Anastomotic integrity after operations for large-bowel cancer: a multicentre study

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BACKGROUND

There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications.

METHODS

We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879).

RESULTS

The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis.

CONCLUSION

We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Superior rectal artery preservation to reduce anastomotic leak rates in familial adenomatous polyposis patients treated with total colectomy and ileorectal anastomosis

BACKGROUND

Total colectomy with ileorectal anastomosis (TC/IRA) is one of the prophylactic surgical options in patients with familial adenomatous polyposis (FAP). This study investigated the effectiveness of superior rectal artery (SRA) preservation during TC/IRA in reducing anastomotic leakage (AL).

METHODS

This retrospective study was based on prospectively collected data (01/2000 - 12/2022) at the National Cancer Institute, Milan, Italy. FAP patients undergoing TC/IRA were enrolled. A 1:1  propensity score matching (PSM) was performed. Associations between SRA preservation and complications were investigated using univariate and multivariate analysis.

RESULTS

The study population included 211 patients undergoing TC/IRA (Sex: 106 Male, 105 Female; Age: median 30 yrs, IQR: 20-48 yrs), 82 with SRA preservation (SRA group) and 129 without SRA preservation (controls). After PSM, 75 patients were considered for each group. SRA preservation was associated with fewer complications (OR 0.331, 95% CI 0.116; 0.942) in univariate logistic regression analysis. AL events were significantly fewer in the SRA group than in the control group (0 vs 12, p = 0.028). The SRA group had fewer overall surgical complication and pelvic sepsis rates (p = 0.020 and p = 0.028, respectively). Median operative time was significantly longer in the SRA group (340 min vs 240 min, p<0.001), and median hospital stay was significantly shorter (6 vs 7 days, p=0.017). Twenty-seven patients in the SRA group experienced intraoperative anastomotic bleeding, which was controlled endoscopically. Superimposable results were obtained analyzing the whole patient cohort.

CONCLUSIONS

SRA preservation can be considered an advantage in this patient population, despite adding a further technical step during surgery and thereby prolonging the operative time. Intraoperative endoscopic checking of possible anastomotic bleeding sites is recommended.

Proteína C reactiva como biomarcador predictivo de fuga anastomótica en cirugía oncológica colorrectal: estudio de cohorte retrospectivo

Introducción. La fuga anastomótica es la complicación más grave del tratamiento quirúrgico del cáncer de colon por su alta morbimortalidad. El diagnóstico evidente, manifestado por la salida de contenido intestinal por drenajes o la herida quirúrgica, ocurre tardíamente (entre el 6º y 8º día). El objetivo de este trabajo fue estudiar la variación de los valores de la proteína C reactiva postoperatoria para hacer un diagnóstico precoz. Métodos. Estudio observacional, analítico, retrospectivo, de una cohorte de pacientes con neoplasia, en quienes se realizó cirugía oncológica con anastomosis intestinal, entre enero de 2019 y diciembre de 2021. Se midieron los valores en sangre de proteína C reactiva postoperatoria (1°, 3° y 5° días). Resultados. Se compararon 225 casos operados que no presentaron fuga con 45 casos con fuga. En los casos sin fuga, el valor de proteína C reactiva al 3º día fue de 148 mg/l y al 5º día de 71 mg/l, mientras en los casos con fuga, los valores fueron de 228,24 mg/l y 228,04 mg/l, respectivamente (p<0,05). Para un valor de 197 mg/l al 3º día la sensibilidad fue de 77 % y para un valor de 120 mg/l al 5º día la sensibilidad fue de 84 %. Conclusión. El mejor resultado de proteína C reactiva postoperatoria para detectar precozmente la fuga anastomótica se observó al 5º día. El valor de 127 mg/l tuvo la mejor sensibilidad, especificidad y valor predictivo negativo, lo cual permitiría el diagnóstico temprano y manejo oportuno de esta complicación.

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

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

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

Objective

This meta-analysis aimed to evaluate whether ketorolac administration is associated with an increased anastomotic leak rate after colorectal surgery.

Methods

The literature was searched using the Web of Science, Embase, and PubMed databases, and the search ended on May 31, 2020. The Newcastle–Ottawa Scale was used to assess methodological quality. Statistical heterogeneity was assessed using the Chi-square Q test and I² statistics. Subgroup analysis was performed, and Egger's test was used to assess publication bias.

Results

This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23]. Low heterogeneity was observed across these studies (I² = 0%, P = 0.51). The results of subgroup analysis showed that the use of ketorolac in case–control and retrospective cohort studies significantly increased the risk of anastomotic leak (P < 0.05). Furthermore, the subgroup analysis revealed that ketorolac use increased anastomotic leak rate in patients in the United States and Canada, and ketorolac plus morphine use did not increase anastomotic leak rate in Taiwanese patients (P < 0.05). No significant publication bias was observed (P = 0.126). Moreover, the analysis of risk factors related to anastomotic leak rate indicated that the total use of ketorolac did not increase the risk of anastomotic leak similar to the control group (P > 0.05).

Conclusion

The meta-analysis indicates that the use of ketorolac increases the risk of anastomotic leak after colorectal surgery.

Systematic Review Registration

PROSPERO, identifier CRD42020195724.

