Anastomotic leaks in colorectal surgery

Safety and efficacy of left colic artery preservation in laparoscopic anterior resection for lower rectal cancer

Background: To evaluate the safety and efficacy of left colic artery (LCA) preservation in laparoscopic anterior resection with D3 lymphadenectomy for lower rectal cancer. Methods: A total of 117 patients with lower rectal cancer who received laparoscopic anterior resection were retrospectively analyzed. Results: No differences were detected in terms of the numbers of harvested lymph nodes and metastatic lymph nodes, the intraoperative and postoperative complications or the postoperative recurrence and survival rates between the two groups (p > 0.05), but the LCA preservation group showed a lower anastomotic leakage rate than the LCA nonpreservation group (2/49 vs 12/68). Conclusion: LCA preservation may help reduce the incidence of anastomotic leakage without impairing surgical and oncological outcomes.

Right hemicolectomy anastomotic leak study: a review of right hemicolectomy in the binational clinical outcomes registry (BCOR)

BACKGROUNDS

Surgery remains mainstay management for colon cancer. Post-operative anastomotic leak (AL) carries significant morbidity and mortality. Rates of, and risk factors associated with AL following right hemicolectomy remain poorly documented across Australia and New Zealand. This study examines the Bowel Cancer Outcomes Registry (BCOR) to address this.

METHODS

A retrospective cohort study was undertaken of consecutive BCOR-registered right hemicolectomy patients undergoing resection for colon cancer (2007-2021). The primary outcome measure was AL incidence. Clinicopathological data were extracted from the BCOR. Factors associated with AL and primary anastomosis were identified using logistic regression. AL-rate trends were assessed by linear regression.

RESULTS

Of 13 512 patients who had a right hemicolectomy (45.2% male, mean age 72.5 years, SD 12.1), 258 (2.0%) had an AL. On multivariate analysis, male sex (OR 1.33; 95% CI 1.03-1.71) and emergency surgery (OR 1.41; 95% CI 1.04-1.92) were associated with AL. Private health insurance status (OR 0.66; 95% CI 0.50-0.88) and minimally-invasive surgery (OR 0.61; 95% CI 0.47-0.79) were protective for AL. Anastomotic technique (handsewn versus stapled) was not associated with AL (P = 0.84). Patients with higher ASA status (OR 0.47; 95% CI 0.39-0.58), advanced tumour stage (OR 0.56; 95% CI 0.50-0.63), and emergency surgery (OR 0.16; 95% CI 0.13-0.20) were less likely to have a primary anastomosis. AL-rate and year of surgery showed no association (P = 0.521).

CONCLUSION

The AL rate in Australia and New Zealand following right hemicolectomy is consistent with the published literature and was stable throughout the study period. Sex, emergency surgery, insurance status, and minimally invasive surgery are associated with AL incidence.

Anastomotic Leak in Colorectal Surgery: Predictive Factors and Survival

<br><b>Introduction:</b> Anastomotic leak (AL) is a serious complication following colorectal surgery.</br> <br><b>Aim:</b> The aim of this study was to identify factors associated with the development of AL and to analyze its impact on survival.</br> <br><b>Materials and methods:</b> All consecutive adult colorectal cancer resections performed between 2007 and 2020 with curative intent and anastomosis formation were included from a prospectively maintained database. The primary outcome measure was the rate of AL. The secondary outcome measure was 5-year overall survival (OS).</br> <br><b>Results:</b> There were 6837 eligible patients. The rate of AL was 2.2% and 4.0% in patients with colon and rectal cancer, respectively. AL was a significant independent predictor of reduced 5-year OS in patients who underwent curative surgery for rectal cancer (odds ratio 2.293, p = 0.009). Emergency surgery (p = 0.015), surgery at a public hospital (p = 0.002), and an open surgical approach (p = 0.021) were all associated with a significantly higher risk of AL in patients with colon cancer, with higher rates of AL noted in left colectomies as compared to right hemicolectomies (4.4% <i>vs.</i> 1.3%, p < 0.001). In rectal cancer patients, AL was associated with neoadjuvant chemoradiotherapy (p = 0.038) and male gender (p = 0.002). The anastomosis formation technique (hand-sewn <i>vs.</i> stapled) did not impact the rate of AL (p = 0.116 and p = 0.198 with colon and rectal cancer, respectively).</br> <br><b>Discussion:</b> Clinicians should be cognizant of the predictive factors for AL and should consider early intervention for at-risk patients.</br>.

