Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile?

Assessment of Colorectal Anastomosis with Intraoperative Colonoscopy: Its Role in Reducing Anastomotic Complications

The use of intraoperative colonoscopy (IOC) to evaluate the integrity of newly created anastomosis has been advocated by some surgeons. However, whether direct visualization of fresh anastomosis can help reduce anastomotic problems is still unclear. This study investigates the impact of immediate endoscopic assessment of colorectal anastomosis on anastomotic problems. This is a retrospective study conducted at a single center. Among six hundred forty-nine patients who underwent stapled anastomosis for left-sided colorectal cancer, the anastomotic complications were compared between patients who underwent IOC and those who did not. Additionally, patients with subsequent intervention after the IOC were compared to those without the intervention. Twenty-seven patients (5.0%) developed anastomotic leakage, and six (1.1%) experienced anastomotic bleeding postoperatively. Of the patients with IOC, 70 patients received reinforcement sutures to secure anastomotic stability. Of 70 patients, 39 patients showed abnormal findings in IOC. Thirty-seven patients (94.9%) who underwent reinforcement sutures did not develop postoperative anastomotic problems. This study demonstrates that IOC assessment with reinforcement sutures does not imminently reduce the rate of anastomotic complications. However, its use may play a role in detecting early technical failure and preventing postoperative anastomotic complications.

Safety profile of a multimodal fail-safe model to minimize postoperative complications in oncologic colorectal resections-a cohort study

BACKGROUND

Despite innovations in surgical techniques, major complications following colorectal surgery still lead to a significant morbidity and mortality. There is no standard protocol for perioperative management of patients with colorectal cancer. This study evaluates the effectiveness of a multimodal fail-safe model in minimizing severe surgical complications following colorectal resections.

METHODS

We compared major complications in patients with colorectal cancers who underwent surgical resections with anastomosis during 2013-2014 (control group) with patients treated during 2015-2019 (fail-safe group). The fail-safe group had preoperative bowel preparation and a perioperative single dose of antibiotics, on-table bowel irrigation and early sigmoidoscopic assessment of anastomosis in rectal resections. A standard surgical technique for tension-free anastomosis was adapted in the fail-safe approach. The chi-square test measured relationships between categorical variables, t-test estimated the probability of differences, and the multivariate regression analysis determined the linear correlation among independent and dependent variables.

RESULTS

A total of 924 patients underwent colorectal operations during the study period; however, 696 patients had surgical resections with primary anastomoses. There were 427 (61.4%) laparoscopic and 230 (33.0%) open operations, while 39 (5.6%) laparoscopic procedures were converted. Overall, the rate of major complications (Dindo-Clavien grade IIIb-V) significantly reduced from 22.6% for the control group to 9.8% for the fail-safe group (p < 0.0001). Major complications mainly occurred due to non-surgical reasons such as pneumonia, heart failure, or renal dysfunction. The rates of anastomotic leakage (AL) were 11.8% (22/186) and 3.7% (n = 19/510) for the control and fail-safe groups, respectively (p < 0.0001).

CONCLUSION

We report an effective multimodal fail-safe protocol for colorectal cancer during the pre-, peri-, and postoperative period. The fail-safe model showed less postoperative complications even for low rectal anastomosis. This approach can be adapted as a structured protocol during the perioperative care of patients for colorectal surgery.

TRIAL REGISTRATION

This study was registered in the German Clinical Trial Register (Study ID: DRKS00023804 ).

Techniques for Diagnosing Anastomotic Leaks Intraoperatively in Colorectal Surgeries: A Review