Risk Factors for Anastomotic Leak, Consideration for Proximal Diversion, and Appropriate Use of Drains

Anastomotic leaks are a major source of morbidity after colorectal surgery. There is a myriad of risk factors that may contribute to anastomotic leaks. These risk factors can be categorized as modifiable, nonmodifiable, and intraoperative factors. Identification of these risk factors allows for preoperative optimization that may minimize the risk of anastomotic leak. Knowledge of such high-risk features may also affect intraoperative decision-making regarding the creation of an anastomosis, consideration for proximal diversion, or placement of a drain. A thorough understanding of the interplay between risk factors, indications for proximal diversion, and utility of drain placement is imperative for colorectal surgeons.

Can maneuverability in the robot assisted laparoscopic stapler during ileoileal anastomosis compensate for shorter stapler length? - A randomized experimental porcine study

BACKGROUND

Ileal anastomosis is imperative in patients given a urinary diversion during radical cystectomy. Proper handling and staplers with a certain length are important to prevent stenosis of the bowel. The study aim was to compare the circumference and diameter of ileoileal anastomoses using the Endo GIA tri-stapler 45 mm and 60 mm iDrive systems compared to the RAL Endowrist DaVinci 45 mm. This was to investigate if the better maneuverability of the robotic stapler would compensate for the shorter stapler length in the RAL Endowrist DaVinci 45.

MATERIALS AND METHODS

Twenty ileoileal anastomoses were performed in a total of three pigs after randomization according to the type of anastomosis technique used (depending on stapler and robotic system) allocated to four groups (each with five anastomoses): (1) iDrive 45 mm, (2) iDrive 60 mm, (3) RAL DaVinci 45 mm (Si-system), and (4) RAL DaVinci 45 mm (Xi-system). Diameter (mm) and circumference (mm) were measured and compared.

RESULTS

Diameters and circumferences in Group 1 were significantly smaller compared to all the other groups, which did not differ from each other, except in Group 2 where anastomoses had a significantly higher circumference than Group 4.

CONCLUSION

The iDrive 60 mm makes the anastomoses with the widest diameter and highest circumference compared to the iDrive 45 mm. With the RAL DaVinci 45 mm, the diameter and circumference were comparable to the iDrive 60 mm and significantly better than the iDrive 45 mm. An explanation may be the better maneuverability and surgeon control of the RAL DaVinci stapler.

Anastomotic Techniques for Abdominal Crohn's Disease: Tricks and Tips

After surgical resection for Crohn's disease (CD) endoscopic recurrence is noted within few weeks and almost 80% of patients will have evidence of endoscopic recurrence at the anastomosis after ileocolic resection at 1 year. With time and if left untreated surgical recurrence will be detected at the preanastomotic segment or at the anastomosis in the vast majority of cases. It has become progressively apparent also based on these historical data that anastomotic configuration plays a major role in the subsequent recurrence of CD in surgically induced remission. In this article, we will review the evidence in the literature to support the different anastomotic configurations and we will discuss the principles of surgical prophylaxis of CD recurrence.

Development and in vivo Assessment of a Rapidly Collapsible Anastomotic Guide for Use in Anastomosis of the Small Intestine: A Pilot Study Using a Swine Model

Various conditions in human and veterinary medicine require intestinal resection and anastomosis, and complications from these procedures are frequent. A rapidly collapsible anastomotic guide was developed for small intestinal end-to-end anastomosis and was investigated in order to assess its utility to improve the anastomotic process and to potentially reduce complication rates. A complex manufacturing method for building a polymeric device was established utilizing biocompatible and biodegradable polyvinylpyrrolidone and polyurethane. This combination of polymers would result in rapid collapse of the material. The guide was designed as a hollow cylinder composed of overlaying shingles that separate following exposure to moisture. An in vivo study was performed using commercial pigs, with each pig receiving one standard handsewn anastomosis and one guide-facilitated anastomosis. Pigs were sacrificed after 13 days, at which time burst pressure, maximum luminal diameter, and presence of adhesions were assessed. Burst pressures were not statistically different between treatment groups, but in vivo anastomoses performed with the guide withstood 10% greater luminal burst pressure and maintained 17% larger luminal diameter than those performed using the standard handsewn technique alone. Surgeons commented that the addition of a guide eased the performance of the anastomosis. Hence, a rapidly collapsible anastomotic guide may be beneficial to the performance of intestinal anastomosis.

Comparison of Platelet-Rich Plasma-Impregnated Suture Material with Low and High Platelet Concentration to Improve Colonic Anastomotic Wound Healing in Rats

Objective

This study was designed to investigate the impact of using suture material impregnated with platelet-rich plasma (PRP) in different platelet concentrations on colonic anastomotic wound healing in rats.

Methods

A total of 24 Sprague Dawley female rats were separated into 3 groups (n = 8 for each) including the control group (CON; standard vicryl suture repair), the low platelet concentrate PRP group (L-PRP; suture material impregnated with PRP containing average 2.7-fold (range, 2.0 to 3.1) higher amount of platelets vs. control), and the high platelet concentrate PRP group (H-PRP; suture material impregnated with PRP containing average 5.1-fold (range, 4.8 to 5.4) higher amount of platelets vs. control). Rats were sacrificed on the postoperative 7^th day for analysis of colonic anastomosis region including macroscopic observation, measurement of anastomotic bursting pressure (ABP), and the hydroxyproline levels and histopathological findings in colon tissue samples.