Indocyanine green fluorescence imaging during laparoscopic rectal cancer surgery could reduce the incidence of anastomotic leakage: a single institutional retrospective cohort study

BACKGROUND

There is insufficient evidence on whether indocyanine green (ICG) fluorescence angiography can reduce the incidence of anastomotic leakage (AL). This retrospective cohort study aimed to evaluate the effect of ICG fluorescence angiography on AL rates in laparoscopic rectal cancer surgery at a single institution.

METHODS

Patients who underwent laparoscopic low anterior resection or intersphincteric resection with ICG fluorescence angiography (ICG group; n = 73) and patients who underwent a similar surgical procedure for rectal cancer without ICG fluorescence (non-ICG group; n = 114) were enrolled consecutively in this study. ICG fluorescence angiography was performed prior to transection of the proximal colon, and anastomosis was performed with sufficient perfusion using ICG fluorescence imaging. AL incidence was compared between both groups, and the risk factors for AL were analyzed.

RESULTS

AL occurred in 3 (4.1%) and 14 (12.3%) patients in the ICG and non-ICG groups, respectively. In the ICG group, the median perfusion time from ICG injection was 34 s, and 5 patients (6.8%) required revision of the proximal transection line. None of the patients requiring revision of the proximal transection line developed AL. In univariate analysis, longer operating time (odds ratio: 2.758; 95% confidence interval: 1.023-7.624) and no implementation of ICG fluorescence angiography (odds ratio: 3.266; 95% confidence interval: 1.038-11.793) were significant factors associated with AL incidence, although the creation of a diverting stoma or insertion of a transanal tube was insignificant.

CONCLUSION

ICG fluorescence angiography was associated with a significant reduction in AL during laparoscopic rectal cancer surgery. Changes in the surgical plan due to ICG fluorescence visibility may help improve the short-term outcomes of patients with rectal cancer.

Combined indocyanine green and quantitative perfusion assessment with hyperspectral imaging during colorectal resections

Anastomotic insufficiencies still represent one of the most severe complications in colorectal surgery. Since tissue perfusion highly affects anastomotic healing, its objective assessment is an unmet clinical need. Indocyanine green-based fluorescence angiography (ICG-FA) and hyperspectral imaging (HSI) have received great interest in recent years but surgeons have to decide between both techniques. For the first time, two data processing pipelines capable of reconstructing an ICG-FA correlating signal from hyperspectral data were developed. Results were technically evaluated and compared to ground truth data obtained during colorectal resections. In 87% of 46 data sets, the reconstructed images resembled the ground truth data. The combined applicability of ICG-FA and HSI within one imaging system might provide supportive and complementary information about tissue vascularization, shorten surgery time, and reduce perioperative mortality.

Border Line Definition Using Hyperspectral Imaging in Colorectal Resections

Simple Summary

Good oxygenation of both bowel ends is an important prerequisite to promote anastomotic healing after colorectal resections. Bowel oxygenation is usually assessed clinically. Hyperspectral imaging is a contactless and contrast-free tool that allows quantifying tissue oxygen intraoperatively. In this study, the results of 105 colorectal resections with hyperspectral imaging are reported.

