Gastrointestinal anastomoses. Factors affecting early complications

Experience sharing on perioperative clinical management of gastric cancer patients based on the "China Robotic Gastric Cancer Surgery Guidelines"

BACKGROUND

With the popularization of robotic surgical systems in the field of surgery, robotic gastric cancer surgery has also been fully applied and promoted in China. The Chinese Guidelines for Robotic Gastric Cancer Surgery was published in the Chinese Journal of General Surgery in August 2021.

METHODS

We have made a detailed interpretation of the process of robotic gastric cancer surgery regarding the indications, contraindications, perioperative preparation, surgical steps, complication, and postoperative management based on the recommendations of China's Guidelines for Robotic Gastric Cancer Surgery and supplemented by other surgical guidelines, consensus, and single-center experience.

RESULTS

Twenty experiences of perioperative clinical management of robotic gastric cancer surgery were described in detail.

CONCLUSION

We hope to bring some clinical reference values to the front-line clinicians in treating robotic gastric cancer surgery.

TRIAL REGISTRATION

The guidelines were registered on the International Practice Guideline Registration Platform ( http://www.guidelines-registry.cn ) (registration number: IPGRP-2020CN199).

Systematic Review and Meta-Analysis on Colorectal Anastomotic Techniques

Purpose

Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery.

Methods

A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK).

Results

All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques' current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions.

Conclusion

Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons' levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body's natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions.

Effects of glycerol and sodium pentaborate containing new formulation on sleeve gastrectomy model in rats

Purpose:

The development of cutting surface leakage and postoperative peritoneal adhesions (PPA) after sleeve gastrectomy (SG) are the most serious operative complications. We investigated the effectiveness of the newly developed glycerol and sodium pentaborate containing formulation on the prevention of these complications.

Methods:

Sixteen Sprague Dawley rats (mean weight 310 ± 50 g, mean age 3 months old) were divided into two groups, consisting of eight rats in each. SG and a double-layer suture technique were performed for each group. In study group, there was the mixture of 2 mL 3% glycerol plus 3% sodium pentaborate formulation, and in the control group 2 mL 0.9% NaCl was injected into the peritoneal cavity. Rats were sacrificed after 30 days, then macroscopic adhesion grade scoring and histopathological evaluations were assessed.

Results:

Macroscopic PPA scores in the control and study groups were 2.75 ± 0.16 and 1.50 ± 0.327, respectively (p = 0.004). Histopatologic fibrosis scores in the control and study groups were 0.87 ± 0.125 and 2.00 ± 0.26, respectively (p = 0.002).

Conclusions:

In SG operation model, glycerol plus sodium pentaborate compound decreased PPA formation and also increased stomach cut surface line fibrosis. This new formulation is hopeful for more safe SG operations.

Iatrogenic injury of duodenum: malady of a therapeutic misadventure

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

Gastrostomy as a Preemptive Measure after Pancreatoduodenectomy against Delayed Gastric Emptying: A Small Case Series and a Review of the Literature

Delayed gastric emptying (DGE) is a common (20–30%) postoperative complication following pancreatoduodenectomy (PD) (Parmar et al., 2013). Various causes and preemptive measures have been suggested to decrease the occurrence of DGE. We added a simple step in the procedure of 26 consecutive pancreatic head resections, which seems to alleviate DGE and has never been highlighted before.

Risk of anastomotic bleeding after left colectomy with preservation of inferior mesenteric artery for diverticular disease: preliminary results

BACKGROUND

The inferior mesenteric artery (IMA) preservation in elective laparoscopic left colectomy for diverticular disease may reduce the risk of anastomotic leakage. However, an increased risk of bleeding is assumed. The aim of this study was to investigate the risk of colorectal anastomosis bleeding when IMA is resected or preserved during left colectomy.

METHODS

A retrospective study of a prospectively collected database was performed. All patients who underwent elective left colectomy, from December 2018 to September 2020 were included. Patients' data and clinical information were collected and analyzed. Patients were categorized in two groups: IMA resected (IMA-R) and IMA preserving (IMA-P) left colectomy. Perioperative outcomes between the two groups were compared.

RESULTS

Sixty-three consecutive patients who underwent left colectomy over a period of three years were enrolled: 42 in IMA-R group and 22 in the IMA-P group. There were no significant differences in demographic and intraoperative characteristics between the two groups, except for patients' age and primary disease. Six patients (9.37%) developed anastomotic bleeding during recovery, more frequently in the IMA-P than IMA-R group, although the difference is not statistically significative (13.6% and 7.3%; P=0.406). All bleedings were self-limited and only one needed red blood cells transfusion. Using the bioabsorbable staple line reinforcement (BSLR) has proved to be advantageous in preventing anastomotic bleeding in the IMA-P group.

CONCLUSIONS

IMA preserving left colectomy seems to be associated with a higher risk of mostly self-limited anastomotic bleeding during recovery. BSLR seems to be effective in this group of patients.

Computed Tomography Findings at 6th Month Related to Chronic Anastomotic Complications After Rectal Surgery

Objective

This study aimed to assess a radiologic test and clinical findings as risk factors of chronic complications after anastomotic leakage (CCAL) in rectal surgery.

Summary of Background Data

Anastomotic leakage (AL) is the most important complication that is related to chronic complications like unhealed chronic sinuses, strictures, and infections.

Methods

This retrospective study included patients who developed anastomotic leakage (AL) after undergoing extraperitoneal anastomosis. Patients with the following characteristics were excluded: (1) patients with no anastomoses, (2) patients undergoing multiple resections due to synchronous colorectal lesions, (3) patients with no curative resections of the primary lesions, and (4) patients experiencing immediate postoperative mortality. Finally, 72 patients were analyzed in this study. The patients were divided into the no chronic complication (NCC) group and the chronic complication (CC) group.

Results

Of the 72 included patients, 17 (23.6%) had CCAL. The patients in the CC group more frequently had radiotherapy and lower tumor compared to the patients in the NCC group. A total of 52 (52/55 [94.5%]) and 4 patients (4/17 [23.5%]) in the NCC group and the CC group achieved bowel continuity 3 years after the primary surgery, respectively (P < 0.0001). According to the multivariate analysis, CT findings at the sixth postoperative month and tumor height were associated with CCAL (P < 0.0001 and P = 0.046, respectively).

Conclusion

This study showed that CT findings at the 6th postoperative month and tumor height were possibly associated with CCAL.

Factors associated with dehiscence and mortality rates following gastrointestinal surgery in dogs

OBJECTIVE

To identify factors associated with dehiscence and mortality rates following gastrointestinal surgery in dogs.

ANIMALS

170 client-owned dogs that underwent gastrointestinal surgery from 2010 to 2016.

PROCEDURES

Medical records of all included dogs were reviewed to collect information on preoperative (breed, sex, age, body weight, American Society of Anesthesiologists [ASA] physical status classification, emergency status, and plasma lactate concentration), intraoperative (indication for surgery, type of surgery, and whether bacterial peritonitis was identified), and postoperative (development of dehiscence and survival status at 2 weeks after surgery) factors. Preoperative and intraoperative factors were evaluated for associations among each other and with postoperative factors.