Colorectal cancer is one of the most common surgically curable malignancies worldwide, having a good prognosis even with liver metastasis. This improved patient outcome is marred by anastomotic leaks (AL) in operated patients of colorectal cancer despite a microscopically margin-negative resection (R0). Various risk factors have been attributed to causing this. Preoperative non-modifiable factors are age, male sex, cancer cachexia, and neoadjuvant chemo-radiotherapy, and modifiable factors are comorbidities, peripheral vascular disease, anemia, and malnutrition. Intraoperative risk factors include intraoperative surgical duration, blood loss and transfusions, fluid management, oxygen saturation, surgical technique (stapled, handsewn, or compression devices), and approach (open, laparoscopic, or robotic). Postoperative factors like anemia, infection, fluid management, and blood transfusions also have an effect. With the advent of enhanced recovery after surgery (ERAS) protocols, many modifiable factors can be optimized to reduce the risk. Prevention is better than cure as the morbidity and mortality of AL are very high. There is still a need for an intraoperative technique to detect the viability of anastomotic ends to predict and prevent AL. Prompt diagnosis of an AL is the key. Many surgeons have proposed using methods like air leak tests, intraoperative endoscopy, Doppler ultrasound, and near-infrared fluorescence imaging to decrease the incidence of AL. All these methods can minimize AL, resulting in significant intraoperative alterations to surgical tactics. This narrative review covers the methods of assessing of integrity of anastomosis during the surgery, which can help prevent anastomotic leakage.

Initial experience with intraoperative testing and repair of colorectal anastomosis using a TAMIS approach after a positive leak test

Anastomotic leak is one of the most feared complications of colorectal anastomosis. Different techniques have been described for intraoperative testing of anastomotic integrity. These include air insufflation, methylene blue and endoscopic visualisation. If an anastomotic leak is identified intraoperatively, there are various management options. Redo anastomosis is a possibility, but may be difficult in some cases. Defunctioning is another option, but there is an associated morbidity and signficant detrimental effect on quality of life. Direct transanal repair is only possible when a low anastomosis has been performed. When the anastomotic leak occurs high in the rectum or a partial mesorectal excision is performed a transanal approach is technically very challenging. We present our experience with transanal minimally invasive surgery (TAMIS) approach for anastomotic assessment and repair in four patients. In all cases, a colorectal anastomosis was performed and the air insufflation test was positive. We assessed the anastomosis with TAMIS. In three cases, a defect was found and subsequently sutured. In one case, a scar in the rectal mucosa was found and reinforced with a suture. A protective ileostomy was performed in two cases, while in the other two cases, no stoma was added. All four patients were discharged with no further complications. Both protective ileostomies were taken down after radiological and endoscopic confirmation of anastomotic integrity and all 4 anastomoses remain intact after follow-up. TAMIS intraoperative assessment and repair of anastomotic leak is a safe and feasible technique whcih may avoid the need for a defunctioning stoma.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Intraoperative Colonoscopy During Colorectal Surgery Does Not Increase Postoperative Complications: An Assessment From the ACS-NSQIP Procedure-targeted Cohort

Intraoperative colonoscopy (IOC) is an adjunct in colorectal surgery to detect the location of the lesions and assessing anastomotic integrity. The authors aimed to evaluate the safety and feasibility and postoperative morbidity of IOC in left-sided colectomy patients for colorectal cancer. Patients undergoing elective left-sided colectomy without any proximal diversion for colorectal cancer between 2013 and 2016 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database. Demographics, comorbidities, short-term outcomes, and postoperative morbidity of patients were evaluated. A total of 8811 patients were identified and IOC was performed for 1143 (12.97%) patients. There was no significant difference in postoperative complications between the IOC and non-IOC groups. Patients with IOC had shorter total hospital length of stay. The use of IOC does not adversely affect short-term outcomes after colorectal resections. Surgeons may utilize IOC liberally for left-sided colorectal resections.

Intraoperative testing of colorectal anastomosis and the incidence of anastomotic leak: A meta-analysis

BACKGROUND

AL remains one of the most threatening complications in colorectal surgery. Significant efforts are put to understand the pathophysiological mechanisms involved in the development of leakage and to create the strategies to prevent it. We aimed to determine whether intraoperative testing of mechanical integrity and perfusion of colorectal anastomosis could reduce the incidence of AL.

METHODS

A systematic review and meta-analysis of papers published before November 2019 on PubMed, Scopus, Web of Science, and Cochrane Library databases and comparing intraoperative testing of the colorectal anastomosis with standard care were conducted. Odds ratios (ORs) and 95% confidence interval (CIs) were used to assess the association between intraoperative testing and AL.