Abstract

Background: A perfusion deficit is a well-defined and intraoperatively influenceable cause of anastomotic leak (AL). Current intraoperative perfusion assessment methods do not provide objective and quantitative results. In this study, the ability of hyperspectral imaging (HSI) to quantify tissue oxygenation intraoperatively was assessed. Methods: 115 patients undergoing colorectal resections were included in the final analysis. Before anastomotic formation, the bowel was extracted and the resection line was outlined and imaged using a compact HSI camera, in order to provide instantaneously quantitative perfusion assessment. Results: In 105 patients, a clear demarcation line was visible with HSI one minute after marginal artery transection, reaching a plateau after 3 min. In 58 (55.2%) patients, the clinically determined transection line matched with HSI. In 23 (21.9%) patients, the clinically established resection margin was entirely within the less perfused area. In 24 patients (22.8%), the HSI transection line had an irregular course and crossed the clinically established resection line. In four cases, HSI disclosed a clinically undetected lesion of the marginal artery. Conclusions: Intraoperative HSI is safe, well reproducible, and does not disrupt the surgical workflow. It also quantifies bowel surface perfusion. HSI might become an intraoperative guidance tool, potentially preventing postoperative complications.

Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer

Objectives

This paper introduces the surgical procedure of "terminal ileum suspension" in the radical resection for low rectal cancer patients and evaluates the possibility of its clinical application.

Methods

This paper retrospectively analyzed the data of patients with low rectal cancer who underwent "terminal ileum suspension" during radical resection of rectal cancer (Dixon) in our hospital, and introduces the specific surgical procedures and key points of "terminal ileum suspension". Observe the relevant conditions of patients during the operation, postoperative recovery and postoperative complications, and analyze the safety and feasibility of this operation ("terminal ileum suspension").

Results

The operation of all 8 patients went smoothly, and no anastomotic leakage, intestinal obstruction, and open diversion of suspended terminal ileum were found. The application of "terminal ileum suspension" in the operation of low rectal cancer has achieved ideal clinical effect, without increasing the rate of anastomotic leakage and rehospitalization, reducing the proportion of the secondary return operation, and reducing the pain of the patients.

Conclusion

"Terminal ileum suspension" is a safe, effective and feasible surgical method for laparoscopic radical resection of low rectal cancer, which can be applied in clinical practice.

Perioperative intrapelvic hyaluronate application as prophylaxis against complications following rectal anastomotic dehiscence: An experimental study

PURPOSE

The aim of this experimental study was to test the method of prevention of postoperative complications, especially infectious, in partial dehiscence following stapler anastomosis in rectal surgeries.

METHODS

The method includes the application of a hyaluronic acid-based gel in combination with triclosan, which has antibacterial properties. The gel was applied to the space around the rectum with an artificial, precisely defined dehiscence so that the dehiscence was separated from the rest of pelvis and the peritoneal cavity to avoid the spread of infection. The study included 30 female pigs. The rectosigmoid colon was mobilized and transected completely. Anastomosis was constructed with circular staplers. A perforator was then used to create precisely defined artificial dehiscence. Subsequently the lesser pelvis was filled with hyaluronic gel such that the site of artificial dehiscence was covered completely.

RESULTS

All animals survived for 14 days until the second-look revision with no signs of failure in the anastomosis healing, local inflammation, and sepsis or postoperative complications, such as chills, refusal of liquid or feed, abdominal distension, and bowel obstruction.

CONCLUSION

Hyaluronic acid applied as a precursor solution around the rectal anastomosis fills the lesser pelvis perfectly. It prevents the leakage of intestinal contents in the lesser pelvis. Triclosan as an antibacterial substance prevents the spread of inflammation in the pelvis or even in the abdominal cavity.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

Defining Anastomotic Leaks After Colorectal Surgery: Results of a National Survey

BACKGROUND

Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist.

MATERIALS AND METHODS

A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery.

RESULTS

Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak.

CONCLUSIONS

These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

Meta-Analysis on the Efficacy of Indocyanine Green Fluorescence Angiography for Reduction of Anastomotic Leakage After Rectal Cancer Surgery

BACKGROUND

Indocyanine green (ICG) fluorescence angiography is a new technique that help surgeons to assess the blood perfusion of the anastomotic intestine. The aim of this study is to evaluate whether ICG fluorescence angiography can reduce the anastomotic leakage (AL) rate after colorectal anastomoses for rectal cancer (RC) patients.