RESULTS

Univariate analyses revealed that preoperative plasma lactate concentration increased with increasing ASA status, and lactate concentrations were significantly higher for nonsurvivors (mean ± SD, 4.6 ± 3.7 mmol/L) than for survivors (2.4 ± 1.7 mmol/L). Multivariate analysis controlling for age, body weight, and plasma lactate concentration revealed that dogs with an ASA status ≥ 3 were more likely to develop dehiscence after gastrointestinal surgery than were dogs with a lower ASA status (OR, 17.77; 95% confidence interval, 2.17 to 144.06). Multivariate analysis also revealed that dogs with an ASA status ≥ 3 or high lactate concentration were less likely to survive than were other dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

These findings regarding ASA status and preoperative plasma lactate concentration and their associations with outcome may help clinicians to determine and provide optimal perioperative care to dogs requiring gastrointestinal surgery as well as to inform owners about prognosis.

Experimental fortification of intestinal anastomoses with nanofibrous materials in a large animal model

Anastomotic leakage is a severe complication in gastrointestinal surgery. It is often a reason for reoperation together with intestinal passage blockage due to formation of peritoneal adhesions. Different materials as local prevention of these complications have been studied, none of which are nowadays routinely used in clinical practice. Nanofabrics created proved to promote healing with their structure similar to extracellular matrix. We decided to study their impact on anastomotic healing and formation of peritoneal adhesions. We performed an experiment on 24 piglets. We constructed 3 hand sutured end-to-end anastomoses on the small intestine of each pig. We covered the anastomoses with a sheet of polycaprolactone nanomaterial in the first experimental group, with a sheet of copolymer of polylactic acid with polycaprolactone in the second one and no fortifying material was used in the Control group. The animals were sacrificed after 3 weeks of observation. Clinical, biochemical and macroscopic signs of anastomotic leakage or intestinal obstruction were monitored, the quality of the scar tissue was assessed histologically, and a newly developed scoring system was employed to evaluate the presence of adhesions. The material is easy to manipulate with. There was no mortality or major morbidity in our groups. No statistical difference was found inbetween the groups in the matter of level of peritoneal adhesions or the quality of the anastomoses. We created a new adhesion scoring system. The material appears to be safe however needs to be studied further to prove its' positive effects.

Association Between Circular Stapler Diameter and Stricture Rates Following Gastrointestinal Anastomosis: Systematic Review and Meta-analysis

BACKGROUND

Stricture is a common complication of gastrointestinal (GI) anastomoses, associated with impaired quality of life, risk of malnutrition, and further interventions. This systematic review and meta-analysis aimed to determine the association between circular stapler diameter and anastomotic stricture rates throughout the GI tract.

METHODS

A systematic literature search of EMBASE, MEDLINE and Cochrane Library was performed. The primary outcome was the rate of radiologically or endoscopically confirmed anastomotic stricture. Pooled odds ratios (OR) were calculated using random-effects models to determine the effect of circular stapler diameter on stricture rates in different regions of the GI tract.

RESULTS

Twenty-one studies were identified: seven oesophageal, twelve gastric, and three lower GI. Smaller stapler sizes were strongly associated with higher anastomotic stricture rates throughout the GI tract. The oesophageal anastomosis studies showed; 21 versus 25 mm circular stapler: OR 4.39 ([95% CI 2.12, 9.07]; P < 0.0001); 25 versus 28/29 mm circular stapler: OR 1.71 ([95% CI 1.15, 2.53]; P < 0.008). Gastric studies showed; 21 versus 25 mm circular stapler: OR 3.12 ([95% CI 2.23, 4.36]; P < 0.00001); 25 versus 28/29 mm circular stapler: OR 7.67 ([95% CI 1.86, 31.57]; P < 0.005). Few lower GI studies were identified, though a similar trend was found: 25 versus 28/29 mm circular stapler: pooled OR 2.61 ([95% CI 0.82, 8.29]; P = 0.100).

CONCLUSIONS

The use of larger circular stapler sizes is strongly associated with reduced risk of anastomotic stricture in the upper GI tract, though data from lower GI joins are limited.

Peripheral vs pedicle division in laparoscopic resection of sigmoid diverticulitis: a 10-year experience

PURPOSE

Laparoscopic rectosigmoid resection is the standard surgical treatment for recurrent sigmoid diverticulitis. However, speaking of mesenterium division, no unique standard procedure is actually provided. Surgeons can perform it at the level of either the sigmoid vessels or the inferior mesenteric vessels. The objective of this study was to compare intra- and postoperative complications of both techniques.

METHODS

From a prospective collected database of patients that underwent elective laparoscopic sigmoid resection between January 2004 and December 2014, a retrospective analysis according to the selected operative technique was performed.

RESULTS

A total of 1016 patients were operated, and a pedicle division of the mesenteric vessels was performed in 280 patients (central group 27.6%) while a peripheral division was performed in 736 patients (peripheral group 72.4%). Comparison of these two groups demonstrated no statistically significant difference regarding age or stage of disease. Thirteen patients (1.3%) developed anastomotic leak; among them, nine belonged to the peripheral group (1.2 vs 1.4% p = 0.794). Twenty-four patients (2.4%) developed postoperative rectal bleeding but only in nine cases was a bleeding of the anastomosis confirmed using endoscopy (seven peripheral group vs two central group, 0.95 vs 0.7% p = 0.712). Moreover, postoperative morbidity did not significantly differ between the two groups. A very low mortality rate was observed, with 2 deaths (both in the peripheral group).

CONCLUSIONS

Ligation of inferior mesenteric vessels does not seem to affect anastomotic healing; both surgical techniques presented similar incidence of anastomotic bleeding. In this analysis, we could not identify any significant difference in overall morbidity and mortality.

Increased Intraoperative Vasopressor Use as Part of an Enhanced Recovery After Surgery Pathway for Pancreatectomy Does Not Increase Risk of Pancreatic Fistula

Purpose: Enhanced recovery after surgery (ERAS) pathways are increasingly implemented. Goal directed fluid therapy (GDFT) is a core component of ERAS pathways that limit excessive volume administration and is associated with increased use of intraoperative vasopressors. Vasopressor effects on anastomotic healing and pancreatic fistula are inconclusive. We hypothesized that intraoperative vasopressor use in an ERAS GDFT algorithm would not increase risk of pancreatic fistulas. Methods: We reviewed all adult patients undergoing pancreatectomy at an academic institution from January 2013 to February 2016, before and after implementation of an ERAS pathway in July 2014. Retrospective chart review was performed. Log-binomial regression, weighted by stabilized inverse probability-of-treatment weights, estimated effect of ERAS and intraoperative vasopressors on fistula risk. Results: One hundred thirty two patients met inclusion criteria: 74 (56.1%) in the ERAS cohort. No significant differences in overall leak risk (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.38-2.09) were observed between the ERAS and pre-ERAS cohorts. Similarly, vasopressor infusions, independent of ERAS pathway, did not significantly increase the risk of anastomotic leaks (RR 1.19, 95% CI 0.52-2.72). Conclusions: Increased use of vasopressor infusions as part of an ERAS pathway for pancreatic surgery is not associated with an increase in the risk of clinically significant pancreatic fistulas.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats

INTRODUCTION

This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy.

METHODS

32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1β) plasma levels.

RESULTS

Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1β plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU.

CONCLUSION

Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

Selective matrix metalloproteinase inhibition increases breaking strength and reduces anastomotic leakage in experimentally obstructed colon

PURPOSE

Colonic obstruction causes loss of collagen and impairment of anastomotic integrity by matrix metalloproteinases (MMPs). Unexpectedly, pharmacological MMP inhibition increased anastomotic leakage (AL) in obstructed colon possibly due to the non-selective nature of these compounds and the experimental model applied. We therefore studied the effects of selective MMP inhibition on the healing of anastomoses in colon obstructed by a novel laparoscopic technique.

