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Yu L, Chen G, Wang H, Wang X, Chen Z, Huang Y, Chi P. MRI diagnose post-operative anastomotic leak in patients with rectal cancer: preliminary experience. BMC Surg 2022; 22:422. [PMID: 36503503 PMCID: PMC9743496 DOI: 10.1186/s12893-022-01872-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most serious postoperative complications after colorectal anastomosis. This study aims to evaluate the feasibility and diagnostic accuracy of magnetic resonance imaging (MRI) in the early detection of AL in patients with clinically suspected AL after rectal anterior resection. METHODS This was a prospective study including patients who underwent anterior resection and postoperative MRI examination. AL was diagnosed by comprehensive indictors, which were mainly confirmed by clinical signs, symptoms, and retrograde contrast enema (RCE) radiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of diagnosing AL with MRI were calculated. RESULTS In total, 347 patients received anterior resection for rectal cancer, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination. The median time interval from surgery to MRI was 10 days (3-21 days). The median distance from anastomosis to anal verge was 4.0 cm (2.0-10 cm), and 11 patients underwent diverted ileostomy. Eighteen patients had an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL in the MRI examination. The overall sensitivity and specificity were 94.4% (95% CI 70.6% to 99.7%) and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). For patients who had anastomosis less than 5 cm, the diagnostic accuracy of MRI was 93.7% (15/16). T2-weighted imaging with fat suppression can effectively reveal the leak track. CONCLUSIONS The accuracy of plain MRI examination in diagnosing AL was favorable for patients with a suspected AL. T2-weighted imaging with fat suppression was the best imaging modality to diagnose AL. A multicenter prospective study with more samples is needed to further determine the safety and feasibility of MRI in the diagnosis of AL.
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Affiliation(s)
- Liang Yu
- grid.411176.40000 0004 1758 0478Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001 Fujian China
| | - Guangliang Chen
- grid.411176.40000 0004 1758 0478Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, Fujian China
| | - Hua Wang
- grid.411176.40000 0004 1758 0478Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, Fujian China
| | - Xiaojie Wang
- grid.411176.40000 0004 1758 0478Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001 Fujian China
| | - Zhifen Chen
- grid.411176.40000 0004 1758 0478Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001 Fujian China
| | - Ying Huang
- grid.411176.40000 0004 1758 0478Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001 Fujian China
| | - Pan Chi
- grid.411176.40000 0004 1758 0478Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001 Fujian China
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Thornblade LW, Simianu VV, Davidson GH, Flum DR. Elective Surgery for Diverticulitis and the Risk of Recurrence and Ostomy. Ann Surg 2021; 273:1157-1164. [PMID: 31651534 PMCID: PMC7174092 DOI: 10.1097/sla.0000000000003639] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the comparative risk of recurrence and ostomy after elective resection or medical therapy for uncomplicated diverticulitis, incorporating outpatient episodes of recurrence. BACKGROUND While surgeons historically recommended colon resection for uncomplicated diverticulitis to reduce the risk of recurrence or colostomy, no prior studies have quantified this risk when considering outpatient episodes of disease. It remains to be determined whether surgery actually decreases those risks. METHODS Retrospective cohort study employing an adjusted time-to-event analysis to assess the relationship of medical or surgical treatment with diverticulitis recurrence and/or receipt of an ostomy. Subjects were adults with ≥1 year continuous enrollment treated for ≥2 episodes of uncomplicated diverticulitis from a nationwide commercial claims dataset (2008-2014). RESULTS Of 12,073 patients (mean age 56 ± 14 yr, 59% women), 19% underwent elective surgery and 81% were treated by medical therapy on their second treatment encounter for uncomplicated diverticulitis. At 1 year, patients treated by elective surgery had lower rates of recurrence (6%) versus those treated by medical therapy (32%) [15% vs 61% at 5 years, adjusted hazard ratio 0.17 (95% confidence interval: 0.15-0.20)]. At 1 year, the rate of ostomy after both treatments was low [surgery (inclusive of stoma related to the elective colectomy), 4.0%; medical therapy, 1.6%]. CONCLUSIONS Elective resection for uncomplicated diverticulitis decreases the risk of recurrence, still 6% to 15% will recur within 5 years of surgery. The risk of ostomy is not lower after elective resection, and considering colostomies related to resection, ostomy prevention should not be considered an appropriate indication for elective surgery.