METHODS

Studies comparing AL rates between use and nonuse of ICG fluorescence angiography up to April 2020 were systematically searched from PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. A pooled analysis was performed for the available data regarding the baseline features, AL rate, and other surgical outcomes. ReMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.

RESULTS

Thirteen studies with a total of 2593 patients (1121 in the ICG group and 1472 in the control group) undergoing colorectal anastomoses after RC surgery were included. In the pooled analysis, the baseline data, operation time, and intraoperative blood loss in 2 groups were all comparable and without significant heterogeneity. However, the AL rate in the ICG group was significantly lower (OR .31; 95% CI .22-.44; P < .00001) than that in the control group. Additionally, ICG fluorescence angiography was associated with a decreased overall complication rate (OR .60; 95% CI .47-.76; P < .0001) in patients who undergo RC surgery.

CONCLUSIONS

The present study revealed that ICG fluorescence angiography reduced AL rate after colorectal anastomoses for RC patients. However, more high-quality randomized controlled trials are needed to confirm this benefit.

Intraoperative fluorescence angiography and risk factors of anastomotic leakage in mini-invasive low rectal resections

BACKGROUND

One of the prerequisites for proper healing of the anastomosis after a colorectal resection is adequate blood supply to the connected intestinal segments. It has been proposed that adequate visualization of the blood flow using indocyanine green (ICG) could lead to the reduction in the incidence of anastomotic leakage (AL). The aim of this study was to assess the effectiveness of intraoperative fluorescence angiography (FA) in decreasing the incidence of AL after minimally invasive low anterior resection (LAR) with total mesorectal excision (TME) in rectal cancer patients and to determine predictors of anastomotic leak.

METHODS

From August 2015 to January 2019, data from 100 patients who underwent mini-invasive TME for rectal cancer using FA with indocyanine green (ICG) were prospectively collected and analyzed. They were compared with retrospectively analyzed data from a historical control group operated by one team of surgeons before the introduction of FA from November 2012 to August 2015 (100 patients). All patients from both groups were operated sequentially in one oncological center in Nový Jičín.

RESULTS

The incidence of AL was significantly lower in the ICG group (19% vs. 9%, p = 0.042, χ² test). In fifteen patients in the ICG group (15%), the resection line was moved due to insufficient perfusion. Using Pearson's χ² test, diabetes (p = 0.036) and application of a transanal drain (NoCoil) (p = 0.032) were identified as other risk factors (RFs) for AL.

CONCLUSION

The use of ICG to visualize tissue perfusion in low rectal resections for cancer can lead to a reduction of AL.

Protective ileostomy does not prevent anastomotic leakage after anterior resection of rectal cancer

OBJECTIVE

To explore whether protective ileostomy is beneficial in preventing anastomotic leakage after anterior resection of rectal cancer.

METHODS

A total of 347 patients underwent anterior resection of rectal cancer in our hospital. Ninety-five patients were treated with protective ileostomy (treatment group), and 252 patients were not (control group). The incidences of anastomotic leakage and permanent stoma were compared between the two groups.

RESULTS

The overall incidences of anastomotic leakage were 6.32% (6/95) and 8.73% (22/252) in the treatment group and control group, respectively. In the cohort of patients who underwent neoadjuvant radiotherapy, the incidence of anastomotic leakage was 5.88% (2/34) and 12.0% (3/25) in the treatment group and control group, respectively. Logistic regression showed that the incidence of anastomotic leakage was not statistically significant. However, diabetes and the anastomotic height significantly affected the occurrence of anastomotic leakage. The permanent stoma rate was 6.42% (6/95) and 5.95% (15/252) in the treatment group and control group, respectively.

CONCLUSION

Protective ileostomy did not show a significant advantage in reducing the incidence of postoperative anastomotic leakage in patients with rectal cancer, and it may lead to a permanent stoma.

The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage.

METHODS

The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I² , and bias was evaluated by funnel plot and Begg's test.

RESULTS

A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12).

CONCLUSIONS

The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.