METHODS

Left colon was obstructed in 38 male Sprague-Dawley rats (226-284 g). After 12 h, stenoses were resected and end-to-end anastomoses constructed. Baseline breaking strength was determined in 6 animals on day 0. The remaining 32 rats were randomized to daily treatment with the selective MMP-8, MMP-9, and MMP-12 inhibitor AZD3342 (n = 16) or vehicle (n = 16). On day 3, anastomoses were evaluated for AL and breaking strength. Isolated anastomotic wound tissue was analyzed on total collagen and pepsin-insoluble and pepsin-soluble collagen by hydroxyproline. The soluble collagens were further differentiated into native, measured by Sircol, and fragmented forms.

RESULTS

Baseline breaking strength was maintained with AZD3342 but decreased by 25% (P = 0.023) in the vehicle group. The anastomotic breaking strength of AZD3342-treated rats was 44% higher (P = 0.008) than the vehicle-treated rats. Furthermore, the AL rate was reduced (P = 0.037) with AZD3342 compared with vehicle treatment. AZD3342 treatment influenced neither the total or insoluble collagen concentrations nor the degree of fragmentation of the soluble collagen triple helices.

CONCLUSION

Selective MMP inhibition increased anastomotic breaking strength and reduced AL after resection of colonic obstruction.

Gastroduodenal and pancreatic surgeries: indications, surgical techniques, and imaging features

This review article focuses on gastroduodenal and pancreatic surgeries with the goal of identifying radiologic findings that translate to important surgical considerations. The topics covered include partial gastrectomy with reconstruction techniques, total gastrectomy, pancreaticoduodenectomy, and pancreaticojejunostomy. Indications, contraindications, surgical techniques, and postoperative imaging are described within each of these topics. Knowledge of these surgical techniques is extremely helpful for the interpreting radiologists to identify expected postoperative anatomy and related complications that would remain clinically relevant to our surgical colleagues and direct timely patient management.

Successful endoscopic treatment of stapled J-pouch ileoanal canal anastomotic hemorrhage by argon plasma coagulation: a case report

Background

Continuous lower gastrointestinal hemorrhage is a rare condition, but it often requires proper management. We report a case of a patient with gastrointestinal hemorrhage 18 years after stapled J-pouch ileoanal canal anastomosis who was successfully treated with argon plasma coagulation.

Case presentation

Our patient was a 54-year-old Japanese man who had developed ulcerative colitis 28 years ago. A J-shaped ileal pouch-anal anastomosis with a double-staple technique was indicated 18 years ago when the patient became refractory to the conventional medication. When he presented to our hospital, 18 years after the operation, the patient complained of faintness and fresh blood in the stool of 2 days’ duration, and was admitted for investigation. Lower endoscopy revealed that the hemorrhage was from a neovascularization area close to the site of ileal pouch-anal anastomosis. Cap-assisted argon plasma coagulation was carried out for hemostasis, and complete hemostasis was achieved without complications.

Conclusions

We present a case of a patient with hemorrhage following a J-shaped ileal pouch-anal anastomosis with a double-staple technique performed 18 years ago. Argon plasma coagulation treatment was successful, suggesting the potential safety and effectiveness of colonoscopic electrocoagulation for controlling unremitting hemorrhage from a neovascularization area around a stapled ileoanal canal anastomotic site.

The effects of scalpel, harmonic scalpel and monopolar electrocautery on the healing of colonic anastomosis after colonic resection

Purpose

In our study, the effects of harmonic scalpel, scalpel, and monopolar electrocautery usage on the health and healing of colon anastomosis after resection was investigated.

Methods

In this study, 120 female albino Wistar rats were divided into 3 groups each containing 40 rats. Group A, resection with scalpel; group B, resection with monopolar electrocautery; group C, resection with harmonic scalpel. The groups were divided into 4 subgroups consisting of 10 rats and analysed in the postoperative 1st, 3rd, 5th, and 7th days. Anastomotic bursting pressures, hydroxyproline levels and histopathological parameters were surrogate parameters for evaluating wound healing.

Results

The tissue hydroxyproline levels did not show any significant difference between the groups and subgroups. The mean bursting pressure of group A on the 5th day was significantly higher than groups B and C (P < 0.001). When the fibroblast and fibrosis scores were evaluated, scores of group C on the 5th day were significantly higher than the other groups, but the results of bursting pressures and biochemical parameters did not support the fibroblast and fibrosis scores. There were not any significant differences between the groups in other histopathologic parameters.

Conclusion

The use of monopolar electrocautery needs more attention since the device causes tissue destruction. The obliterating effect of harmonic scalpel on luminal organs is an important problem, especially if an anastomosis is planned. Despite the disadvantages of scalpel, its efficacy on early wound healing is better than the other devices.

Cyanoacrylate application on colonic anastomosis: is it safe or not?

INTRODUCTION

Major complications of colonic anastomosis include fistula, bleeding, and anastomotic stricture, and the most common one is anastomotic leakage. Many organic or inorganic tissue adhesives are being used such as fibrin glue or cyanoacrylate to strengthen or protect colonic anastomosis. Up to now, a great number of studies have been carried out to investigate the effects of these biomaterials.

AIM

To determine the effect of cyanoacrylate application on anastomosis safety.

MATERIAL AND METHODS

In this experimental study, rats were divided into two groups; a control group and an experimental group. Full-thickness incisions were done on the left colon of the rats, and then end-to-end anastomosis was performed by using 5/0 silk separated sutures. In the experimental group we applied cyanoacrylate over the sutures. The samples were taken on the 7th day.

RESULTS

In the control group the average tissue hydroxyproline levels and the average bursting pressures were significantly higher than in the experimental group.

CONCLUSIONS

The purpose of all the experimental studies is to prevent and reduce anastomotic complications. Despite all the studies that have been done, colonic anastomosis complications continue to be a problem. As a result, we suggest that cyanoacrylate has a negative effect on the healing process of colonic anastomosis.

GM6001 Increases Anastomotic Leakage following Colonic Obstruction Possibly by Impeding Epithelialization

BACKGROUND

Emergency operations performed on an obstructed colon are accompanied by an increased risk of anastomotic insufficiency. Tissue-destructive matrix metalloproteinase (MMP) activity is elevated in the obstructed colon and contributes to a loss of suture-holding submucosal collagen, which may be mediated by tumor necrosis factor (TNF)-α. Our aim was to study the effect of the non-selective MMP and TNF-α converting enzyme (TACE) inhibitor GM6001 (30 mg/kg) on anastomosis repair in obstructed left colon. GM6001 has been proved to be highly efficacious in elective anastomosis rodent models.

METHODS

A partial obstruction of the distal colon was induced in male Sprague-Dawley rats. After 4 d the obstructed colonic segment was resected, and an end-to-end anastomosis was constructed. Seven days later, the anastomoses were evaluated for clinical leakage. Histopathological and immunohistochemical assessments were also performed. Finally, the direct effect of GM6001 on epithelialization was studied in cultured colonic epithelial cells.

