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Yung HC, Daroch AK, Parikh R, Mathur DV, Kafexhiu IK, Goodman E. Diagnostic Modalities for Early Detection of Anastomotic Leak After Colorectal Surgery. J Surg Res 2024; 301:520-533. [PMID: 39047384 DOI: 10.1016/j.jss.2024.06.042] [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: 12/11/2023] [Revised: 06/02/2024] [Accepted: 06/30/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Anastomotic leak (AL) remains a severe complication following colorectal surgery, leading to increased morbidity and mortality, particularly in cases of delayed diagnosis. Existing diagnostic methods, including computed tomography (CT) scans, contrast enemas, endoscopic examinations, and reoperations can confirm AL but lack strong predictive value. Early detection is crucial for improving patient outcomes, yet a definitive and reliable predictive test, or "gold standard," is still lacking. METHODS A comprehensive PubMed review was focused on CT imaging, serum levels of C-reactive protein (CRP), and procalcitonin (PCT) to assess their predictive utility in detecting AL after colorectal resection. Three independent reviewers evaluated eligibility, extracted data, and assessed the methodological quality of the studies. RESULTS Summarized in detailed tables, our analysis revealed the effectiveness of both CRP and PCT in the early detection of AL during the postoperative period. CT imaging, capable of identifying fluid collection, pneumoperitoneum, extraluminal contrast extravasation, abscess formation, and other early signs of leak, also proved valuable. CONCLUSIONS Considering the variability in findings and statistics across these modalities, our study suggests a personalized, multimodal approach to predicting AL. Integrating CRP and PCT assessments with the diagnostic capabilities of CT imaging provides a nuanced, patient-specific strategy that significantly enhances early detection and management. By tailoring interventions based on individual clinical characteristics, surgeons can optimize patient outcomes, reduce morbidity, and mitigate the consequences associated with AL after colorectal surgery. This approach emphasizes the importance of personalized medicine in surgical care, paving the way for improved patient health outcomes.
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Affiliation(s)
- Halley C Yung
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY.
| | - Alisha K Daroch
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY
| | - Rooshi Parikh
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY
| | - Dharam V Mathur
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY
| | - Ide K Kafexhiu
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY
| | - Elliot Goodman
- Sophie Davis School of Biomedical Education and City University of New York (CUNY) School of Medicine, New York, NY
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Pla-Martí V, Martín-Arévalo J, Moro-Valdezate D, García-Botello S, Pérez-Santiago L, Barrachina-Martinez I, González-de-Julián S, Vivas-Consuelo D, Espí-Macías A. Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis. Tech Coloproctol 2024; 28:76. [PMID: 38954099 PMCID: PMC11219427 DOI: 10.1007/s10151-024-02936-0] [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] [Received: 12/06/2023] [Accepted: 05/15/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. METHOD This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. RESULTS A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was - €74,915.28 per patient without anastomotic complications. CONCLUSION The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.
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Affiliation(s)
- V Pla-Martí
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain.
- Department of Surgery, University of Valencia, Valencia, Spain.
| | - J Martín-Arévalo
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
| | - D Moro-Valdezate
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
| | - S García-Botello
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
| | - L Pérez-Santiago
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
| | - I Barrachina-Martinez
- Research Unit for Health Economics and Management, Universitat Politècnica de València, Camino de Vera S/N, 46022, Valencia, Spain
| | - S González-de-Julián
- Research Unit for Health Economics and Management, Universitat Politècnica de València, Camino de Vera S/N, 46022, Valencia, Spain
| | - D Vivas-Consuelo
- Research Unit for Health Economics and Management, Universitat Politècnica de València, Camino de Vera S/N, 46022, Valencia, Spain
| | - A Espí-Macías
- Department of General and Digestive Surgery, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Av. Blasco Ibáñez, 17, 46010, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
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Fujimoto N, Ogino T, Miyoshi N, Uemura M, Doki Y, Eguchi H. Avoiding stoma creation due to super-morbid obesity: A report of two surgical cases of colorectal cancer. Int J Surg Case Rep 2024; 114:109171. [PMID: 38113563 PMCID: PMC10772238 DOI: 10.1016/j.ijscr.2023.109171] [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: 11/08/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION A stoma is commonly created in patients with a high risk of anastomotic leakage. However, patients with obesity have a higher incidence of stoma-related complications, and the decision to create a stoma should be carefully considered. We report two cases of patients with colorectal cancer and super-morbid obesity wherein stoma creation was avoided. PRESENTATION OF CASES Case 1 involved a 52-year-old male patient with a body mass index (BMI) of 41.8 kg/m2 who underwent a robotic-assisted laparoscopic low anterior resection after neoadjuvant chemotherapy for lower rectal cancer. Although temporary diverting ileostomy was initially considered, stoma creation was skipped intraoperatively, considering the complication risk-benefit ratio. Case 2 involved a 42-year-old female patient with a BMI of 64 kg/m2 who underwent open partial non-curative colon resection for descending colon cancer complicated by colonic perforation and abscess formation. The patient was considered to be at high risk of stoma-related complications due to high mobility of the subcutaneous fat of abdominal wall; therefore, we decided not to create a stoma preoperatively. DISCUSSION Considering the high risk of stoma-associated complications, avoiding stoma creation and implementing preventive measures against potential complications are alternative options for patients with super-morbid obesity. CONCLUSION We present our experience two cases in which stoma creation was avoided for super-morbid obese patients with BMI over 40.