Laparoscopic Ultra Low Anterior Resection: Single Center, 6-Year Study

Background: This study represents a prospective analysis of a series of laparoscopic ultra low anterior resection (ULAR) done at a laparoscopic surgical center to assess the surgical outcome, oncological efficacy, and quality of life after surgery. Methods: Over a period of 6 years (2013-2018), 43 patients aged between 40 and 68 years, with very low rectal cancers (3-6 cm from the anal verge), within T3N1M0 stage, assessed by positron emission tomography-computed tomography and pelvic magnetic resonance imaging, underwent neoadjuvant chemoradiotherapy (nCRT) followed by laparoscopic ULAR and simultaneous diversion ileostomy. Results: The overall complication rate was low and there was an overall leak rate of 9.3% with a radiological leak (Grade A) in 3 of the 43 patients (7%), but only 1 (2.3%) patient required a local lavage and a resuturing for secondary hemorrhage. Recurrence was seen in 2/43 (4.7%), one of whom had a conversion to abdominoperineal resection. The other had distant metastasis and refused further treatment. The functional outcome is assessed in 41 (95.3%) patients by low anterior resection syndrome (LARS) score and a reasonable quality of life with major LARS was seen in only 7.3% of the patients at a follow-up ranging from 1 to 6 years. Conclusion: The nCRT followed by laparoscopic ULAR is a feasible option for operable very low rectal cancers and is associated with minimal postoperative events, a low local recurrence and less incidence of LARS.

The significance of intraoperative fluorescence angiography in miniinvasive low rectal resections

Introduction

Anastomotic leak is a very serious complication in colorectal surgery. Tissue perfusion of the anastomosis plays an integral role in its multifactorial etiology. Fluorescence angiography using indocyanine green allows visualization of perfusion in real time.

Aim

To evaluate the effectiveness of intraoperative fluorescence angiography as a tool to decrease the incidence of anastomotic leak after laparoscopic or robotic low resection of the rectum for cancer.

Material and methods

Intraoperative fluorescence angiography was performed sequentially in 50 patients during low rectal resection for cancer with total mesorectal excision, primary anastomosis and protective ileostomy using laparoscopic or robotic technique. The results were compared to a historical control group of 50 patients with the same procedure without the use of fluorescence angiography.

Results

The patient sets were comparable in basic demographic and clinical parameters. Intraoperative visualization of perfusion by fluorescence angiography was achieved in all patients without unwanted side-effects. In 6 (12%) patients, the resection line was adjusted based on the fluorescence angiography. The incidence of anastomotic leak was insignificantly lower in the group with fluorescence angiography (18% vs. 10%), which led to significantly shorter hospital stay. Other postoperative complications were comparable between the two groups.

Conclusions

Fluorescence angiography using indocyanine green is a safe and effective method with the potential of reducing anastomotic leak during minimally invasive low resection of the rectum for cancer.

Operative Management of Anastomotic Leaks after Colorectal Surgery

Anastomotic leak is associated with increased morbidity and mortality after colorectal surgery. Although surgical techniques have improved over time, anastomotic leak is still a reality in colorectal surgery with rates ranging from as low as 1% for low-risk anastomoses, such as enteroenteric or ileocolic, to 19% for high-risk coloanal anastomoses. There are many varied risk factors for anastomotic leak. However, many of the risk factors have not been definitively proven in high-quality studies. Presumably, risk factors are cumulative and every effort should be made to optimize modifiable risk factors in the perioperative period. Treatment of anastomotic leak should start with the determination of patient stability followed by resuscitation and diagnostic imaging or operative exploration. Operative findings will dictate surgical approach with the goal of controlling sepsis and stabilizing the patient. If nonoperative treatment is undertaken, close patient monitoring is necessary to ensure control of sepsis and that intervention is undertaken if the clinical picture changes. Early intervention at each stage is key to decreasing the morbidity of anastomotic leak.