RESULTS

Unlike the robust beneficial effect on anastomosis under uncomplicated conditions, here GM6001 had a negative impact on anastomotic wound healing following colonic obstruction and substantially (p=0.004) more rats in the GM6001 group (75%) than in the control group (11%) had developed anastomotic leakage. In the anastomotic wounds, the myofibroblast abundance and cell proliferation were similar in the two groups. Histologically, GM6001 treatment resulted in wider and minimally epithelialized wounds that were commonly necrotic on the luminal side and infiltrated with numerous granulocytes. In vitro, GM6001 also delayed (p=0.026) epithelialization of denuded intestinal epithelium grown on type I collagen.

CONCLUSIONS

Non-selective MMP/TACE inhibition with GM6001 increased the anastomotic complications following colon obstruction. Inhibition of epithelialization is one possible mechanism responsible for the increased leakage following GM6001 treatment.

Infliximab treatment reduces tensile strength in intestinal anastomosis

BACKGROUND

The antitumor necrosis factor (infliximab [IFX]) has gained widespread use in the treatment of inflammatory bowel disease. However, several patients must undergo surgical treatment due to treatment failure and there is a potential risk that preoperative IFX treatment may have a negative effect on the healing process in intestinal anastomosis. The objective of this study was to examine the effect of repeated IFX treatment on anastomotic strength and degree of inflammation in the anastomotic line in the small intestine of rabbits.

METHODS

Thirty-two rabbits were randomized (2:1) to receive either repeated IFX treatment or placebo. On day 15, three separate end-to-end anastomoses were performed on the jejunum. On postoperative day 5, tensile strength and bursting pressure for the anastomoses were tested and histologic changes examined.

RESULTS

We found a significantly reduced tensile strength in the IFX group (1.94 ± 0.44 N) compared with the placebo group (3.33 ± 0.39 N), (P < 0.001). Calculation of Spearman correlation coefficients showed a positive significant correlation between minimal tensile strength and serum values of IFX (coefficient = -0.63; P = 0.003) as well as number of sutures in the tested anastomosis (coefficient = 0.51; P = 0.024). The general histologic score was significantly higher in the placebo group (5.00 ± 1.26 versus 3.31 ± 1.65, P = 0.03).

CONCLUSIONS

Repeated high-dose IFX treatment reduces tensile strength significantly in rabbits and should be investigated further as a potential risk factor of anastomotic dehiscence in inflammatory bowel disease surgery.

Risk factors for failure of percutaneous drainage and need for reoperation following symptomatic gastrointestinal anastomotic leak

BACKGROUND

Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks.

METHODS

Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD.

RESULTS

Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P = .03) and cancer surgery (P = .01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD.

CONCLUSIONS

Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Rapid morphological changes and loss of collagen following experimental acute colonic obstruction

PURPOSE

Anastomosis of an acutely obstructed colon is associated with an increased risk of dehiscence. In experimental models, acute obstruction decreases collagen in the colonic wall, but the time course and propagation along the colon of the biochemical changes are unknown. Furthermore, there is a paucity of information on the correlation between these biochemical changes and histological features.

METHODS

Forty male Sprague Dawley rats were subjected to partial obstruction by placing a silicone ring around the left colon 30 mm above the reflection. Obstruction was maintained for 0, 1, 2, 3 or 4 days. Samples from five different locations along the colon were analysed on circumference, tissue water content, collagen concentration and histomorphology. Neutrophil and macrophage infiltration was characterized immunohistochemically.

RESULTS

The colonic circumference and water content increased (p < 0.001), while the collagen concentration decreased by 48 % (p < 0.01) proximal to the obstruction already after 1 day. The degree of dilation and collagen reduction did not change significantly over the subsequent 3 days of obstruction, whereas the water content normalized by day 3. Mucosal and submucosal oedema and the relative neutrophil infiltration were highest after 1 day in the colonic segment proximal to the stenosis while the macrophage population continued to increase to day 4. Muscular necrosis in addition to ganglionitis and neuritis in the nervous plexus increased with duration of obstruction.

CONCLUSIONS

The pronounced and rapid changes of the composition of cells and the extracellular matrix of the colonic wall following acute obstruction may be of guidance for present surgical treatments and future pharmacological interventions.

The effect of fibrin glue on the intensity of colonic anastomosis in the presence and absence of peritonitis: an experimental randomized controlled trial on rats

Aim. Anastomotic leakage after colon anastomosis is the most frequent and most feared complication with its highest mortality rate. In this study, we aimed to expose the impact of performing fibrin glue on sutured colocolic anastomosis, in the presence of experimental peritonitis, on anastomosis safety. Method. In this experimental study, the rats were divided into two groups as control group (Groups 1 and 3) and experimental group (Groups 2 and 4). They were also divided as clean abdomen (Groups 1 and 2) and infected abdomen (3 and 4) groups. Full-thickness incisions were made on the proximal colon of both groups of rats. The control group's anastomoses were conducted only with sutures, whereas in experimental group, fibrin glue was applied over the sutures. The samples were taken on the 10th day. Results. Highest values for average levels of hydroxyproline in the tissues and anastomotic bursting pressures were detected when fibrin glue was applied on sutured anastomosis in clean abdomen. In the histopathological staging performed in line with Ehrlich-Hunt model, lowest values were detected during the presence of peritonitis. Conclusion. As a result, it has been established that the use of fibrin glue over sutured colocolic anastomosis, both in clean abdomen and in the presence of peritonitis, had increased anastomosis safety.

Identification of risk factors for esophagojejunal anastomotic leakage after gastric surgery

BACKGROUND

Despite the development of the surgical technique and improvements in perioperative management, anastomotic leakage still occurs at esophagojejunal anastomoses after total or proximal gastrectomy. Anastomotic leakage is one of the major complications of concern, chiefly because it can lead to death. The objective of the present study was to identify the risk factors for esophagojejunal anastomotic leakage.

METHODS

The study was based on retrospective analysis of the data of a total of 1,640 consecutive patients who underwent total, proximal, or completion gastrectomy, including esophagojejunal anastomosis, between 1999 and 2008.

RESULTS

Thirty-five patients (2.1 %) developed anastomotic leakage. Univariate analysis revealed patient age, pulmonary insufficiency, lymph node dissection, combined resection of other organs, omental resection, operative time, blood loss, intraoperative blood transfusion, and postoperative creatinine level were the significant factors influencing anastomotic leakage. Multivariate analysis identified pulmonary insufficiency and the duration of the operation as the predictors of anastomotic leakage.

CONCLUSIONS

To avoid leakage, surgeons should take care in creating the anastomosis in gastrectomy patients, particularly in cases of poor pulmonary function or when the procedure requires a longer operation.

A nationwide study on anastomotic leakage after colonic cancer surgery

AIM

Anastomotic leakage (AL) is a major challenge in colorectal cancer surgery due to increased morbidity and mortality. Possible risk factors should be investigated differentially, distinguishing between rectal and colonic surgery in large-scale studies to avoid selection bias and confounding.

METHOD

The incidence and risk factors associated with AL were analysed in an unselected nationwide prospective cohort of patient subjected to curative colonic cancer surgery with primary anastomosis and entered into The Danish Colorectal Cancer Group database between May 2001 and December 2008.

RESULTS

AL occurred in 593 (6.4%) of 9333 patients. Laparoscopic surgery [odds ratio (OR) 1.34; 95% confidence interval (CI) 1.05-1.70; P=0.03); left hemicolectomy (OR 2.02; 95% CI 1.50-2.72; P=0.01) or sigmoid colectomy (OR 1.69; 95% CI 1.32-2.17; P=0.01); intra-operative blood loss (OR 1.04; 95% CI 1.01-1.07; P=0.03); blood transfusion (OR 10.27; 95% CI 6.82-15.45; P<0.001) and male gender (OR 1.41; 95% CI 1.12-1.75; P=0.02) were associated with AL in the multivariate analysis.