RESULTS

A total of 23 studies totaling 7115 patients were included. Pooled analysis revealed intraoperative tests, for integrity (OR 0.52, 95% CI 0.34-0.82, P < .001) and perfusion (OR 0.40, 95% CI 0.22-0.752, P < .001) of the lower gastrointestinal tract anastomoses are associated with significantly lower AL rate.

CONCLUSIONS

Intraoperative testing for either integrity or perfusion of anastomoses both reduce the AL rate. Studies looking at the combination of these two testing methods of anastomosis, especially intraoperative endoscopy, and indocyanine green fluorescence angiography may be very promising to further reduction of the AL.

Experimental Study of Mechanical Integrity Testing in Stapled Large Bowel: Methylene Blue Leak Test Is Not Inferior to Air Leak Test

Background/Objectives

Anastomotic leakage remains the most devastating postoperative complication in colorectal surgery. The mechanical integrity of the newly formed colorectal anastomosis can be evaluated by visual inspection intraoperatively; both air leak and liquid leak tests are also used to evaluate the integrity of stapled colorectal anastomoses. It is not clear whether double-stapled anastomoses are more prone to leaks than single-stapled anastomoses. The aim of our study was to compare the methylene blue and the air leak test in the experimental setting of single-stapled and double-stapled porcine bowels.

Methods

Twenty-four distal colons were excised from slaughtered pigs without delay. The proximal bowel end was closed with a linear stapler using blue cartridges. The bowels were randomly divided into single-stapled or double-stapled groups. Air leak and methylene blue leak tests were performed. A digital pressure monitor with a gradual pressure increase function was used to both gradually increase pressure within the bowel and to determine the pressure at which the stapler line disintegrated.

Results

Air leakage occurred at a mean pressure of 51.62 (±16.60) mm Hg and methylene blue leakage occurred at 46.54 (±16.78) mm Hg (p = 0.31). The air and methylene blue leaks occurred at comparable pressures in single-stapled bowels and in double-stapled bowels (47.21 [±14.02] mm Hg vs. 50.96 [±19.15] mm Hg, p = 0.6).

Conclusions

The methylene blue solution leak test is not inferior to the air leak test. There is no significant difference in bursting pressure between single-stapled and double-stapled anastomoses.

Utility of intra-operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta-analysis

BACKGROUND

Anastomotic leak (AL) after colorectal resection leads to increased oncological and non-oncological, morbidity and mortality. Intra-operative assessment of a colorectal anastomosis with intra-operative flexible sigmoidoscopy (IOFS) has become increasingly prevalent and is an alternative to conventional air leak test. It is thought that intra-operative identification of an AL or anastomotic bleeding (AB) allows for immediate reparative intervention at the time of anastomosis formation itself. We aim to assess the available evidence for the use of IOFS to prevent complications following colorectal resection.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature between January 1980 and June 2020 was performed. Comparative studies assessing IOFS versus conventional air leak test were compared, and outcomes were pooled.

RESULTS

A total of 4512 articles were assessed, of which eight were found to meet the inclusion criteria. A total of 1792 patients were compared; 884 in the IOFS arm and 908 in the control arm. IOFS was associated with an increase in the rate of positive leak test (odds ratio (OR) 5.21, P > 0.001), a decrease in AL (OR 0.45, P = 0.006) and a decrease in post-operative AB requiring intervention (OR 0.40, P = 0.037).

CONCLUSION

In a non-randomized meta-analysis, IOFS increases the likelihood of identifying an anastomotic defect or bleeding intra-operatively. This allows for immediate intervention that decreases the rate of AL and AB. This adds impetus for performing routine IOFS after a left-sided colorectal resection with anastomosis and highlights the need for randomized controlled trial to confirm the finding.

Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis

AIM

Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity.

METHODS

PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates.

RESULTS

Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB.

CONCLUSION

This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis

BACKGROUND

Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL.

METHODS

A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology.

RESULTS

Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87).

CONCLUSIONS

This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery.

