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Emile SH. Assessment of the integrity and perfusion of colorectal anastomoses: which tools do we need? Updates Surg 2024; 76:2093-2094. [PMID: 39017821 DOI: 10.1007/s13304-024-01950-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 07/12/2024] [Indexed: 07/18/2024]
Affiliation(s)
- Sameh Hany Emile
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, USA.
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt.
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Catarci M, Guadagni S, Masedu F, Guercioni G, Ruffo G, Viola MG, Borghi F, Scatizzi M, Patriti A, Baiocchi GL. Intraoperative left-sided colorectal anastomotic testing in clinical practice: a multi-treatment machine-learning analysis of the iCral3 prospective cohort. Updates Surg 2024; 76:1715-1727. [PMID: 38767835 DOI: 10.1007/s13304-024-01883-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Current evidence about intraoperative anastomotic testing after left-sided colorectal resections is still controversial. The aim of this study was to analyze the impact of Indocyanine Green fluorescent angiography (ICG-FA) and air-leak test (ALT) over standard assessment on anastomotic leakage (AL) rates according to surgeon's perception of anastomosis perfusion and/or integrity in clinical practice. METHODS A database of 2061 patients who underwent left-sided colorectal resections was selected from patients enrolled in a prospective multicenter study. It was retrospectively analyzed through a multi-treatment machine-learning model considering standard visual assessment (NW; No. = 899; 43.6%) as the reference treatment arm, compared to ICG-FA alone (WP; No. = 409; 19.8%), ALT alone (WI; No. = 420; 20.4%) or both (WPI; No. = 333; 16.2%). Twenty-four covariates potentially affecting the outcomes were included and balanced into the model within the subgroups. The primary endpoint was AL, the secondary endpoints were overall morbidity (OM), major morbidity (MM), reoperation for AL, and mortality. All the results were reported as odds ratio (OR) with 95% confidence intervals (95%CI). RESULTS The WPI subgroup showed significantly higher AL risk (OR 1.91; 95% CI 1.02-3.59; p 0.043), MM risk (OR 2.35; 95% CI 1.39-3.97; p 0.001), and reoperation for AL risk (OR 2.44; 95% CI 1.12-5.31; p 0.025). No other significant differences were recorded. CONCLUSIONS This study showed that the surgeons' perception of both anastomotic perfusion and integrity (WPI subgroup) was associated to a significantly higher risk of AL and related morbidity, notwithstanding the extensive use of both ICG-FA and ALT testing.
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Affiliation(s)
- Marco Catarci
- General Surgery Unit, Sandro Pertini Hospital, ASL Roma 2, Via dei Monti Tiburtini, 385, 00157, Rome, Italy.
| | - Stefano Guadagni
- General Surgery Unit, University of L'Aquila, L'Aquila, Italy
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | | | - Giacomo Ruffo
- General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | | | - Felice Borghi
- Oncologic Surgery Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, TO, Italy
| | - Marco Scatizzi
- General Surgery Unit, Santa Maria Annunziata & Serristori Hospital, Florence, Italy
| | - Alberto Patriti
- Department of Surgery, S. Salvatore Hospital, AST Marche 1, Pesaro e Fano, PU, Italy
| | - Gian Luca Baiocchi
- General Surgical Unit, Department of Clinical and Experimental Sciences, University of Brescia at the ASST Cremona, Cremona, Italy
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Carannante F, Piozzi GN, Miacci V, Bianco G, Melone G, Schiavone V, Costa G, Caricato M, Khan JS, Capolupo GT. Quadruple Assessment of Colorectal Anastomosis after Laparoscopic Rectal Resection: A Retrospective Analysis of a Propensity-Matched Cohort. J Clin Med 2024; 13:5092. [PMID: 39274305 PMCID: PMC11396664 DOI: 10.3390/jcm13175092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/17/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Anastomotic leakage (AL) is one of the most feared complications in colorectal surgery, with an incidence of 12-39% and associated risk of mortality of 2-24%. The causes of AL and the ways to prevent it are currently under investigation. This study aims to verify if a quadruple assessment of colorectal anastomosis could reduce AL incidence. Methods: A retrospective analysis of prospectively collected data on rectal cancer surgery performed from January 2015 to December 2017 and from January 2021 to December 2023 at a tertiary referral cancer centre was performed. Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. Results: A total of 293 patients were enrolled. AL incidence was lower in the quadruple assessment group than in the control group, reaching a statistically significant result (7.7% vs. 16%; p = 0.001). This result was also confirmed after a propensity score match analysis (PSM), in which the AL rate was lower in the quadruple assessment group (5.4% vs. 12.3%; p = 0.01). Conclusions: This study shows how the systematic implementation of a quadruple assessment when performing a colorectal anastomosis could increase awareness on anastomotic success and reduce the incidence of AL.