CONCLUSION

The main finding that a laparoscopic approach was associated with an increased risk of AL should prompt close future monitoring. There was no evidence that centralization of surgery to high-volume hospitals reduced the rate of AL.

An alternative to conventional hand-sewing colocolic anastomosis: anastomosis with absorbable surgical barrier film without sutures

AIM

As a result of its high morbidity and mortality rates, anastomotic leakage is one of the most feared complications in colorectal surgery. Therefore, this issue is one of the most relevant in colorectal surgery and a lot of work has been conducted to research it. The aim of this experimental study was to compare colocolic anastomosis performed by using absorbable surgical barrier film without suture and conventional anastomosis performed by hand-sewing technique in terms of anastomosis safety.

METHOD

In this study, 40 Norway Wistar Albino 3-month-old female rats were used. Each weighed between 250 and 300g. The rates were divided into two groups, a control group and an experimental group. Full-thickness incisions were made on the ascending colon of both groups of rats. The control group's anastomoses were conducted using a hand-sewn technique consisting of one layer of nonabsorbable sutures (Gambee suture). The experimental group's anastomoses were performed using absorbable surgical barrier film without sutures. Afterwards, sample pieces of the anastomosis area were taken from all rats on either the 3rd or the 7th day following the operation, resulting in subgroups that led to a total of four test groups. The samples taken were subjected first to an anastomosis bursting pressure test followed by histopathological examinations and a test to detect the levels of hydroxyproline in the tissue.

RESULTS

The control groups (groups 1 and 3) had average anastomotic bursting pressures of 33.0±9.49mmHg and 146.0±15.06mmHg respectively, whereas experimental groups (groups 2 and 4) had average anastomotic bursting pressures of 58.0±10.33mmHg and 190.0±25.82mmHg respectively. Mann-Whitney U-test analysis of the bursting pressure values indicates the differences between groups 1 and 2 (3rd day postoperatively) and groups 3 and 4 (7th day postoperatively) to be statistically significant (P=0.0001 and P=0.0003 respectively). Values obtained from histopathological staging conducted according to the Ehrlich-Hunt model where the evaluation criteria in this model are: amount of inflammatory cells, fibroblasts, neovascularization and collagen and which were analysed using the Mann-Whitney U-test have shown no significant difference between 3rd day postoperatively groups 1 and 2 (P=0.579) while the difference between 7th day postoperatively groups 3 and 4 was found to be significant (P=0.023). Average levels of hydroxyproline in the tissue were 88.18±8.04mg/l for group 1, 56.31±5.40mg/l for group 2, 135.0± 6.30mg/l for group 3 and 100.2±15.42mg/l for group 4. Analysis of values in the groups using the Mann-Whitney U-test indicate a significant difference (P < 0.0001) both between groups 1 and 2 and between groups 3 and 4.

CONCLUSION

The use of absorbable surgical barrier film without sutures for colocolic anastomosis in rats may be safe.

A novel colonic anastomosis technique involving fixed polyglycolic acid mesh

BACKGROUND

Polyglycolic acid mesh (PAM) reinforcement of colonic anastomoses were evaluated.

METHODS

Twenty female albino rabbits were divided into two groups. Each rabbit underwent segmental colonic resection with single-layer anastomosis. In one group of rabbits, PAM of length equal to the circumference of the anastomosis was applied. Rabbits were sacrificed on postoperative day 10 and peritoneal adhesions, anastomosis burst pressure, and anastomosis histopathological characteristics were evaluated.

RESULTS

The average burst pressure for the control and PAM groups was 149±15.95 mmHgand 224±124.5 mmHg, respectively (p=0.578). All control anastomoses burst, whereas only five (50%) PAM anastomoses burst (p<0.03). There was no anastomotic leakage in the control group, whereas three PAM group anastomoses leaked (p=0.210). The collagen fiber density and amount of neovascularization were lower in the PAM than the control group (p=0.001 and p=0.002, respectively). The average peritoneal adhesion value was 1.6±0.51 in the control group and 2.9±0.31 in the PAM group (p<0.0001).

CONCLUSION

The new fixed PAM-reinforced anastomosis technique resulted in an increased risk of anastomosis leakage and peritoneal adhesion, but also higher in non-burst anastomoses.

Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer

BACKGROUND

Postoperative anastomotic hemorrhage is a relatively rare complication, but it is lethal if not treated immediately.

METHODS

Of 1400 patients with gastric cancer who underwent gastrectomy between September 2002 and December 2007, postoperative anastomotic hemorrhage was observed in 6 patients. The surgical procedures, bleeding sites, methods of hemostasis, and clinical courses of these 6 patients were analyzed.

RESULTS

Of the 1400 patients, 878, 72, and 450 underwent distal, proximal, and total gastrectomy, respectively. The bleeding sites were as follows: transection line of the stomach using a linear stapler (n = 1); gastroduodenostomy using a circular stapler (n = 3); gastrojejunostomy by hand-suture (n = 1); and esophagojejunostomy using a circular stapler (n = 1). Five patients achieved complete hemostasis with endoscopic treatment. One patient underwent re-operation for anastomotic hemorrhage without endoscopic therapy. Two patients had delayed gastric emptying, and one patient developed an intraabdominal abscess after hemostatic treatment.

CONCLUSION

Postoperative anastomotic hemorrhage is an infrequent but potentially life-threatening complication. Endoscopy appears to be useful for both the confirmation of bleeding and therapeutic intervention.

Efeito do ácido ascórbico e da hidrocortisona na cicatrização anastomótica intestinal

OBJETIVO: Comparar a resistência cicatricial de anastomoses jejunais em ratos, submetidos à administração de vitamina C e de hidrocortisona, em distintos períodos pós-operatórios. MÉTODOS: Foram estudados 40 ratos Wistar, submetidos à secção e subsequente anastomose término-terminal de segmento jejunal, a 10 cm da flexura duodenojejunal. Os animais foram distribuídos em quatro grupos (n=10): Grupo I - controle; Grupo II - administração de vitamina C oral 100 mg/kg; Grupo III - administração de hidrocortisona intraperitoneal 10 mg/kg; Grupo IV - administração de vitamina C mais hidrocortisona nas doses e vias de administração acima. Avaliaram-se as pressões de ruptura anastomótica no 5º e 21º dias do pós-operatório. RESULTADOS: Os ratos que receberam vitamina C isolada ou associada a hidrocortisona tenderam a ter pressão de ruptura maior do que os demais grupos, tanto no 5º quanto no 21º dia pós-operatório. CONCLUSÃO: A vitamina C contribui para aumentar a resistência das anastomoses jejunais dos ratos durante os primeiros cinco dias do pós-operatório. A resistência das anastomoses jejunais murinas foi pouco influenciada pela administração de corticóide intraperitoneal.

Diagnosis of gastrointestinal anastomotic dehiscence after hospital discharge: Impact on patient management and outcome

BACKGROUND

Anastomotic leaks are inevitable complications of gastrointestinal surgery. Early hospital discharge protocols have increased concern regarding outpatient presentation with anastomotic leaks.

METHODS

One hundred anastomotic leaks in 5,387 intestinal operations performed at a single institution from 2002 to 2007 were identified from a prospectively maintained database. Statistical analysis was conducted by the unpaired t test, Chi-square test, and analysis of variance.