Results

Total injury scores were significantly lower in the L-PRP and H-PRP groups than those in the control group (median (range) 13.00 (7.00) and 11.50 (6.00) vs. 15.50 (4.00), p < 0.05 and p < 0.01, respectively). ABP values (180.00 (49.00) vs. 124.00 (62.00) and 121.00 (57.00) mmHg, p < 0.001 for each) and tissue hydroxyproline levels (0.56 (0.37) vs. 0.25 (0.17) and 0.39 (0.10) μg/mg tissue, p < 0.001 and p < 0.05, respectively) were significantly higher in the L-PRP group as compared with those in the control and H-PRP groups.

Conclusion

In conclusion, our findings revealed PRP application to colonic anastomosis sutures to promote the anastomotic healing process. The platelet concentration of PRP seems to have a significant impact on the outcome with superior efficacy of L-PRP over H-PRP in terms of bursting pressures and collagen concentration at the anastomotic site.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Technical and Clinical Considerations for Successful Management of Postoperative Bowel Perforation by Percutaneous Foley Catheter Placement

Purpose

The aim of this study was to analyze several technical and clinical factors associated with the successful management of postoperative leakage by percutaneous Foley catheter placement.

Materials and Methods

Thirty-two patients were included in this retrospective study. Postoperative gastrointestinal leakage was diagnosed by computed tomography (CT) and the patients underwent percutaneous Foley catheter placement into the leakage site through Jackson-Pratt tubes or imaging-guided methods. Clinical success was defined as successful Foley catheter removal without symptom recurrence within 1 week and the risk factors for clinical failure were analyzed.

Results

In all patients, percutaneous Foley catheter placement was successfully achieved without complications. Foley catheter was placed at a median of 10 days (range, 1–68) after the confirmation of leakage on CT. Clinical success was achieved in 26 of the 32 patients (81%). Systemic comorbidity (p < 0.001) and failed oral intake (p = 0.015) were the statistically significant risk factors for clinical failure.

Conclusion

Percutaneous Foley catheter placement can be considered an effective approach for the management of postoperative bowel leakage. The presence of systemic comorbidity and successful oral diet after Foley catheter placement are significant factors for successful clinical recovery.

Comparison of Honey versus Polylactide Anti-Adhesion Barrier on Peritoneal Adhesion and Healing of Colon Anastomosis in Rabbits

BACKGROUND:

Postoperative adhesion is still a consequence of intra-abdominal surgeries, which results in bowel obstruction and abdominopelvic pain. Bowel anastomosis as a common abdominal surgery has the incidence of leakage in up to 30% of patients that increase morbidity and mortality. Due to similar pathways of adhesion formation and wound healing, it is important to find a way to reduce adhesions and anastomosis leakage.

AIM:

This study was designed to compare antiadhesive as well as anastomosis healing improvement effect of honey and polylactide anti-adhesive barrier film.

METHODS:

Forty-five rabbits divided into three groups of honey, adhesion barrier film, and control group in an animal study. Under a similar condition, rabbits underwent resection and anastomosis of cecum under general anaesthesia. In the first group, honey was used at the anastomosis site, in the second one polylactide adhesion barrier film utilised, and the third one was the control group. Adhesion, as well as anastomosis leakage, was assessed after 21 days. Data were analysed using the Statistical Package for Social Scientists (SPSS) for Windows version 25.

RESULTS:

Three groups of 15 rabbits were studied. The results showed that mean peritoneal adhesion score (PAS) was lower in the honey group (1.67) in comparison to the adhesion barrier film group (3.40) and the control group (6.33).

CONCLUSION:

Bio-absorbable polylactide barrier has an anti-adhesion effect but is not suitable for intestinal anastomosis in rabbits. Further studies needed to evaluate these effects on human beings.

Healing of Ischemic Colon Anastomosis in Rats Could Be Provided by Administering Dexpanthenol or Coenzyme Q10

Background: In this study, the effectiveness of dexpanthenol and coenzyme Q10 (CoQ10) on the healing of ischemic colon anastomosis was investigated. Methods: Forty eight male Wistar Albino rats were divided into four equal groups (Sham-S, Sham-I, DXP, Q10). Following full layer colon resection, single layer colon anastomosis, without creating ischemia, was performed on the Sham-S group. The same experimental model was performed on remaining groups after ischemia was created. Intraperitoneal dexpanthenol and CoQ10 was administered to the DXP and Q10 groups once a day for three days. Ten days later, all colon anastomoses were investigated histopathologically and biochemically, as well as their burst pressure values, in all sacrificed rats. Results: The highest burst pressure value was observed in the Sham-S group, decreasing from high to low in the DXP, Q10, and Sham-I groups, respectively (p = 0.008). Furthermore, tissue hydroxyproline (p = 0.001) level values were significantly different among the groups. Additionally, histopathological analysis revealed a significant difference among groups regarding reepithelization (p = 0.027) and polymorphonuclear leukocyte density (p = 0.022). Conclusions: This preliminary study has shown that ischemia-reperfusion injury may impair the healing of colon anastomosis and it has been concluded that dexpanthenol and CoQ10 may have positive effects on the healing of ischemic colon anastomosis in rat, although re-epithelization may be adversely affected using CoQ10.

The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery

Purpose:

Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery.

Materials and Methods:

In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups.