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Affiliation(s)
- Filippo Carannante
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Research Unit of Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
| | - Guglielmo Niccolò Piozzi
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3FT, UK
| | - Valentina Miacci
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Research Unit of Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
| | - Gianfranco Bianco
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Research Unit of Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
| | - Gennaro Melone
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
| | - Vincenzo Schiavone
- Advanced Biomedical Sciences Department, "Federico II" University, AOU "Federico II", Via S. Pansini 5, 80131 Naples, Italy
| | - Gianluca Costa
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Department of Life Science, Health and Health Professions, Link Campus University, 00165 Rome, Italy
| | - Marco Caricato
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Research Unit of Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3FT, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth PO1 2UP, UK
| | - Gabriella Teresa Capolupo
- UOC Chirurgia Colorettale, Fondazione Policlinico Universitario Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
- Research Unit of Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico, Via Àlvaro del Portillo 200, 00128 Rome, Italy
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Mathew J, Kazi M, Sukumar V, Thakur S, Desouza A, Saklani A. Factors predicting successful resolution and long-term outcomes of benign anastomotic strictures following rectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1307-1313. [PMID: 36918333 DOI: 10.1016/j.ejso.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/25/2022] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
AIM Although advances in treatment have improved sphincter-preservation rates in rectal cancer, the incidence of benign anastomotic strictures has also increased. This retrospective single-institution study sought to determine the incidence of benign anastomotic strictures and the factors associated with their successful resolution following treatment. METHODOLOGY From January 2010 to December 2019, consecutive patients undergoing endoscopic dilatation and/or surgery for benign anastomotic strictures developing after radical sphincter-sparing resections for rectal cancer were evaluated. To model the relationship between outcomes and potential independent variables, sequential univariate and multivariate analyses were performed using binary logistic regression. RESULTS Of 2069 rectal cancer patients undergoing sphincter-preserving surgery, benign anastomotic strictures were identified in 110 (5.3%). Mean age was 48.2 ± 13.98 years; 73.6% were male. Distal tumor-extent was within 6 cm of the anal verge in 60%; 80.9% patients received neoadjuvant radiotherapy. Surgical approach in 71.8% was open, 74.5% being anterior or low anterior resections and 70.9% of anastomoses stapled. Covering stoma was performed in 91.8%. On follow-up, strictures of median length 4 cm were identified at median 3 cm from the anal verge. Endoscopic dilatation was offered in 89.1%, whereas 9.1% required redo-surgery. Overall, 49.1% experienced sustained stricture-resolution with dilatation and 45.4% required re-intervention. At last follow-up, 72.7% were stoma-free. On multivariate analysis, good performance status, absence of anastomotic leak, and short-segment strictures predicted successful stricture-resolution. CONCLUSION Endoscopic dilatation is an effective first-line therapy, with redo anastomosis used to salvage those failing conservative measures. Adverse performance status, anastomotic leak and greater stricture length may predict detrimental outcomes in terms of stricture resolution.