RESULTS

Overall anastomotic leak with a rate of 2.6% for colonic and 0.53% for small bowel anastomoses. Mean time to anastomotic leak diagnosis was 7 days after operation. Twenty-six patients presented after discharge, with mean time to diagnosis 12 days versus 6 days for inpatients (P<.05). Patients presenting after hospital discharge were younger, had lesser American Society of Anesthesiologists (ASA) scores, and were more likely to have colon cancer and less likely to have Crohn's disease. Ninety-two patients required operative management, of whom 81 (90%) underwent diversion. No difference in management, intensive care unit (ICU) requirement, duration of stay, or mortality between inpatient versus outpatient diagnosis was demonstrated. Follow-up at mean of 36 months demonstrated no difference in readmission, reoperation, or mortality rate between outpatient and inpatient diagnosis. Restoration of gastrointestinal continuity was achieved in 61-67% in the outpatient and 59% in the inpatient group (P=NS).

CONCLUSION

Outpatient presentation delays diagnosis but does not alter management or clinical outcome, or decrease the probability of ostomy reversal. Prolonging hospital stay to capture patients who develop anastomotic leak seems to be unwarranted. For patients requiring operative management, we recommend diversion as the safest option with a subsequent 61% reversal rate.

Effects of preoperative pelvic irradiation on colonic anastomosis healing. An experimental study in rats

PURPOSE

Colorectal anastomosis is a constant worry-issue among surgeons because of high rates of complications, specially the dehiscence. The preoperative irradiation on cancer surgeries might interfere in the healing process, leading to an unfavorable outcome.

METHODS

In the present study, two groups of rats were irradiated previously to a colorectal anastomosis surgery, with intervals of 4 and 8 weeks between the procedures. Seven days after the surgery, healing process was evaluated for dehiscence presence and histologic inflammatory characteristics. Also, levels of hydroxyproline, metalloproteinases and vascular endothelial growth factor were measured.

RESULTS

Our results showed a higher incidence of dehiscences on the animals submitted to irradiation, compared to controls, with a reduced inflammatory activity in the healing tissue.

DISCUSSION

Comparing both irradiated groups, those irradiated 8 weeks before surgery showed higher levels of hydroxyproline and metalloproteinases, indicating higher efficiency of the healing process. In conclusion, preoperative irradiation interferes with intestinal anastomosis healing and a larger time interval between both procedures is safer in terms of the healing quality.

Staple line haemorrhage following laparoscopic left-sided colorectal resections may be more common when the inferior mesenteric artery is preserved

BACKGROUND

Anastomotic bleeding following stapled left-sided colorectal resections is uncommon. There have been few reports on the incidence, severity, management and outcome of such stapled line haemorrhage in the literature. Here, we report our experience of anastomotic bleeding from a stapled anastomosis in laparoscopic left-sided colorectal surgery.

METHODS

Data were collected prospectively on all patients undergoing laparoscopic colorectal surgery from 2003. Patients who had a left-sided stapled anastomosis requiring intervention for staple line haemorrhage were studied. Patients who underwent laparoscopic surgery for benign colorectal disease were compared with those who underwent laparoscopic surgery for a malignant condition. Risk factors for bleeding, management and outcome are reported.

RESULTS

Over a 5-year period, 143 patients underwent laparoscopic left-sided colorectal surgery, 72 for benign disease and 71 for a malignant condition. Postoperative anastomotic bleeding occurred in six patients (4%). All were in the benign pathology group, and all had preservation of the inferior mesenteric artery during surgery. None of the patients required operative intervention for staple line haemorrhage.

CONCLUSIONS

Anastomotic bleeding from a stapled anastomosis in laparoscopic left-sided colorectal surgery is an infrequent complication and it may be more common with preservation of the inferior mesenteric artery. In the majority, bleeding is self limiting and will settle with nonoperative means. Endoscopic procedures may be useful for confirmation of bleeding and for therapeutic intervention, and may avoid the need for surgical intervention.

Anastomotic leaks after bowel resection: what does peer review teach us about the relationship to postoperative mortality?

BACKGROUND

Anastomotic leak is a dreaded complication of intestinal surgery and has been associated with a high mortality rate. But it is uncertain exactly which patient populations are at risk of death from the leak. We sought to assess the impact of surgeon volume on leak rate and to better understand the relationship of a leak to postoperative mortality.

STUDY DESIGN

All adult patients having a small or large bowel resection with anastomosis at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained quality database; data were entered by a specially trained nurse practitioner who rounded daily with housestaff. Patients with a postoperative leak based on standardized criteria were identified. Patient characteristics, surgical procedure, and operating surgeon were noted. Overall complication and leak rates by surgeon were compared using Fisher's exact test. Individual case review by a group of peers was performed for all patients with a leak who died, to determine the relationship to mortality.

RESULTS

Five hundred fifty-six patients underwent resection with anastomosis during the study period. There were 27 patients with leaks (4.9%), 6 of whom died. Leak rate for the highest-volume surgeons ranged from 1.6% to 9.9% (p <0.01), and overall complication rate varied from 30.5% to 44% (p=0.04). In four of six deaths, leaks occurred in very ill patients undergoing emergency procedures and appeared to be premorbid events. In only one patient did the leak appear to be the primary cause of death.

CONCLUSIONS

The variability in leak rate by surgeons doing similar operations suggests that many leaks may be preventable. But death after a leak is most often a surrogate for a critically ill patient and was infrequently the actual cause of death.

The effects of hyperbaric oxygen therapy on colonic anastomosis in rats with peritonitis

The aim of this study is to investigate the healing effect of hyperbaric oxygen (HBO) on colonic anastomoses in the presence of experimentally induced peritonitis. Thirty-two rats were allocated randomly into short-term anastomosis (STA), short-term anastomosis + HBO treatment (STA+HBO), long-term anastomosis (LTA), and long-term anastomosis + HBO (LTA+HBO) treatment groups. The STA and LTA groups were administered fluid resuscitation and antibiotics for 3 and 7 days, respectively, whereas the HBO treatment groups received additional HBO therapy for 3 and 7 days, respectively. The rats were reoperated on the third and the seventh days of anostomoses for evaluation. The bursting pressures in STA+HBO and LTA+HBO therapy groups were significantly higher than those in groups with anastomoses alone (p < .001 and p < .01). HBO therapy did not affect the fibrotic index neither in STA nor in LTA groups (p > .05 for both); however, it was significantly higher in LTA+HBO group than that in STA+HBO group (p < .05). The hydroxyproline level was significantly higher in LTA group than in STA group (p < .05), yet HBO therapy did not affect the hydroxyproline levels in STA or LTA groups (p > .05 for both). It is concluded that hyperbaric oxygen treatment has positive effects on colonic anastomotic healing in case of peritonitis.

Polypropylene mesh covered colonic anastomosis. Results of a new anastomosis technique

BACKGROUND

The morbidity and mortality rates of anastomosis leakage of the gastrointestinal system, are high. In this study we covered the colonic anastomosis with polypropylene mesh on the safety of the anastomosis was investigated.

METHODS

Twenty female albino rabbits were divided into two groups. First of all, a segmental colon resection was performed in both the groups and a single layer of anastomosis was made. In addition, a polypropylene mesh as long as the circumference of the anastomosis in the study group. All the rabbits were sacrificed on the 10th postoperative day and the explosion pressure of the anastomosis, histopathological investigation of the anastomotic contour, and peritoneal adhesion were compared.