Results:

Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis.

Conclusions:

The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

Is a Drain Necessary after Colonic Anastomosis?

To date, there have been no clinical investigations of the usefulness of drains following colonic anastomosis in elective operations. We report a prospective study in which 49 patients were randomized to have a corrugated silastic drain (Portex) placed next to the colonic anastomosis. These patients were compared with a control group of 57 patients who had no drain. The two groups were similar in age, sex, diagnosis and site of anastomosis. There was no difference in outcome between the two groups. Anastomotic leakage occurred in six patients in each group. Wound infections were noted in 10 patients in each group. Two patients with a drain and one patient without a drain died from leakage at the anastomosis. This study provides no evidence to support the use of a corrugated drain after anastomosis of the colon.

Collagenase Inhibition in the Healing Colon

A randomized controlled trial was performed to assess the effect of intravenous aprotinin (Trasylol) on the healing of experimental colonic anastomoses in the rabbit following a standard left colonic resection anastomosis. Assessment of tensile strength was by means of both bursting pressure and breaking strength. Those animals subjected to bursting pressure assessment received intravenous aprotinin 80 000 KIU (kallikrein inhibitory units) at the time of anaesthesia, and postoperatively 160000 KIU per day given in divided doses for three days. Control animals received saline placebo. A further group of animals received a lower loading and maintenance aprotinin dose (40 000 KIU and 60000 KIU per day respectively) with control animals receiving saline. Breaking strength was employed as the means of assessment.

The mean bursting pressures were 47.7 ∓ 2.9 mmHg and 37.5 ∓ 3.4 mmHg for aprotinin and controls respectively (P≤0.05). The mean difference in collagen content of the anastomosis compared to the resected specimen was +1.25 ∓0.50 μg/mg and −1.02 ∓ 0.47 ug/mg for aprotinin and placebo groups (P ≤ 0.005).

The mean breaking strength in the aprotinin group was 169.6 ∓74.5 g and 110.0 ∓65.9 g for the saline group (P≤0.02). The mean difference in collagen content of the anastomosis compared to the resected specimen was +0.95 ∓0.69 ug/mg and −1.5 ∓0.78 ug/mg for the aprotinin and saline groups respectively (P≤0.05).

The significant elevation of both bursting pressure and breaking strength assessments, with a significant improvement in the collagen content of the anastomoses, may be the result of collagenase inhibition following the use of intravenous aprotinin in the experimental model.

Mortality in a University Surgical Unit: What is an Avoidable Death?

Between January 1978 and December 1987 there were 23 557 surgical admissions to the University Surgical Unit in Southampton. During this period there were 543 deaths, an overall death per admission rate of 2.3%. During the 10-year period the number of admissions per year had risen from 1884 in 1978 (death per admission=3.6%) to 3467 in 1987 (death per admission rate=1.7%).

At the monthly audit meeting an attempt was made to classify each death as ‘avoidable’ or ‘unavoidable’. During this 10-year period it was considered that there were 89 ‘avoidable’ deaths. This represents an avoidable mortality rate (AMR) of 0.38%.

These ‘avoidable’ deaths were due to a wide variety of causes and this paper discusses the lessons learnt from a review of surgical mortality and outlines how units might compare results.

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.

Surgical sutures: coincidence or experience?

BACKGROUND

Knotting sutures by hand is still important in daily surgical routine, especially laparotomy closure. The expectation is that hand suturing relies on the experience and subjective estimation of the surgeon. The aim of this study was to investigate whether hand suturing tension is reproducible and if surgical experience influences reproducibility.

METHODS

At the annual Congress of the German Association of Surgery, 118 surgeons performed repetitive sutures on a standardized and certified measuring device simulating the final knot of a fascial closure. Each surgeon was asked to perform five identical single knots in a row using the suture tension that each considered ideal. Tension during knotting was measured in Newtons. The surgeons were divided into five subgroups based on surgical experience: group 1, <1 year; group 2, 2-5 years; group 3, 6-10 years; group 4, 11-20 years; and group 5, >30 years.

RESULTS

The tension measured at the end of knotting ranged from 0.19 to 10 N. The mean suture tension at endpoint was 3.88 N for group 1 and slightly higher in the other groups, but not significantly different. The overall mean suture tension was 5.43 N and did not correlate with surgical experience. Suture tension was not reproducible.

CONCLUSION

Sequential suture tension varied, even among experienced surgeons. The ideal tissue-dependent suture tension has not been defined. Measured values appear to be intuitive, relying on individual feeling rather than the level of experience.

Predicting Value of Serum Procalcitonin, C-Reactive Protein, Drain Fluid Culture, Drain Fluid Interleukin-6, and Tumor Necrosis Factor-α Levels in Anastomotic Leakage after Rectal Resection

BACKGROUND

Anastomotic leak is the most dreaded septic complication of colorectal surgical procedures. Death is proportional to the time between occurrence and diagnosis of the leakage. Biomarkers, which may help to predict anastomotic leakage before appearance of its clinical features, may be beneficial in preventing adverse outcomes. This study investigates a biomarker that might be useful to predict rectal anastomotic leakage before its clinical presentation.

PATIENTS AND METHODS

Serum procalcitonin and C-reactive protein (CRP) levels, bacterial proliferation, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels of drain fluid were evaluated in 50 consecutive patients who underwent low anterior resection without diverting ostomy for rectal carcinoma.