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Affiliation(s)
- Naoto Fujimoto
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan; Therapeutics for Inflammatory Bowel Diseases, Graduate school of medicine, Osaka University, Suita, Osaka, Japan.
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate school of medicine, Osaka University, Suita, Osaka, Japan
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Bhargava A, Gharde P, Tayade H, Inamdar A. A Miraculous Save: Gangrenous Bowel and Meckle's Diverticulum With Acute Superior Mesenteric Artery Thrombosis. Cureus 2024; 16:e52947. [PMID: 38406144 PMCID: PMC10893989 DOI: 10.7759/cureus.52947] [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: 08/29/2023] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
The superior mesenteric artery (SMA) is vital for parts of the small intestine and ascending colon. Thrombosis of this major artery is a severe and potentially fatal condition involving the occlusion of the arterial vascular supply, causing ischemia predisposing to gangrene. Meckel's diverticulum is a congenital outpouching in the lower part of the small intestine. The condition of gangrenous meckels diverticulum is, therefore, even more limited. This study presents a unique case of a 45-year-old male with coexisting features of SMA thrombus with acute small bowel intestinal obstruction. During the study, the patient was found to have sickle cell anemia with an AS pattern, which may have predisposed the formation of a thrombus. The patient underwent sequential management of active thrombus by thrombolysis first, followed by resection anastomosis for gangrenous bowel. With precise monitoring and therapeutic care, the patient made a remarkable recovery. The condition possesses a high mortality rate. Prompt recognition and timely intervention in this case are of utmost significance.
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Affiliation(s)
- Abhilasha Bhargava
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Harshal Tayade
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Akash Inamdar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Percutaneous Drainage vs. Surgery as Definitive Treatment for Anastomotic Leak after Intestinal Resection in Patients with Crohn's Disease. J Clin Med 2023; 12:jcm12041392. [PMID: 36835926 PMCID: PMC9961459 DOI: 10.3390/jcm12041392] [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: 12/31/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Anastomotic leak (AL) remains one of the most relevant complications after intestinal resection for Crohn's disease (CD). While surgery has always been considered the standard treatment for perianastomotic collection, percutaneous drainage (PD) has been proposed as a potential alternative. METHODS Retrospective study in consecutive patients treated with either PD or surgery for AL after intestinal resection for CD between 2004 and 2022. AL was defined as a perianastomotic fluid collection confirmed by radiological findings. Patients with generalized peritonitis or clinical instability were excluded. PRIMARY AIM To compare the success rate of PD vs. surgery. Secondary aims: To compare the outcomes at 90 days after the procedures; to identify the variables associated with the indication for PD. RESULTS A total of 47 patients were included, of which 25 (53%) underwent PD and 22 (47%) surgery. The success rate was 84% in the PD and 95% in the surgery group (p = 0.20). There were no significant differences between the PD and surgery group in postoperative medical and surgical complications, discharge, readmission or reoperation rates at 90 days. PD was more likely to be performed in patients with later diagnosis of AL (OR 1.25, 95% CI 1.03-1.53, p = 0.027), undergoing ileo-colic anastomosis alone (OR 3.72, 95% CI 2.29-12.45, p = 0.034) and treated after 2016 (OR 6.36, 95% CI 1.04-39.03, p = 0.046). CONCLUSION The present study suggests that PD is a safe and effective procedure to treat anastomotic leak and perianastomotic collection in CD patients. PD should be indicated in all eligible patients as an effective alternative to surgery.
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Cheng SL, Xie L, Wu HW, Zhang XF, Lou LL, Shen HZ. Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report. World J Clin Cases 2022; 10:8406-8416. [PMID: 36159539 PMCID: PMC9403701 DOI: 10.12998/wjcc.v10.i23.8406] [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: 04/12/2022] [Revised: 05/18/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.
CASE SUMMARY A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).
CONCLUSION For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.
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Affiliation(s)
- Si-Le Cheng
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Lu Xie
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Hao-Wei Wu
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Li-Lan Lou
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Hong-Zhang Shen
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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