Early closure of the protective ileostomy after rectal resection should become part of the Enhanced Recovery After Surgery (ERAS) protocol: a randomized, prospective, two-center clinical trial

Introduction

Protective loop ileostomy (PLI) is used to reduce the anastomotic leak rate after resection of the rectum. It is an effective, yet burdensome procedure contradicting the aims of enhanced recovery after surgery (ERAS) by slowing down recovery. Early closure (EC) of the PLI has the potential to change the situation, and it should become part of ERAS.

Aim

To analyze the effectiveness of EC in ERAS patients.

Material and methods

A randomized clinical trial was performed between October the 1^st, 2016 and December the 31^st, 2017. Fifty-eight adult patients (24 females, 34 males, mean age: 55.7 and 56.2) operated on for rectal carcinoma according to the ERAS protocol with PLI were randomly assigned to the late (L) or early (E) closure group (14 days after discharge). Time to start adjuvant chemotherapy, complication rate, and health care costs were analyzed.

Results

There were no significant differences between groups regarding the length of surgery (83.2 ±15.9 vs. 87.1 ±21.7 min, in E and L, respectively), intraoperative blood loss (15.2 ±7.5 vs. 17.3 ±11.1 ml, respectively), median hospital stay, or the time to pass flatus and stool. The difference in the time needed to start the adjuvant treatment (38.7 ±5.7 vs. 33.2 ±5.8 days, p < 0.01), was compensated by the reduction of time living with a stoma (17.2 vs. 299.0 days) and health care costs: (43.68 vs. 698.42 USD).

Conclusions

Early closure is a safe and effective therapeutic approach, improving the recovery. Therefore it should be implemented as part of the ERAS protocol for rectal cancer patients.

Necrotizing Fasciitis Resulting from an Anastomotic Leak after Colorectal Resection

One of the most feared complications in colorectal surgery is an anastomotic leak (AL) following a colorectal resection. While various recommendations have been proposed to prevent this potentially fatal complication, anastomotic leaks still occur. We present a case of an AL resulting in a complicated and fatal outcome. This case demonstrates the importance of high clinical suspicion, early recognition, and immediate management.

Long-Term Survival in Octogenarians After Surgical Treatment for Colorectal Cancer: Prevention of Postoperative Complications is Key

Background

Whether to treat octogenarians with colorectal cancer (CRC) in the same manner as younger patients remains a challenging issue. The purpose of this study was to analyse postoperative complications and long-term survival in a consecutive cohort of octogenarians who were surgically treated for CRC.

Methods

Octogenarians with primary CRC suitable for curative surgery between January 2008 and December 2011 were included. Data about comorbidities, tumour stage, and complications were retrospectively collected from patient files. Data about survival were retrieved with use of the Dutch database for persons and addresses. To identify factors associated with severe postoperative complications and postoperative survival, logistic regression analyses, and Cox regression analyses were performed. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CI) were estimated.

Results

In a series of 108 octogenarians, median age was 83 years (range 80–94 years). Median follow-up was 47 (range 1–107) months. Major postoperative complications occurred in 25% of the patients. No risk factors for development of severe postoperative complications could be identified. The 30-day mortality was 7%; 1- and 5-year mortality was 19% and 56%, respectively. Overall median survival was 48 months: 66 months in patients without complications versus 13 months in patients with postoperative complications. Postoperative complications were most predictive of decreased survival (HR 3.16; 95% CI 1.79–5.59), even including tumour characteristics, comorbidity, and emergency surgery.

Conclusions

Long-term survival in octogenarians deemed fit for surgery is reasonably good. Prevention of major postoperative complications could further improve clinical outcome.

Male gender is associated with an increased risk of anastomotic leak in rectal cancer patients after total mesorectal excision

Background

The impact of a patient's gender on the development of anastomotic leak (AL) in rectal cancer patients following total mesorectal excision (TME) remains controversial. The aim of this study was to evaluate the association between patients' gender and the risk of AL.

Methods

All rectal cancer patients following TME with a primary anastomosis during the study period from 2010 to 2014 were examined. Comparisons of the post-operative AL incidence rate between male and female patients were performed.