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Affiliation(s)
- Joseph Mathew
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Mufaddal Kazi
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Vivek Sukumar
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Swarnim Thakur
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Ashwin Desouza
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
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Freund MR, Kent I, Agarwal S, Wexner SD. Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers. Tech Coloproctol 2022; 26:181-186. [PMID: 35091791 DOI: 10.1007/s10151-021-02557-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. METHODS Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy. RESULTS One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks. CONCLUSION ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.
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Affiliation(s)
- M R Freund
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - I Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S Agarwal
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Emile SH, Khan SM, Wexner SD. Impact of change in the surgical plan based on indocyanine green fluorescence angiography on the rates of colorectal anastomotic leak: a systematic review and meta-analysis. Surg Endosc 2022; 36:2245-2257. [PMID: 35024926 DOI: 10.1007/s00464-021-08973-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In the present study, patients with colorectal anastomoses that were assessed with indocyanine green (ICG) fluorescence angiography (FA) were compared to patients who had only white light visual inspection of their anastomosis. The impact of change in surgical plan guided by ICG-FA on anastomotic leak (AL) rates was assessed. METHODS PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried for eligible studies. Studies included were comparative cohort studies and randomized trials that compared perfusion assessment of colorectal anastomosis with ICG-FA and inspection under white light. Main outcome measures were change in surgical plan guided by ICG-FA and rates of AL. Risk of bias was assessed using RoB-2 and ROBINS-1 tools. Differences between the two groups in categorical and continuous variables were expressed as odds ratio (OR) with 95% confidence interval (CI) and weighted mean difference. RESULTS This systematic review included 27 studies comprising 8786 patients (48.5% males). Using ICG-FA was associated with significantly lower odds of AL (OR 0.452; 95% CI 0.366-0.558) and complications (OR 0.747; 95% CI 0.592-0.943) than the control group. The weighted mean rate of change in surgical plan based on ICG-FA was 9.6% (95% CI 7.3-11.8) and varied from 0.64% to 28.75%. A change in surgical plan was associated with significantly higher odds of AL (OR 2.73; 95% CI 1.54-4.82). LIMITATIONS Technical heterogeneity due to using different dosage of ICG and statistical heterogeneity in operative time and complication rates. CONCLUSION Assessment of colorectal anastomoses with ICG-FA is likely to be associated with lower odds of anastomotic leak than is traditional white light assessment. Change in plan based on ICG-FA may be associated with higher odds of AL. PROSPERO registration number: CRD42021235644.
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Affiliation(s)
- Sameh Hany Emile
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, 35516, Egypt. .,Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.
| | - Sualeh Muslim Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Abstract
Fluorescence vision using indocyanine green is a surgical tool with increasing applications in colorectal cancer surgery. This tool has received acceptance in several disciplines as a potential method to improve visualization of the surgical field, improve lymph node resection and decrease the incidence of anastomotic leaks (ALs). In colorectal surgery specifically, some studies have shown that intraoperative fluorescence imaging is a safe and feasible method to evaluate anastomotic perfusion, and its use could affect the incidence of anastomotic leaks. Currently, controlled trials are carried out to validate these conclusions, as well as new indications for indocyanine green such as detection and guidance in the management of hepatic colorectal metastases, visualization of ureters and even as tumor marking and improvement the lymph node harvest of early tumors. These advances could offer great value to surgeons and patients, by improving the accuracy and results of cancer resections.
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Carannante F, Lauricella S, Mazzotta E, Mascianà G, Caricato M, Capolupo GT. Quadruple control of colorectal anastomoses. An Italian centre experience - a video vignette. Colorectal Dis 2021; 23:1944. [PMID: 33864333 DOI: 10.1111/codi.15678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Filippo Carannante
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sara Lauricella
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | - Erica Mazzotta
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | - Gianluca Mascianà
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | - Marco Caricato
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
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