RESULTS

The anastomoses of all the subjects in the control group had exploded and the average explosion pressure was 149 +/- 16 mmHg. However, in the study group, the anastomoses did not explode in nine (90%) of the subjects, whereas it exploded in only one (10%) with a pressure of 260 mmHg. The average explosion pressure in the study group was 315 +/- 30 mmHg (p < 0.0001). No significant difference was established between the groups according to the histopathological classification of the anastomotic contour performed according to the Ehrlich-Hunt model (p > 0.05). Peritoneal adhesions of the groups is not statistically different (p > 0.05).

CONCLUSION

During the short follow-up period, this new technique significantly increased the safety of the anastomosis, moreover it did not cause any increase in peritoneal adhesions. This success has most probably occurred as a result of the external mechanical support to the anastomosis.

Effect of systemic corticosteroids on elective left-sided colorectal resection with colorectal anastomosis

BACKGROUND

The impact of systemic steroid therapy on surgical outcome after elective left-sided colorectal resection with rectal anastomosis is not well known.

METHODS

We compared 606 consecutive patients including 53 patients who were on steroids and undergoing surgery between 1995 and 2005.

RESULTS

Postoperative mortality and anastomotic leakage rates were equivalent. The postoperative complications rate, especially infections, was higher in steroid-treated patients than in non-steroid-treated patients: 38% (20 of 53 patients) versus 25% (139 of 553 patients), respectively (P = .046). In the steroid group, univariate analysis revealed 3 significant risk factors for postoperative complications: blood transfusion, preoperative anticoagulation, and chronic respiratory failure. In a multivariate analysis, blood transfusion and chronic respiratory failure remained independent factors for postoperative complications.

CONCLUSION

Patients on steroids have a higher incidence of postoperative complications after elective left-sided colorectal resection with rectal anastomosis.

Duodenojejunostomy leaks after pancreaticoduodenectomy

BACKGROUND

A duodenojejunostomy (DJ) or gastrojejunostomy (GJ) leak is a potentially fatal complication after pancreaticoduodenectomy (PD). However, due to its rarity, this complication has not been fully characterized.

METHODS

We reviewed 3,029 PDs performed at our institution over a 26-year period and identified patients who suffered a leak at the DJ or GJ anastomosis. Perioperative data from patients with such a leak were examined in detail and were compared to patients who did not experience such a leak after PD.

RESULTS

A total of 13 patients experienced a DJ or GJ leak after PD, amounting to a 0.4% leak rate. Common clinical signs of a leak included an acute abdomen, enterocutaneous fistula, and a fever. Twelve of thirteen patients also had a leukocytosis, with five patients having a peak white blood cell count exceeding 30,000 cells/mm(3). The median time interval between surgery and diagnosis of the DJ or GJ leak was 10 days; three patients were diagnosed after being discharged from the hospital and one patient was diagnosed on the day of their planned discharge. In a multivariate model, perioperative risk factors for a DJ or GJ leak included a preoperative BUN-to-creatinine ratio > 20 (odds ratio = 6, p = 0.01), intraoperative blood loss > or =1 l (odds ratio = 6, p = 0.03), and a total pancreatectomy (odds ratio = 7, p = 0.005). In the DJ or GJ leak group, 12 of 13 patients were managed operatively. The median postoperative length of stay was 35 days after PD, and four patients died within 4 months of surgery as a result of their complicated postoperative course.

CONCLUSION

DJ or GJ leaks occur infrequently after PD, but are associated with substantial morbidity. The clinical presentation is usually delayed, and surgical management is the preferred approach. Early diagnosis, attention to preoperative volume status, and continued efforts to control blood loss may minimize the impact of DJ or GJ leaks in some instances.

Anastomotic leaks after intestinal anastomosis: it's later than you think

PURPOSE

Anastomotic leaks are among the most dreaded complications after colorectal surgery. However, problems with definitions and the retrospective nature of previous analyses have been major limitations. We sought to use a prospective database to define the true incidence and presentation of anastomotic leakage after intestinal anastomosis.

METHODS

A prospective database of two colorectal surgeons was reviewed over a 10-year period (1995-2004). The incidence of leak by surgical site, timing of diagnosis, method of detection, and treatment was noted. Complications were entered prospectively by a nurse practitioner directly involved in patient care. Standardized criteria for diagnosis were used. A logistic regression model was used to discriminate statistical variation.

RESULTS

A total of 1223 patients underwent resection and anastomosis during the study period. Mean age was 59.1 years. Leaks occurred in 33 patients (2.7%). Diagnosis was made a mean of 12.7 days postoperatively, including four beyond 30 days (12.1%). There was no difference in leak rate by surgeon (3.6% vs. 2.2%; P = 0.08). The leak rate was similar by surgical site except for a markedly increased leak rate with ileorectal anastomosis (P = 0.001). Twelve leaks were diagnosed clinically versus 21 radiographically. Contrast enema correctly identified only 4 of 10 leaks, whereas CT correctly identified 17 of 19. A total of 14 of 33 (42%) patients had their leak diagnosed only after readmission. Fifteen patients required fecal diversion, whereas 18 could be managed nonoperatively.

CONCLUSIONS

Anastomotic leaks are frequently diagnosed late in the postoperative period and often after initial hospital discharge, highlighting the importance of prospective data entry and adequate follow-up. CT scan is the preferred diagnostic modality when imaging is required. More than half of leaks can be managed without fecal diversion.

Risk Factors for Anastomotic Leakage after Surgery for Colorectal Cancer: Results of Prospective Surveillance

BACKGROUND

Anastomotic leakage in operations for colorectal cancer not only results in morbidity and mortality, but also increases the risk of local recurrence and worsens prognosis. So a better understanding of risk factors for developing anastomotic leakage in colorectal cancer surgery is important to surgeons. The aim of this study was to determine the incidence and risk factors for clinical anastomotic leakage after elective surgery for colorectal cancer.

STUDY DESIGN

We conducted prospective surveillance of all elective colorectal resections performed by a single surgeon in a single university hospital from November 2000 to July 2004. The outcomes of interest was clinical anastomotic leakage. Eighteen independent clinical variables were examined by univariate and multivariate analyses.

RESULTS

A total of 391 patients undergoing elective operations for colorectal cancer were admitted to the program. Clinical anastomotic leakage was identified in 11(2.8%) patients. Univariate and multivariate analyses showed that preoperative steroid use (odds ratio=8.7), longer duration of operation (odds ratio=9.9), and wound contamination (odds ratio=7.8) were independently predictive of clinical anastomotic leakage. Although there were no statistical differences in leakage rates between patients with and without covering stoma, all four patients requiring reoperation for leakage were without covering stoma.

CONCLUSIONS

Preoperative steroid use, longer duration of operation, and contamination of the operative field were independent risk factors for developing clinical anastomotic leakage after elective resection for colorectal cancer. Surgeons should be aware of such high-risk patients, which would help them to decide whether to create a diversion stoma during surgery.

Complications following full-thickness small intestinal biopsy in 66 dogs: a retrospective study

OBJECTIVES

To retrospectively report the complications seen after full-thickness multiple small intestinal biopsies were performed in 66 dogs.

METHODS

Animals that died as a result of enteric wound breakdown were compared with the surviving population to identify fatal risk factors.