RESULTS

Anastomotic leakage occurred in seven of 50 (14%) patients. Serum CRP and procalcitonin levels at post-operative day three were higher in patients with anastomotic leakage (p = 0.01, p = 0.02 respectively). Drain TNF-α values were increased 63.2% on post-operative day five when compared with post-operative day three in patients with anastomotic leakage, but were decreased in patients without leakage. There was no statistical difference for drain IL-6 levels between groups. The bacterial proliferation rate of drain fluid culture in the leakage group was 42.9% at post-operative day three and 85.7% at post-operative day five (p = 0.29 and p = 0.0001, respectively).

CONCLUSIONS

High serum CRP and procalcitonin values on post-operative day three are alarming, and assessment of anastomotic leakage by abdominal imaging with rectal contrast is suggested. In addition, increasing levels of TNF-α and bacterial proliferation in drain fluid are predictive, whereas IL-6 is not.

Differences in surgical site infection between laparoscopic colon and rectal surgeries: sub-analysis of a multicenter randomized controlled trial (Japan-Multinational Trial Organization PREV 07-01)

BACKGROUND

The incidence of surgical site infection (SSI) is reportedly lower in laparoscopic colorectal surgery than in open surgery, but data on the difference in SSI incidence between colon and rectal laparoscopic surgeries are limited.

METHODS

The incidence and risk factors for SSI, and the effect of oral antibiotics in colon and rectal laparoscopic surgeries, were investigated as a sub-analysis of the JMTO-PREV-07-01 (a multicenter, randomized, controlled trial of oral/parenteral vs. parenteral antibiotic prophylaxis in elective laparoscopic colorectal surgery).

RESULTS

A total of 582 elective laparoscopic colorectal resections, comprising 376 colon surgeries and 206 rectal surgeries, were registered. The incidence of SSI in rectal surgery was significantly higher than in colon surgery (14 vs. 8.2 %, P = 0.041). Although the incidence of incisional SSI was almost identical (7 %) between the surgeries, the incidence of organ/space SSI in rectal surgery was significantly higher than in colon surgery (6.3 vs. 1.1 %, P = 0.0006). The lack of oral antibiotics was significantly associated with the development of SSI in colon surgery. Male sex, stage IV cancer, and abdominoperineal resection were significantly associated with SSI in rectal surgery. The combination of oral and parenteral antibiotics significantly reduced the overall incidence of SSI in colon surgery (relative risk 0.41, 95 % confidence interval 0.19-0.86).

CONCLUSION

The incidence of SSI in laparoscopic rectal surgery was higher than in colon surgery because of the higher incidence of organ/space SSI in rectal surgery. The risk factors for SSIs and the effect of oral antibiotics differed between these two procedures.

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.

Ketorolac Use and Postoperative Complications in Gastrointestinal Surgery

OBJECTIVE

To study the association between ketorolac use and postoperative complications.

BACKGROUND

Nonsteroidal anti-inflammatory drugs may impair wound healing and increase the risk of anastomotic leak in colon surgery. Studies to date have been limited by sample size, inability to identify confounding, and a focus limited to colon surgery.

METHODS

Ketorolac use, reinterventions, emergency department (ED) visits, and readmissions in adults (≥ 18 years) undergoing gastrointestinal (GI) operations was assessed in a nationwide cohort using the MarketScan Database (2008-2012).

RESULTS

Among 398,752 patients (median age 52, 45% male), 55% underwent colorectal surgery, whereas 45% had noncolorectal GI surgery. Five percent of patients received ketorolac. Adjusting for demographic characteristics, comorbidities, surgery type/indication, and preoperative medications, patients receiving ketorolac had higher odds of reintervention (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32), ED visit (OR 1.44, 95% CI 1.37-1.51), and readmission within 30 days (OR 1.11, 95% CI 1.05-1.18) compared to those who did not receive ketorolac. Ketorolac use was associated with readmissions related to anastomotic complications (OR 1.20, 95% CI 1.06-1.36). Evaluating only admissions with ≤ 3 days duration to exclude cases where ketorolac might have been used for complication-related pain relief, the odds of complications associated with ketorolac were even greater.

CONCLUSIONS

Use of intravenous ketorolac was associated with greater odds of reintervention, ED visit, and readmission in both colorectal and noncolorectal GI surgery. Given this confirmatory evaluation of other reports of a negative association and the large size of this cohort, clinicians should exercise caution when using ketorolac in patients undergoing GI surgery.

Prediction of anastomotic leak in colorectal cancer surgery based on a new prognostic index PROCOLE (prognostic colorectal leakage) developed from the meta-analysis of observational studies of risk factors

PURPOSE

To obtain a prognostic index, which has been named PROCOLE (prognostic colorectal leakage), it can predict the risk that a certain individual may suffer anastomotic leakage.

METHODS

The methodology consists of a systematic review to identify potential risk factors for anastomotic leakage and a meta-analysis of studies of each of these factors. In the meta-analysis, the prognostic index integrates factors that are statistically significant, which are weighted according to the estimated value of the effect size. The prognostic index was validated using retrospectively collected data from patients who underwent colorectal cancer surgery anastomosis at our institution.