Results

Of all patients examined (n = 956), 587 (61.4%) were males and 369 (38.6%) were females. Male patients were more likely to have a history of smoking and drinking alcohol, but less likely to have a history of abdominal surgery compared to female patients. A higher incidence rate of pre-operative bowel obstruction and larger tumor volume in male patients was observed in our study. Of all the patients, 81 (8.5%) developed post-operative AL. More male patients (n = 62, 10.6%) suffered from AL than females (n = 19, 5.1%) (P = 0.003). Multivariate logistic regression analyses confirmed the association between male gender and AL [odds ratio (OR): 2.41, 95% confidence interval (CI): 1.37-4.23, P = 0.002]. Similar results were also obtained in patients who underwent laparoscopic TME (OR: 2.11, 95% CI: 1.15-3.89, P = 0.016).

Conclusions

Male patents were found to have an increased risk for AL following TME with a primary anastomosis. A temporary protecting stoma may help to protect the anastomosis and lessen the risk for AL especially in male patients.

Conversion is a risk factor for postoperative anastomotic leak in rectal cancer patients - A retrospective cohort study

AIM

The impact of conversion from laparoscopic surgery to laparotomy on the development of anastomotic leak (AL) in rectal cancer patients following laparoscopic low anterior resection (LAR) with total mesorectal excision (TME) has not been evaluated. The aim of this study was to evaluate the impact of conversion on the risk of AL and develop a prediction nomogram for postoperative AL.

METHODS

All rectal cancer patients following laparoscopic LAR with TME from January 2010 to October 2014 were enrolled in the primary cohort. Comparisons of the postoperative anastomotic leak incidence rate between converted patients and non-converted patients were performed using both univariate and multivariate logistic regression analyses. The result of multivariable analysis was used to develop the predicting model and the performance of nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort containing 200 patients from November 2014 to October 2015 was assessed.

RESULTS

Of all patients enrolled (n=646), 592 (91.6%) patients underwent totally laparoscopic surgery, and 54 (8.4%) were converted from laparoscopic surgery to laparotomy. Converted group patients were more likely to have a higher body mass index (BMI), prolonged length of stay (LOS), increased overall postoperative complication rates and advanced clinical T stage (T3 or T4), pathological N stage (N1 or N2) and pathological TNM stage (III or IV). The percentage of patients who had preoperative radiotherapy for rectal cancer was higher in non-converted patients. Patients who underwent conversion to laparotomy (n=10, 18.5%) were more likely to suffer from postoperative AL than those undergoing totally laparoscopic surgery (n=38, 6.4%) (P=0.004). Multivariate logistic regression analyses confirmed the association between conversion and postoperative AL (Odds ratio [OR], 95% confidence interval [CI]: 2.71 [1.31-5.63], P=0.007). Conversion, gender, and clinical N stage incorporated in the individualized prediction nomogram showed good discrimination, with a C-index of 0.697 (C-index, 0.621 and 0.772 through internal validation), and good calibration. In the validation cohort, the main results were consistent with the findings of the primary cohort, with a C-index of 0.670 (C-index, 0.562 and 0.777 through internal validation). Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Conversion during laparoscopic LAR was found to be associated with an increased risk for the postoperative AL in RC patients. A nomogram model incorporating conversion, gender and patient's clinical N stage seems to offers a useful tool for predicting postoperative AL in these patients.

Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients

BACKGROUND

Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection.

METHODS

This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak.

RESULTS

Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale.

CONCLUSION

The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.

Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation

BACKGROUND

Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.

METHODS

We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.

RESULTS

Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 109/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.

CONCLUSION

This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.

Anastomotic leaks in gastrointestinal surgery and their prevention

Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.

Risk factors, short and long term outcome of anastomotic leaks in rectal cancer

Background

An anastomotic leak (AL) after colorectal surgery is one major reason for postoperative morbidity and mortality. There is growing evidence that AL affects short and long term outcome. This prospective German multicentre study aims to identify risk factors for AL and quantify effects on short and long term course after rectal cancer surgery.