RESULTS

Seventeen dogs had hypoalbuminaemia and eight had albumin levels below 20 g/I at surgery. Twelve dogs had concurrent disease, of which seven had skin disease. Seven dogs suffered minor complications which resolved with treatment. Eight dogs (12 per cent) died or were euthanased between three and nine days postoperatively (mean [sd] 4.5 [2.1]) due to enteric wound breakdown. Seven of these dogs developed septic peritonitis and one died of haemorrhage. No statistically significant differences were identified in any of the parameters examined for the development of fatal enteric wound dehiscence.

CLINICAL SIGNIFICANCE

Full-thickness intestinal biopsy is not a benign procedure. However, this study concludes that there are no consistent predictors for patients at increased risk of enteric wound breakdown.

Risk factors for leakage following intestinal anastomosis in dogs and cats: 115 cases (1991-2000)

OBJECTIVE

To identify factors associated with leakage following intestinal anastomosis in dogs and cats.

DESIGN

Retrospective study.

ANIMALS

90 dogs and 25 cats.

PROCEDURE

Medical records of all dogs and cats that underwent intestinal resection and anastomosis between 1991 and 2000 were reviewed, and information on 27 factors was recorded.

RESULTS

Anastomotic leakage was identified in 13 of the 90 dogs but in none of the 25 cats. Preoperative factors significantly associated with development of anastomotic leakage in dogs included preoperative peritonitis, serum albumin concentration, a left shift, and indication for surgery (dogs with intestinal foreign bodies were more likely to have leakage than dogs that underwent surgery for any other cause). Postoperative and case management factors significantly associated with development of leakage included duration of hospitalization, supplemental alimentation, whether the dog ate the day after surgery, blood product administration, and outcome (died vs survived). Discriminant analysis was performed, and dogs with 2 or more of the following factors were predicted to develop anastomotic leakage: preoperative peritonitis, intestinal foreign body, and serum albumin concentration < or = 2.5 g/dL. The model accurately predicted whether leakage would develop in 67 of 80 (84%) dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that a variety of factors may be associated with development of intestinal anastomotic leakage in dogs. In particular, dogs with 2 or more of the following risk factors are predicted to be at high risk for developing anastomotic leakage: preoperative peritonitis, intestinal foreign body, and serum albumin concentration < or = 2.5 g/dL.

Management of Gastrojejunal Anastomotic Leaks after Roux-en-Y Gastric Bypass

Anastomotic leaks after Roux-en-Y gastric bypass (RYGB) potentially result in considerable morbidity and mortality. In the present report we describe our experience with the management of gastrojejunal anastomotic leaks. Tachycardia and fever are considered early signs of anastomotic disruption. Patients weighing less than 350 pounds underwent radiographic testing to diagnose gastrojejunal disruption. Those with severe leaks or patients too large for radiographic evaluation underwent exploratory laparotomy. For severe anastomotic disruptions a retrograde transanastomotic jejunal sump drain was placed. Twenty-four (1.3%) anastomotic leaks occurred in 1789 RYGBs. Five of the leaks were classified as severe and required retrograde sump tube placement. There was one mortality and all of the other patients completely recovered. Aggressive and early intervention for anastomotic disruption after RYGB is necessary to ensure the best possible outcomes for patients with this complication. A high index of suspicion for leaks in postoperative RYGB patients with tachycardia is required if patients are to have good outcomes when complications develop.

New concepts in the management of patients with penetrating abdominal wounds

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.

Strength of colonic anastomoses and skin incisional wounds in old rats - influence by diabetes and growth hormone

The influence of advanced age on the mechanical strength of colonic anastomoses and skin incisional wounds in diabetic rats was investigated after 0 (suture binding capacity) and after 7 days of healing. Furthermore, the effects of growth hormone (GH) injections to old diabetic rats were investigated. Diabetes in old rats did not influence the strength of colonic anastomoses after 0 and 7 days. However, in these diabetic animals, the strength of skin incisional wounds was reduced by 27% after 7 days of healing (P< 0.01). GH injections administered to old diabetic rats doubled the mortality compared with that of saline-injected old diabetic rats (P< 0.01). GH injections did not influence the strength formation of either colonic anastomoses or skin incisional wounds in old normal rats. In conclusion, the healing of colonic anastomoses in diabetic rats was not compromised by old age, while the strength of skin wounds was decreased.

The failed gastrointestinal anastomosis: an inevitable catastrophe?

BACKGROUND

There is a great deal of conflicting data regarding risk factors for anastomotic leakage, with most studies being small and looking only at anastomoses performed at one level of the gastrointestinal (GI) tract. Surgeons have looked at patient and technical variables with inconsistent findings. The purpose of this study was to evaluate the incidence, possible predictive factors, and results of treatment of anastomotic dehiscence in patients undergoing operations at all levels of the GI tract.

STUDY DESIGN

We evaluated the records of 2,842 patients undergoing esophagogastrectomy, total or partial gastrectomy, enterectomy, and partial or subtotal colectomy over a 12-year period. Complete demographic data, comorbidity, and details regarding anastomotic technique were collected on all patients sustaining leaks along with diagnostic methods used, treatment modalities, and outcomes data. Using age and gender-matched case control methodology, we compared patients sustaining an anastomotic leak to those undergoing successful anastomoses.

RESULTS

Fifty-one of 2,842 patients (1.8%), ranging from 1.1% of enterectomy patients to 4.8% of total gastrectomy patients, sustained an anastomotic dehiscence. Foregut procedures were accompanied by a significantly increased rate of leakage, and depending on location, diagnosis was made between the 6th and 9th postoperative day. For each procedure, deaths from factors other than leakage far exceeded deaths from leaks. Standard risk stratifiers did not predict occurrence of leakage. Overall, 24% of patients sustaining a leak died, and this complication necessitated multiple reoperations and significantly increased length of hospital stay.

CONCLUSIONS

In view of these findings, standard preoperative strategies to prepare these patients for operation may prove unsuccessful, because minimizing the incidence of anastomotic leaks will have little overall impact on survival. In addition, efforts to accomplish early hospital discharge may prove hazardous, because many of these patients manifest their leaks later in the postoperative period than is generally assumed. Improved management of GI tract disruption, including aggressive attempts at diagnosis, ICU care, antibiotics, and nutritional support may further increase survival in these patients.

Intestinal anastomosis in children: a comparative study between two different techniques

PURPOSE

The aim of this study was to compare the incidence of surgical complications between two different surgical techniques for intestinal anastomosis in children.

METHODS

This was a clinically controlled, randomized study with blind follow-up from 18 to 36 months performed at the Reference Government Hospital in Mexico City. Eighty-six children required intestinal anastomosis, ages ranged between 1 month and 16 years, with emergency or elective surgery. Anastomoses of duodenum, rectum, with enteroplasty or protected with a proximal stoma were excluded. Two randomized groups were formed: (1) anastomosis with one layer of suture (Gambee stitches) and (2) with two layers of suture (first with Connel-Mayo stitches then with Lembert). Both groups were controlled in the principal variables without differences, and the follow-up concerning postoperative recovery was blind for the surgical team.

RESULTS

Forty-two cases in group 1 and 44 in group 2 were compared. Intestinal dehiscence was found in 5 of 86 (5.8%), two from group I and three from group II (P value, not significant). Surgical time for anastomosis with one layer was an average of 26 minutes versus 43 minutes with two layers (P<.001). There were no stenoses within the follow-up period.

CONCLUSIONS

This study proves that intestinal anastomosis with one layer of suture is as safe as anastomosis with two layers in children, and the time spent for completion of the procedure is significantly less with one plane of suture. For those reasons, it is the method of choice for intestinal anastomosis in children.