Use of laparoscopic equipment for colonoscopy intraoperatively in case of lack of colonoscope

In the case where intraoperative endoscopy is necessary and there is no endoscope available in the hospital, there is a solution, the use of available laparoscopic equipment. The technique is simple and without being time consuming. All its needed is a laparoscopic video- camera, and laparoscopic ports. The whole procedure takes place in the surgical field and provides an immediate solution for the endoscopic inspection of stomach, small intestine and large intestine. We describe the first case where it takes place in an open right colectomy in a patient with colon cancer and a suspicious lesion at the left colon. Further studies are needed to evaluate the indications and the effectiveness of the method.

Feasibility and Safety of Intraoperative Colonoscopy after Segmental Colectomy and Primary Anastomosis

Patients presenting with near-obstructing colon lesions requiring segmental colectomy may benefit from intraoperative colonoscopy (IOC) after primary anastomosis for a more timely and accurate diagnosis of synchronous lesions. The aim of this study is to demonstrate the feasibility and safety of this technique. A retrospective cohort study of patients undergoing single-stage segmental colectomy and anastomosis at a single tertiary care institution from 2011 to 2013 was performed. One Hundred and sixty-eight consecutive patients underwent segmental colectomy and primary anastomosis of which 78 (46%) were unable to receive preoperative colonoscopy (POC) because of near-obstructing lesions and received IOC after the anastomosis. IOC detected synchronous adenomatous polyps in 24.4 per cent, diverticular disease in 19 per cent, and colitis/proctitis in 2.5 per cent. The IOC group was not significantly different from the POC group with regard to overall morbidity (31% vs 39% P = 0.45), anastomotic leakage (1.3% vs 0%, P = 0.46), or wound infection (5.1% vs 1.1%, P = 0.18). Operation time was 19 minutes longer in the intra-operative group, but overall length of hospital stay was not significantly different (6.4 ± 2.9 days vs 7.3 ± 4.6 days). In patients unable to receive POC because of partial obstruction, IOC after primary anastomosis is both feasible and safe for detecting proximal synchronous lesions.

Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery

INTRODUCTION

In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice.

METHODS

We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review.

RESULTS

The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery.

CONCLUSION

Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery.

An endoscopic mucosal grading system is predictive of leak in stapled rectal anastomoses

BACKGROUND

Anastomotic leak is a devastating postoperative complication following rectal anastomoses associated with significant clinical and oncological implications. As a result, there is a need for novel intraoperative methods that will help predict anastomotic leak.

METHODS

From 2011 to 2014, patient undergoing rectal anastomoses by colorectal surgeons at our institution underwent prospective application of intraoperative flexible endoscopy with mucosal grading. Retrospective review of patient medical records was performed. After creation of the colorectal anastomosis, application of a three-tier endoscopic mucosal grading system occurred. Grade 1 was defined as circumferentially normal appearing peri-anastomotic mucosa. Grade 2 was defined as ischemia or congestion involving <30% of either the colon or rectal mucosa. Grade 3 was defined as ischemia or congestion involving >30% of the colon or rectal mucosa or ischemia/congestion involving both sides of the staple line.

RESULTS

From 2011 to 2014, a total of 106 patients were reviewed. Grade 1 anastomoses were created in 92 (86.7%) patients and Grade 2 anastomoses were created in 10 (9.4%) patients. All 4 (3.8%) Grade 3 patients underwent immediate intraoperative anastomosis takedown and re-creation, with subsequent re-classification as Grade 1. Demographic and comorbidity data were similar between Grade 1 and Grade 2 patients. Anastomotic leak rate for the entire cohort was 12.2%. Grade 1 patients demonstrated a leak rate of 9.4% (9/96) and Grade 2 patients demonstrated a leak rate of 40% (4/10). Multivariate logistic regression associated Grade 2 classification with an increased risk of anastomotic leak (OR 4.09, 95% CI 1.21-13.63, P = 0.023).

CONCLUSION

Endoscopic mucosal grading is a feasible intraoperative technique that has a role following creation of a rectal anastomosis. Identification of a Grade 2 or Grade 3 anastomosis should provoke strong consideration for immediate intraoperative revision.