RESULTS

The mean and standard deviation of the PROCOLE prognostic index in patients with anastomotic leakage is 1.9 ± 6.13, whereas in controls, it is 3.63 ± 2.1. The predictive ability of the PROCOLE, assessed by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC), results in an AUC of 0.82 with a 95% confidence interval (CI) (0.75, 0.89) of the AUC, and it can be considered a good prognostic indicator.

CONCLUSIONS

The PROCOLE prognostic index predicts the risk of a certain individual developing anastomotic leakage after colorectal cancer surgery. Specifically, the PROCOLE prognostic index establishes a discrimination value threshold of 4.83 for recommending the implementation of a protective stoma. We have developed free software with a simple interface that only requires the selection of risk factors to obtain the PROCOLE value.

Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus

BACKGROUND AND OBJECTIVES

When deciding about the use of a defunctioning stoma in rectal cancer surgery, benefits and risks need to be weighed. This study investigated: (1a) factors associated with the use of defunctioning stomas; (1b) hospital variation; and (2) surgeons' perceptions regarding factors that determine this decision.

METHODS

Population-based data from the Dutch Surgical Colorectal Audit were used. Factors for receiving a defunctioning stoma were analyzed with multivariate logistic regression analysis. Hospital variation was assessed before and after case-mix adjustment. A survey was performed among gastroenterological surgeons on the importance of factors for the decision to construct a defunctioning stoma.

RESULTS

In total 4368 patients were analyzed and 103 (34%) surgeons participated. Male gender, higher body mass index, lower tumors, preoperative radiotherapy, and treatment in a teaching/university hospital increased the odds for a defunctioning stoma. Unadjusted hospital variation ranged from 0% to 98%. Variation remained after case-mix adjustment (0-100%). There was large variation in factors considered important for the decision; almost all factors were ranked as 'most important' at least once.

CONCLUSIONS

There is large variation in the use of defunctioning stomas for patients with rectal cancer, and a lack in uniformity of the selection criteria. These results underline the need to improve current decision making and identification of high-risk patients.

Use of transanastomotic double-pigtail stents in the management of grade B colorectal leakage: a pilot feasibility study

INTRODUCTION

Anastomotic leakage (AL) is a major complication of colorectal surgery. The leakage is classified as grade B when the patient's clinical condition requires an active therapeutic intervention but does not require further surgery. The management of grade B AL commonly includes administration of antibiotics and/or the placement of a pelvic drainage performed under radiological guidance or transanal drain. The objective of this study was to evaluate the feasibility and the efficacy of endoscopic transanastomotic drainage using double-pigtail stents (DPSs) in the management of grade B AL in colorectal surgery.

PATIENTS AND METHODS

Between September 2011 and December 2014, 650 patients underwent a colorectal procedure in our university hospital; 8.7 % presented with AL, including 42.8 % with grade B. Fourteen patients required endoscopic management and constituted the study population. The study's primary objective was to assess the feasibility and efficacy of DPS placement for the treatment of grade B AL after colorectal surgery. The secondary endpoints were the requirement for radiological drainage, the DPS placement failure rate, the rate of stoma closure and, lastly, feasibility of chemotherapy (if indicated).

RESULTS

DPS placement was feasible in 92.8 % of the 14 patients (n = 13). The overall success rate for endoscopic management was 78.5 % (n = 11). The median length of hospitalization after DPS placement was 5 days (3-17). The average duration of drainage through a DPS was 62 days (28-181). Five patients (35.7 %) also underwent drainage with radiological guidance. Of the 10 patients with stoma, closure occurred in 80 %. All patients that required adjuvant chemotherapy were able to receive it.

CONCLUSION

The treatment of AL requires multidisciplinary collaboration to save the anastomosis. DPS placement under endoscopic control is associated with AL healing, good clinical tolerance and the ability to undergo chemotherapy and is an alternative to repeat laparotomy when radiological drainage is unfeasible or inefficient.

Infected retroperitoneal pelvic necrosis in severe acute pancreatitis: how can we manage it?

OBJECTIVES

Retroperitoneal necrosis in the pelvic cavity is a rare complication of severe acute pancreatitis (SAP), mainly developing in critically ill patients. Because of its particular anatomy, it is difficult to perform drainage or surgery. We hypothesized that computed tomography (CT)-guided drainage is an effective approach for the infected retroperitoneal necrosis. The aim of this study is to evaluate the safety and effectiveness of CT-guided transgluteal drainage in SAP patients with infected retroperitoneal pelvic necrosis.

MATERIALS AND METHODS

Twelve SAP patients with infected retroperitoneal pelvic necrosis underwent CT-guided transgluteal drainage with a 12-month follow-up. The safety and effectiveness of drainage were measured by the complication rate and the rate of clinical success.

RESULTS

All the 12 patients underwent a successful drainage under the guidance of CT and their clinical symptoms disappeared within 48 h. One patient died of another serious complication of SAP and in the remaining 11 patients, complete resolution was achieved without major complications. The mean catheter indwelling time was 21.5 days. Repeated CT during the follow-up period showed no recurrence in the remaining 11 patients.

CONCLUSION

Transgluteal drainage under the guidance of CT was found to be an effective and appropriate approach for infected pelvic necrosis in SAP patients.

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

Background and Purpose

Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated.

Methods

Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction.

Results

Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals’ adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals’ adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates.

Conclusions

A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.

Diverting ileostomy in colorectal surgery: when is it necessary?