Methods

From 1 January 2000 to 31 December 2010 381 hospitals attributed patients to the prospective multicentre study Quality Assurance in Colorectal Cancer managed by the Otto-von-Guericke-University Magdeburg (Germany). Included were 17 867 patients with histopathologically confirmed rectal carcinoma and primary anastomosis. Risk factor analysis included 13 items of demographic patient data, surgical course, hospital volume und tumour stage.

Results

In 2 134 (11.9%) patients an AL was diagnosed. Overall hospital mortality was 2.1% (with AL 7.5%, without AL 1.4%; p < 0.0001). In multivariate analysis male gender, ASA-classification ≥III, smoking history, alcohol history, intraoperative blood transfusion, no protective ileostomy, UICC-stage and height of tumour were independent risk factors. Overall survival (OS) was significantly shorter for patients with AL (UICC I-III; UICC I, II or III - each p < 0.0001). Disease free survival (DFS) was significantly shorter for patients with AL in UICC I-III; UICC II or UICC III (each p < 0.001). Rate of local relapse was not significantly affected by occurrence of AL.

Conclusion

In this study patients with AL had a significantly worse OS. This was mainly due to an increased in hospital mortality. DFS was also negatively affected by AL whereas local relapse was not. This emphasizes the importance of successful treatment of AL related problems during the initial hospital stay.

The effects of hyperthermic intraperitoneal chemoperfusion on colonic anastomosis: an experimental study in a rat model

INTRODUCTION

Cytoreductive surgery (CRS) with subsequent hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising modality to treat and prevent peritoneal metastases. However, this treatment is associated with signficant morbidity and mortality. Whether or not CRS with HIPEC interferes with anastomotic healing has also been debated. This study was designed to investigate the effects of mitomycin C, cisplatin, oxaliplatin, and doxorubicin used in HIPEC treatment on colonic anastomosis healing in a rat model.

METHODS

Sixty Wistar albino rats were employed in the study. Sigmoid resection and end-to-end colorectal anastomosis was performed in all rats. Group 1 rats underwent the surgical procedure alone, while group 2 rats were given hyperthermic intraperitoneal lavage with heated saline following surgery. Groups 3, 4, 5, and 6 had surgery with concomitant HIPEC treatment with mitomycin C, cisplatin, oxaliplatin, and doxorubicin, respectively. Anastomotic bursting pressures and hydroxyproline levels were evaluated.

RESULTS

Regarding the hydroxyproline levels, groups 1 and 2 showed significantly higher values than other groups (p<0.001). However, there was no significant difference between the HIPEC treatment groups (groups 3, 4, 5, and 6) (p>0.05). When groups were compared regarding bursting pressure values, no significant differences were observed (p = 0.81).

CONCLUSIONS

This study demonstrated that the HIPEC procedure with mitomycin C, cisplatin, oxaliplatin and doxorubicin had negative effects on hydroxyproline levels, but had no detrimental effect on anastomotic bursting pressure in a rat model.

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery.

METHOD

This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage.

RESULTS

A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001).

CONCLUSION

In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Risk factors for anastomotic dehiscence in colon cancer surgery--a population-based registry study

PURPOSE

The aim of this was to assess potential risk factors for anastomotic dehiscence in colon cancer surgery in a national cohort.

METHODS

All patients, who had undergone a resection of a large bowel segment with an anastomosis between 2008 and 2011, were identified in the Swedish Colon Cancer Registry. Patient factors, socioeconomic factors, surgical factors, and medication and hospital data were combined to evaluate risk factors for anastomotic dehiscence.

RESULTS

The prevalence of anastomotic dehiscence was 4.3 % (497/11 565). Male sex, ASA classification III-IV, prescribed medications, bleeding more than 300 mL, and uncommon colorectal resections were associated with a higher risk of anastomotic dehiscence. Hospital stay was increased with 14.5 days, and 30-day mortality as well as long-term mortality was higher in the anastomotic dehiscence group.

CONCLUSIONS

There are several factors that are possible to know preoperatively or during surgery that can indicate whether an anastomosis is an appropriate option. Anastomotic dehiscence increases hospital stay and long-term mortality.