Intraoperative colonoscopy in patients with colorectal cancer: Review of recent developments

The use of intraoperative colonoscopy has increased alongside progress in the development of colonoscopy-associated devices and techniques, including the colonoscope itself. In the present review, we focus on four circumstances in which intraoperative colonoscopy is beneficial to colorectal surgery: (i) intraoperative determination of a tumor's location; (ii) observation of the proximal colon in cases of obstructive colorectal cancer; (iii) confirmation of the integrity of anastomosis; and (iv) novel surgical techniques that combine laparoscopic and endoscopic surgery. In light of the findings of our review, a combination of colonoscopy and surgery-especially laparoscopic surgery-is expected to facilitate the optimal handling of a variety of colorectal tumors, ranging from benign cases to advanced and obstructive cases.

Is the intraoperative air leak test effective in the prevention of colorectal anastomotic leakage? A systematic review and meta-analysis

OBJECTIVE

The intra-operative air leak test (ALT) is a common intraoperative test used to identify mechanically insufficient anastomosis. This meta-analysis aims to determine whether ALT aids to the reduction of postoperative colorectal anastomotic leakage (CAL).

METHODS

A literature search was performed to select studies in acknowledged databases. Full text articles targeting ALT during colorectal surgery were included. Quality assessment, risk of bias, and the level-of-evidence of the inclusions were evaluated. ALT methodology, ALT(+) (i.e., leak observed during the test) rate, and postoperative CAL rate of the included studies were subsequently analyzed.

RESULTS

Twenty studies were included for analysis, in which we found substantial risks of bias. A lower CAL rate was observed in patients who underwent ALT than those did not; however, the difference was not significant (p = 0.15). The intraoperative ALT(+) rate greatly varied among the included studies from 1.5 to 24.7 %. ALT(+) patients possessed a significantly higher CAL rate than the ALT(-) patients (11.4 vs. 4.2 %, p < 0.001).

CONCLUSIONS

Based on the available evidence, performing an ALT with the reported methodology has not significantly reduced the clinical CAL rate but remains necessary due to a higher risk of CAL in ALT(+) cases. Unfortunately, additional repairs under current methods may not effectively decrease this risk. Results of this review urge a standardization of ALT methodology and effective methods to repair ALT(+) anastomoses.

Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?

AIM

The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test.

METHOD

All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test.

RESULTS

A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%.

CONCLUSIONS

Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.

Diverting ileostomy in colorectal surgery: when is it necessary?

PURPOSE

The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice.

METHODS

Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion.

RESULTS

Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion.

CONCLUSIONS

Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.

Intraoperative assessment of colorectal anastomotic integrity: a systematic review

BACKGROUND

Surgeons have attempted to minimize postoperative anastomotic complications by employing intraoperative tests and manoeuvres to assess colorectal anastomotic integrity. These have evolved over time with improvement in operative technology and techniques. This systematic review aims to examine the impact of such intraoperative assessments.

METHODS

A systematic review of studies assessing intraoperative anastomotic assessments and their impact on postoperative anastomotic complications was performed. Intraoperative measures undertaken as a result of intraoperative assessments and postoperative anastomotic complications were analysed.

RESULTS

37 Studies were identified. 13 studies evaluated basic mechanical patency tests, ten studies evaluated endoscopic visualisation techniques and 14 studies evaluated microperfusion techniques. Postoperative anastomotic complications were significantly lower in patients tested with basic mechanical patency tests compared to those untested (non-RCT: 4.1 vs. 8.1 %, p = 0.03, RCTs: 5.8 vs. 16.0 %, p = 0.024). There were no differences in postoperative anastomotic complications between tested and non-tested cohorts in non-randomised cohort studies evaluating endoscopic visualisation techniques. However, intraoperative measures taken after abnormal intraoperative tests may have reduced the number of postoperative complications. Perfusion analysis techniques are not in routine widespread clinical practice as yet, but newer techniques such as fluorescent dyes and imaging under near infrared light show technical feasibility.

CONCLUSIONS

Intraoperative colorectal anastomotic assessment has evolved together with advancement of technology in the surgical setting. Moderate benefit in terms of lower postoperative anastomotic complications has been shown with basic mechanical patency testing and more recently with intraoperative endoscopic visualisation of colorectal anastomoses. The next advance and possible introduction into routine practice may include the use of microperfusion techniques. The latest in this group of techniques, which utilise autofluorescent dyes such as Indocyanine green, hold great potential. Well-planned controlled studies or ideally, randomised controlled trials need to be conducted to further assess the benefit of these latest techniques.