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3
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Budin C, Staniloaie D, Vasile D, Ilco A, Balan DG, Popa CC, Stiru O, Tulin A, Enyedi M, Miricescu D, Georgescu DE, Georgescu TF, Badiu DC, Mihai DA. Hypocalcemia: A possible risk factor for anastomotic leak in digestive surgery. Exp Ther Med 2021; 21:523. [PMID: 33815596 PMCID: PMC8014963 DOI: 10.3892/etm.2021.9955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/18/2021] [Indexed: 11/22/2022] Open
Abstract
Anastomotic leaks (ALs) remain the most severe complication in digestive surgery, as well as the most consumptive in terms of human and financial resources. There is an abundance of international research which has focused on identifying and correcting risk factors, and on individualized surgical management as well. The most frequent risk factors are male sex, obesity, diabetes, advanced malignant disease, ASA score, perioperative blood loss or perioperative transfusion, long operation time, emergency operation and altered nutritional status. The aim of the present study was to measure the preoperative serum calcium level and to find a possible correlation between calcium levels and the risk of AL occurrence. A retrospective analysis of medical records for 122 patients who underwent surgical gut resection with anastomosis for different pathologies was carried out. Preoperative serum calcium level and the occurrence of AL was noted. The results revealed that the average value of total blood calcium was 8.78 mg/dl, without a significant difference in sex groups. Hypocalcemia was identified in 44 patients (36.1%). AL was identified in 8 patients (6.6%), with a statistically insignificant difference between male and female patients. The average value of blood calcium in the AL patient group was 8.07 mg/dl, while in patients without AL the average value was 8.83 mg/dl. Hypocalcemia, defined as a serum calcium level below 8.5 mg/dl, was observed in 7 of the 8 patients presenting with AL (87.5%) and 37 patients who did not present with AL (32.5%), a significant difference with which to consider and include hypocalcemia in the group of risk factors for AL (P=0.001). In conclusion, preoperative low serum calcium level can represent a risk factor for AL in digestive surgery.
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Affiliation(s)
- Constantin Budin
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniel Staniloaie
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Danut Vasile
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Alexandru Ilco
- Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Daniela-Gabriela Balan
- Department of Physiology, Faculty of Dental Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Cristian Constantin Popa
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Cardiovascular Surgery, 'Prof. Dr. C.C. Iliescu' Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Mihaly Enyedi
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Radiology, 'Victor Babes' Private Medical Clinic, 030303 Bucharest, Romania
| | - Daniela Miricescu
- Department of Biochemistry, Faculty of Dental Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dragos Eugen Georgescu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Teodor Florin Georgescu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dumitru Cristinel Badiu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Bagdasar-Arseni' Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Doina-Andrada Mihai
- Department of Diabetes, Nutrition and Metabolic Diseases, Prof. N.C. Paulescu National Institute of Diabetes, Nutrition and Metabolic Disease, 020021 Bucharest, Romania.,Department of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
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4
