Anaesthesia, Royal College of Anaesthetists, London, UK.
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre, University College Hospital, London, UK; Health Services Research Centre, National Institute of Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Perioperative and Critical Care Theme, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
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Veziant J, Gaillard M, Barat M, Dohan A, Barret M, Manceau G, Karoui M, Bonnet S, Fuks D, Soyer P. Imaging of postoperative complications following Ivor-Lewis esophagectomy. Diagn Interv Imaging 2021; 103:67-78. [PMID: 34654670 DOI: 10.1016/j.diii.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.
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Affiliation(s)
- Julie Veziant
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Martin Gaillard
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Anthony Dohan
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Maximilien Barret
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology and Digestive Oncology, Hôpital Cochin, APHP.Centre, 75014 Paris, France
| | - Gilles Manceau
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Mehdi Karoui
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Stéphane Bonnet
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Philippe Soyer
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
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Affiliation(s)
- David B Stewart
- Division of General Surgery, Southern Illinois University School of Medicine, Springfield
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Abstract
PURPOSE Anastomotic leak (AL) following colorectal cancer resection is associated with considerable morbidity and mortality with an impact on recurrence rates and survival. The impact of obesity on AL rates is debated. This meta-analysis aims to investigate the relationship between obesity and AL. METHODS A search was conducted of the PubMed/MEDLINE, and Web of Science databases and included studies were split into Western and Asian groups based on population-specific body mass index (BMI) ranges for obesity. A meta-analysis was performed to assess the impact of obesity on AL rate following colorectal cancer resection. RESULTS Two thousand three hundred and four articles were initially screened. Thirty-one studies totaling 32,953 patients were included. Patients with obesity had a statistically significant increase in AL rate in all Western and Asian study groups. However, this increase was only clinically significant in the rectal anastomotic subgroups-Western: 10.8% vs 8.4%, OR 1.57 (1.01-2.44) and Asian: 9.4% vs 7.4%, OR 1.58 (1.07-2.32). CONCLUSIONS The findings of this analysis confirm that obesity is a significant risk factor for anastomotic leak, particularly in rectal anastomoses. This effect is thought to be primarily mediated via technical difficulties of surgery although metabolic and immunological factors may also play a role. Obesity in patients undergoing restorative CRC resection should be discussed and considered as part of the pre-operative counselling.
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Somashekhar SP, Rohit KC, Ramya Y, Zaveri SS, Ahuja V, Namachivayam AK, Ashwin KR. Bowel Anastomosis After or Before HIPEC: A Comparative Study in Patients Undergoing CRS+HIPEC for Peritoneal Surface Malignancy. Ann Surg Oncol 2021; 29:214-223. [PMID: 34462817 DOI: 10.1245/s10434-021-10661-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. There is no consensus statement regarding the optimal timing for bowel anastomoses to perform after or before HIPEC. METHODS Patients who underwent CRS+HIPEC and had at least one bowel anastomosis were retrospectively analyzed to evaluate if timing of anastomosis done after or before HIPEC had an impact on bowel complication rates (anastomotic leak and perforation). RESULTS From 2013 to 2019, 214 of 370 patients underwent CRS+HIPEC and had at least one bowel anastomosis. Of these 214 patients, 104 and 110 patients had anastomosis after and before HIPEC, respectively. A total of 324 anastomoses were performed, with a mean of 0.87 anastomoses per patient (range 1-4). The incidence of anastomotic leaks was comparable between the pre- and post-HIPEC groups (3.6% vs. 4.8%; p > 0.05), as was the bowel complication rate (7.6% vs. 7.2%). After multivariate analysis, prior surgical score >1 (odds ratio [OR] 4.3), recurrent cancers (OR 7.4), and more than two anastomosis (OR 3.8) were considered independent risk factors for bowel complications. CONCLUSION Anastomosis of the bowel performed after or before HIPEC does not affect bowel complication rates (leak/perforation). Higher prior surgical score, surgery for recurrent cancers, and more than two bowel anastomosis are independent risk factors for predicting bowel complications. Prehabilitation, standardization of steps, immediate attention and repair of serosal tears, and thorough inspection of the bowel before closure helps to decrease bowel complications. The timing of anastomosis can be at the discretion of the surgeon.
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Affiliation(s)
- S P Somashekhar
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Kumar C Rohit
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India.
| | - Yethadka Ramya
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Shabber S Zaveri
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | - Vijay Ahuja
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
| | | | - K R Ashwin
- Manipal Comprehensive Cancer Centre, Manipal Hospital, Bangalore, India
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients. J Gastrointest Surg 2021; 25:2000-2010. [PMID: 32869144 PMCID: PMC7970451 DOI: 10.1007/s11605-020-04781-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice. METHODS Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge. RESULTS Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar. CONCLUSIONS Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.
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50
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Luigiano C, Di Leo M, Eusebi LH, Barabino M, De Nicola E, Giovenzana M, Opocher E, Iabichino G, Palamara MA, Giacobbe G, Tortora A, Virgilio C, Abenavoli L, Pallio S, Consolo P. Management of Leaks Following Laparoscopic Sleeve Gastrectomy Using Specifically Designed Large Covered Metal Stents. Rev Recent Clin Trials 2021; 16:303-308. [PMID: 33563171 DOI: 10.2174/1574887116666210204142417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/22/2020] [Accepted: 01/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Leaks are the major complication associated with laparoscopic sleeve gastrectomy. OBJECTIVE The study aimed to assess the efficacy and safety of specifically designed large covered metal stents for the management of post-laparoscopic sleeve gastrectomy leaks. METHODS Prospectively collected databases from three Italian Endoscopy Units were reviewed. The primary outcome of the study was to evaluate the clinical success of stents placement, defined as complete resolution of clinical and laboratory signs of sepsis with radiological evidence of leak closure. Secondary outcomes were stent-related adverse events and mortality. RESULTS Twenty-one patients (67% females, mean age 45 years) were included in the study and a total of 26 stents were placed. Technical success of stent placement was achieved in all cases (100%). Clinical success was observed in 85.5% of patients. Stent-related adverse events occurred in 9 patients (43%), with stent migration as the most frequent complication (33%). Adverse events were more frequently observed in patients who had undergone bariatric surgery prior to laparoscopic sleeve gastrectomy compared to patients without previous surgery (83% et al. 27%, p=0.018). CONCLUSION The placement of specifically designed covered metal stents appears to be an effective and safe therapeutic approach for post-laparoscopic sleeve gastrectomy leaks. Stent migration can be a frequent complication.
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Affiliation(s)
- Carmelo Luigiano
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Milena Di Leo
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Leonardo Henry Eusebi
- Gastroenterology and Endoscopy Unit, Department of Medical and Surgical Sciences, S. Orsola University Hospital, Via G. Massarenti, 9, 40138 Bologna, Italy
| | - Matteo Barabino
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Enrico De Nicola
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Marco Giovenzana
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Enrico Opocher
- Unit of Hepatobiliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of Milan, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Giuseppe Iabichino
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Maria Angela Palamara
- Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudiní, 8, 20142 Milano, Italy
| | - Giuseppa Giacobbe
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Andrea Tortora
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Clara Virgilio
- Unit of Gastroenterology and Digestive Endoscopy, ARNAS Garibaldi, 95122 Catania, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University "Magna Graecia", Viale Europa - 88100 Catanzaro, Italy
| | - Socrate Pallio
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
| | - Pierluigi Consolo
- Unit of Digestive Endoscopy, University of Messina, Hospital "G. Martino", Via Consolare Valeria 2 - 98124 Messina, Italy
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