Prediction and diagnosis of colorectal anastomotic leakage: A systematic review of literature

Although many studies have focused on the preoperative risk factors of anastomotic leakage after colorectal surgery (CAL), postoperative delay in diagnosis is common and harmful. This review provides a systematic overview of all available literature on diagnostic tools used for CAL. A systematic search of literature was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. Articles were selected when a diagnostic or prediction tool for CAL was described and tested. Two reviewers separately assessed the eligibility and level of evidence of the papers. Sixty-nine articles were selected (clinical methods: 11, laboratory tests: 12, drain fluid analysis: 12, intraoperative techniques: 22, radiology: 16). Clinical scoring leads to early awareness of probability of CAL and reduces delay of diagnosis. C-reactive protein measurement at postoperative day 3-4 is helpful. CAL patients are characterized by elevated cytokine levels in drain fluid in the very early postoperative phase in CAL patients. Intraoperative testing using the air leak test allows intraoperative repair of the anastomosis. Routine contrast enema is not recommended. If CAL is clinically suspected, rectal contrast-computer tomography is recommended by a few studies. In many studies a “no-test” control group was lacking, furthermore no golden standard for CAL is available. These two factors contributed to a relatively low level of evidence in the majority of the papers. This paper provides a systematic overview of literature on the available tools for diagnosing CAL. The study shows that colorectal surgery patients could benefit from some diagnostic interventions that can easily be performed in daily postoperative care.

Evaluating the vascularity of intestinal anastomoses--can narrow band imaging play a role?

A variety of factors are critical for the success of bowel anastomoses. The most crucial patient factor is adequate vascularity of the bowel ends which are to be anastomosed. Currently, intraoperative features such as healthy looking bleeding edges of the bowel are considered to be signs of adequate vascular supply. However, once the anastomosis is performed, external appearances may not be reliable. In order to improve evaluation of the bowel as well as the anastomosis, our group has adopted the routine use of post-anastomosis intraoperative colonoscopy. Intraoperative colonoscopy provides vital information regarding the integrity of the anastomosis (leak testing) and also visualizes the mucosa of the bowel. Narrow Band Imaging (NBI) is a novel real-time imaging technique which is an integral component of many modern colonoscopes. We hypothesize that NBI assessment of vascularity at the time of intestinal anastomosis can improve safety and reduce the risks of anastomotic complications following surgery.

Increased utilization of flexible endoscopic methods during colorectal resection over a 3-year period

INTRODUCTION

Intraoperative endoscopy (IE) is performed during some colorectal resections (CRR) mainly to inspect circular stapled anastomoses (CSA) and to locate small neoplasms. This study's purpose was to determine how often rigid and flexible lower endoscopic methods were used during CRR by one colorectal surgeon over three 1-year periods.

METHODS

Data concerning the indication for surgery and IE, type of resection, and the use of rigid and flexible methods were obtained from a prospective database and from hospital charts during Period 1 (P1), 1/1/05 to 12/31/05; P2, 7/1/06 to 6/31/07; and P3, 7/01/07 to 6/30/08. The endoscopic CO2 insufflation device was introduced during P2. The utilization rates (UR) for rigid and flexible methods and the overall UR in each time period were compared. The chi(2) and Fisher exact test were used for analysis.

RESULTS

No significant differences were found in overall endoscopy UR between periods (94-109/per period.) A significantly higher flexible UR was noted during P3 (43.1% of all CRR) than during P1 (18.6%, P < .001) or P2 (28.7%, P < .03). There was a concomitant significant drop in the rigid UR during Period 3 (1.8% of all CRR) when compared with P1 (24.5%, P < .001) or P2 (27.7%, P < .001).

CONCLUSION

The overall UR did not significantly vary; however, during P3 the flexible UR increased whereas the rigid UR decreased (vs P1, P2; P < .05). The addition of extra endoscopes and an endoscopic CO2 insufflation device to the operating room coincided with increased flexible UR.