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Awad S, El-Rahman AIA, Abbas A, Althobaiti W, Alfaran S, Alghamdi S, Alharthi S, Alsubaie K, Ghedan S, Alharthi R, Asiri M, Alzahrani A, Alotaibi N, Shoma A, Sheishaa MSA. The assessment of perioperative risk factors of anastomotic leakage after intestinal surgeries; a prospective study. BMC Surg 2021; 21:29. [PMID: 33413244 PMCID: PMC7789647 DOI: 10.1186/s12893-020-01044-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/28/2020] [Indexed: 12/18/2022] Open
Abstract
Background Anastomotic leaks (AL) are among the most serious complications due to the substantial impact on the quality of life and mortality. Inspite of the advance in diagnostic tools such as laboratory tests and radiological adjuncts, only moderate improvement has been recorded in the rate of detected leaks. The purpose of the research was to assess the perioperative risk factors for AL. Methods This study was achieved at MUH and MIH/Egypt within the period between January 2016 and January 2019 for the candidates who underwent bowel anastomosis for small intestinal (except duodenal one) and colorectal pathology. The collected data were analyzed using SPSS of V-26. Results This study included 315 cases, among them, 27 cases (8.57%) developed AL. The percentage of covering stoma was significantly higher in the non-leakage group vs leakage one (24.3% vs 11.1% respectively). lower albumin, operative timing, perforation, and covering stoma were shown as significant risk factors for leakage, but with multivariate analysis for these factors, the emergency operation, and serum albumin level was the only independent risk factors that revealed the significance consequently (p = 0.043, p = 0.015). The analysis of different predictors of AL on the third day showed that the cut-off point in RR was 29 with 83% sensitivity and 92% specificity in prediction of leakage, the cut-off point in RR was 118 with 74% sensitivity and 87% specificity in prediction of leakage and the cut-off point in CRP was 184.7 with 82% sensitivity and 88% specificity in prediction of AL and all had statistically significant value. Conclusions The preoperative serum albumin level and the emergency operations are independent risk factors for anastomotic leakage. Moreover, leakage should be highly suspected in cases with rising respiratory rate, heart rate, and CRP levels.
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Affiliation(s)
- Selmy Awad
- General Surgery Department, Mansoura University Hospitals, Mansoura, 35516, Egypt.
| | | | - Ashraf Abbas
- General Surgery Department, Mansoura University Hospitals, Mansoura, 35516, Egypt
| | - Waleed Althobaiti
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Shaker Alfaran
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Saleh Alghamdi
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Saleh Alharthi
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Khaled Alsubaie
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Soliman Ghedan
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Rayan Alharthi
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Majed Asiri
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Azzah Alzahrani
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Nawal Alotaibi
- General Surgery Department, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Ashraf Shoma
- General Surgery Department, Mansoura University Hospitals, Mansoura, 35516, Egypt
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Benčurik V, Škrovina M, Martínek L, Bartoš J, Macháčková M, Dosoudil M, Štěpánová E, Přibylová L, Briš R, Vomáčková K. Intraoperative fluorescence angiography and risk factors of anastomotic leakage in mini-invasive low rectal resections. Surg Endosc 2020; 35:5015-5023. [PMID: 32970211 DOI: 10.1007/s00464-020-07982-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Vladimír Benčurik
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic. .,AGEL Research and Training Institute, Prostejov, Czech Republic.