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increased collagen maturity with sildenafil citrate: experimental high risk colonic anastomosis model

BACKGROUND

Inadequate healing and high anastomosis leak rates at rectal anastomosis may be due to lack of supportive serosal layer and technical difficulty of low anterior resections. Positive effects of sildenafil on wound healing were observed. The aim of this study was to simulate rectal anastomosis as a technical insufficient anastomosis and investigate the effects of sildenafil on anastomosis healing.

METHODS

Colonic anastomoses were carried out in 64 rats and randomized into four groups, CA-S, complete anastomoses without sildenafil (10 mg/kg for 5 days); CA+S, complete anastomoses with sildenafil; IA-S, incomplete anastomoses without sildenafil; IA+S, incomplete anastomoses with sildenafil. Half of the rats in every group were sacrificed on post-operative day (POD) 3, half of them sacrificed on POD 7. Tissues from the anastomoses were used for functional, histochemical, biochemical investigations.

RESULTS

Sildenafil treatment resulted in increased bursting pressures in IA+S on POD 7 (p=0.010). Collagen maturity was higher in IA+S on POD 3 and POD 7, CA+S on POD 7 (p=0.010; p=0.010; p<0.007). Collagen content was higher in IA+S on POD 7 (p<0.001). Glutathione, hydroxyproline levels were similar. Malondialdehyde levels were lower in IA+S on POD 3 (p<0.001). Epithelization score was higher in IA+S on POD 7 (p=0.007). Inflammation score was higher in CA-S group on POD 3 and POD 7 (p<0.001; p<0.001). Neutrophil score was lower in CA+S on POD 3 (p=0.005).

CONCLUSION

An increase in collagen content, maturity, and epithelization, a decrease in neutrophil infiltration, oxidative stress and better mechanical strength were observed with the administration of sildenafil.

The art of bowel anastomosis

Anastomotic techniques have greatly improved over the past two centuries, and postoperative complications have fallen accordingly. Factors contributing to anastomotic failure include location and systemic diseases such as sepsis and hemorrhagic shock. Factors that have not demonstrated any difference in outcome include stapled versus hand sewn anastomosis, continuous versus interrupted sutures, and single versus two layer anastomosis. Successful intestinal anastomosis necessitate adequate exposure and access, gentle tissue handling, absence of tension and distal obstruction, hemodynamic stability with adequte tissue oxygenation, and meticulous surgical technique.

Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center

Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.

Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis?

OBJECTIVE

To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement.

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Tertiary referral center.

PATIENTS

Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection.

INTERVENTION

Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared.

MEASUREMENTS AND MAIN RESULTS

Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%).

CONCLUSION

A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.

Surgical site infections following short-term radiotherapy and total mesorectal excision: results of a randomized study examining the role of gentamicin collagen implant in rectal cancer surgery

BACKGROUND

Despite the findings of several randomized clinical studies, the role of gentamicin collagen implant (GCI) in rectal cancer surgery is unclear. Local pelvic application of GCI following preoperative radiotherapy and total mesorectal excision (TME) was evaluated to determine the risk of surgical site infections (SSI).

METHODS

In this single-center trial, 176 patients with rectal cancer after preoperative, short-term radiotherapy (5 × 5 Gy) were randomized either to the study group in which GCI was used or in the control group without GCI. Prior to surgery and intraoperatively five patients were excluded from the study. The remaining 171 patients were analyzed; 86 were in the study group and 85 in the control group.

RESULTS

There were no statistically significant differences in the overall rate of early postoperative complications between the study and control group: 25.6 and 34.1 % respectively; p = 0.245, relative risk (RR) 0.750 [95 % confidence interval (CI) 0.471-1.195]. The reoperation rate was similar in both groups: 12.8 versus 9.4 %; p = 0.628; RR 1.359; (95 % CI 0.575-3.212). The total rate of SSI and organ space SSI were 22.2 and 15.8 % without differences between the study and control group. In patients without anastomotic leakage, the risk of organ space SSI was significantly reduced in patients who received GCI: 2.6 versus 13.0 %; p = 0.018.

CONCLUSIONS

Application of GCI in the pelvic cavity after short-term preoperative radiotherapy and TME may reduce the risk of organ space SSI but only in the absence of anastomotic leakage.

Colic anastomotic leakage risk factors

BACKGROUND

Anastomotic leakage is a dreaded complication of colorectal surgery, as it greatly increases the morbidity, mortality and has been associated with augmented local recurrence and diminished survival. The frequency of this complication is high in emergency colorectal surgery, especially for bowel occlusion, (13% for emergency vs. 4% in elective), due to visceral distension and, therefore, an incongruence in the size of each of the stumps, combined with the lack of mechanical preparation and risk of fecal contamination during operation.

METHODS

We studied the incidence of anastomotic fistula in the surgery clinic of the "Sf. Pantelimon" Emergency Hospital, between 2006 and 2010, on a lot of 251 patients who underwent different types of colic resection. Apart from the anatomic location of the disease, and the level of anastomosis, we included in our database the following criteria: the patient's age and gender, type of colic pathology, surgical technique, emergency or elective surgery, comorbidities.

RESULTS

An ileocolic anastomosis was performed for 84 patients (33,46 %), for 114 patients (45,41%) a colo-colic anastomosis was carried out, 2 patients (0,79%) had ileorectal anastomosis and 51 patients (20,31%) underwent a colorectal anastomosis. From the comparative analysis of risk factors (the emergency interventions, the anastomosis location, the age and gender of the patient), a significantly increased value of the relative risk of anastomotic fistula was registered for the cases with emergency intervention (x 6,61) and for the colorectal anastomosis following the left hemi colectomies (x 2,23).

DISCUSSIONS

In our study, among the clinical and biological factors analyzed, emergency intervention was the most significant factor associated with anastomotic leakage. Surgery performed in emergency settings, on debilitated patients without adequate preoperative preparation, has an increased risk for anastomotic dehiscence.

Anastomotic leak or organ space surgical site infection: What are we missing in our quality improvement programs?

BACKGROUND

Expert panels of colorectal surgeons consistently rank anastomotic leak as among the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases do not collect data on anastomotic leaks and rely on reported organ space surgical site infections (OSI) as a proxy for identifying anastomotic leaks. This study questions the validity of using OSI as a surrogate for anastomotic leak.

METHODS

The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 12 hospitals that prospectively collects colectomy-specific metrics, including anastomotic leak, in addition to standard National Surgical Quality Improvement Program (NSQIP) data, including OSIs. Cases with an organ space infection and/or anastomotic leak were selected from the 2010-2011 UNYSQI database. Patient characteristics and outcomes were compared for cases with organ space infections and anastomotic leaks.

RESULTS

Overall, 3% of colectomies had a reported organ space infection and 4% had an anastomotic leak. Among cases having anastomotic leaks, only 25% were also coded as having an organ space infection, leaving 75% of anastomotic leaks not captured by the NSQIP database (κ = 0.272; P ≤ .001).

CONCLUSION

Organ space infection is a poor surrogate for anastomotic leak, resulting in grossly underestimated leak rates and seemingly represents different postoperative courses. Procedure-specific quality measures for colorectal surgery should include data collection on anastomotic leaks to provide accurate data for use in improving patient care.

Intraoperative crystalloid overload leads to substantial inflammatory infiltration of intestinal anastomoses-a histomorphological analysis

BACKGROUND

It has been shown that crystalloid fluid-overload promotes anastomotic instability. As physiologic anastomotic healing requires the sequential infiltration of different cells, we hypothesized this to be altered by liberal fluid regimes and performed a histomorphological analysis.

METHODS

36 Wistar rats were randomized into 4 groups (n=8-10 rats/group) and treated with either liberal (+) or restrictive (-) perioperative crystalline (Jonosteril = Cry) or colloidal fluid (Voluven = Col). Anastomotic samples were obtained on postoperative day 4, routinely stained and histophathologically reviewed. Anastomotic healing was assessed using a semiquantitative score, assessing inflammatory cells, anastomotic repair and collagenase activity.

RESULTS

Overall, the crystalloid overload group (Cry (+)) showed the worst healing score (P < 0.01). A substantial increase of lymphocytes and macrophages was found in this group compared to the other three (P < 0.01). Both groups that received colloidal fluid (Col (+) and Col (-)) as well as the group that received restricted crystalloid fluid resuscitation (Cry (-)) had better intestinal healing. Collagenase activity was significantly higher in the Cry (+) group.

CONCLUSION

Intraoperative infusion of high-volume crystalloid fluid leads to a pathological anastomotic inflammatory response with a marked infiltration of leukocytes and macrophages resulting in accelerated collagenolysis.

Multiple large bowel resections: potential risk factor for anastomotic leak

OBJECTIVES

Identify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL.

METHODS

All cases of AL after LBR for OC between 01/01/1994 and 05/20/2011 were identified and matched 1:2 with controls for age (±5 years), sub-stage (IIIA/IIIB; IIIC; IV), and date of surgery (±4 years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL.

RESULTS

42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95% CI 1.13-6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL patients had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95% CI 1.18-3.57, P=0.011).

CONCLUSIONS

Multiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

AIM

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events.

METHOD

Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality.

RESULTS

In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016).

CONCLUSION

The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Effects of montelukast on the healing of ischemic colon anastomoses

BACKGROUND

The aim of this study was to examine whether treatment with montelukast, a selective leukotriene antagonist, would affect anastomotic healing in a reperfused colon rat model with remote ischemia/reperfusion injury.

METHODS

Rats (n = 12 per group) were intraperitoneally administered normal saline or 10 mg/kg montelukast sodium 60 minutes before and for 5 days after surgery. Ischemia was induced for 45 minutes through superior mesenteric artery occlusion. A left colon anastomosis was made. Blood and perianastomotic tissue samples were obtained on postoperative day 5.

RESULTS

Mean anastomotic bursting pressures of the control and montelukast groups were 159.17 ± 29.99 and 216.67 ± 26.40, respectively (P < .001). Compared with saline, montelukast treatment increased the mean tissue hydroxyproline level (2.46 ± .30 vs 3.61 ± .33 μmol/L) and decreased tissue caspase-3 activity (36.06 ± 5.72 vs 21.78 ± 3.87) and malondialdehyde levels (3.43 ± .34 vs 2.29 ± .34 nmol/g) (P < .001 for all). Other plasma markers of injury also showed differences.

CONCLUSIONS

Montelukast prevented ischemia/reperfusion-induced damage in a rat model of colonic anastomotic wound healing.