| | - Matej Škrovina
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic.,Department of Surgery, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic.,AGEL Research and Training Institute, Prostejov, Czech Republic
| | - Lubomír Martínek
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic.,Department of Surgery, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiří Bartoš
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic
| | - Mária Macháčková
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic
| | - Michal Dosoudil
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic
| | - Erika Štěpánová
- Department of Surgery, Hospital Novy Jicin, Purkyňova 2138/16, Novy Jicin, 74101, Czech Republic
| | - Lenka Přibylová
- Department of Applied Mathematics, Faculty of Electrical Engineering and Computer Science, VSB - Technical University of Ostrava, Ostrava, Czech Republic
| | - Radim Briš
- Department of Applied Mathematics, Faculty of Electrical Engineering and Computer Science, VSB - Technical University of Ostrava, Ostrava, Czech Republic
| | - Katherine Vomáčková
- Department of Surgery, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
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6
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Farkas NG, Welman TJP, Ross T, Brown S, Smith JJ, Pawa N. Unusual causes of large bowel obstruction. Curr Probl Surg 2018; 56:49-90. [PMID: 30777150 DOI: 10.1067/j.cpsurg.2018.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Nicholas G Farkas
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
| | - Ted Joseph P Welman
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Talisa Ross
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah Brown
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Jason J Smith
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nikhil Pawa
- West Middlesex University Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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7
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Barlas AM, Kuru S, Kismet K, Cavusoglu T, Bag YM, Senes M, Cihan N, Celepli P, Unal Y, Hucumenoglu S. Rectal application of argan oil improves healing of colorectal anastomosis in rats1. Acta Cir Bras 2018; 33:565-576. [PMID: 30110058 DOI: 10.1590/s0102-865020180070000002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/20/2018] [Indexed: 01/21/2023] Open
Abstract
PURPOSE To investigate the possible effects of argan oil on the healing of colorectal anastomoses. METHODS n Group 1 (sham), laparotomy was performed and the colon was mobilized. In the control (Group 2) and argan oil (Group 3) groups, colonic resection and anastomosis were applied. To the control and sham groups, 2 mL of 0.9% NaCl was administred rectally, and in the argan oil group, 2 mL/day argan oil was applied rectally for 7 days. RESULTS The mean bursting pressures of the argan oil and sham groups were significantly higher than the values in the control group. A significant difference was determined between the tissue hydroxyproline and prolidase levels of control group and other groups. Histopathologically, argan oil showed significant beneficial effects on colonic wound healing. In the argan oil and sham groups, the tissue malondialdehyde and fluorescent oxidation product levels were found to be lower and total sulfhydryl levels were higher than the control group. CONCLUSIONS The rectally administered argan oil was observed to have significantly ameliorated wound healing parameters and exerted a significant antioxidant effect. This is the first study in the literature about the beneficial effects of argan oil on colorectal anastomoses.
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Affiliation(s)
- Aziz Mutlu Barlas
- MD, General Surgeon, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Conception and design of the study
| | - Serdar Kuru
- Associate Professor, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Design of the study and analysis of data
| | - Kemal Kismet
- Associate Professor, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Design of the study and manuscript writing
| | - Turgut Cavusoglu
- Associate Professor, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Critical revision
| | - Yusuf Murat Bag
- MD, General Surgeon, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Design of the study
| | - Mehmet Senes
- Associate Professor, Ankara Education and Research Hospital, Department of Biochemistry, Ankara, Turkey. Performed the biochemical analyses
| | - Neslihan Cihan
- MD, Biochemist, Ankara Education and Research Hospital, Department of Biochemistry, Ankara, Turkey. Performed the biochemical analyses
| | - Pinar Celepli
- MD, Pathologist, Ankara Education and Research Hospital, Department of Pathology, Ankara, Turkey. Histopathological examinations
| | - Yilmaz Unal
- MD, General Surgeon, Ankara Education and Research Hospital, Department of General Surgery, Ankara, Turkey. Conception of the study and interpretation of data
| | - Sema Hucumenoglu
- Full Professor, Ankara Education and Research Hospital, Department of Pathology, Ankara, Turkey. Histopathological examinations
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8
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Kuru S, Kismet K, Bag YM, Barlas AM, Senes M, Durak M, Yumusak N, Urhan MK, Cavusoglu T, Pekcici R. Does the application of Ankaferd Blood Stopper rectally have positive effects on the healing of colorectal anastomosis and prevention of anastomotic leakage? An experimental study. Biomed Pharmacother 2017; 96:968-973. [DOI: 10.1016/j.biopha.2017.11.140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 01/18/2023] Open
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9
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van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
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10
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Şenocak R, Özer MT, Kaymak Ş, Kılbaş Z, Günal A, Uyanık M, Kozak O. Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model? J INVEST SURG 2016; 30:101-109. [PMID: 27690726 DOI: 10.1080/08941939.2016.1230156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis. MATERIALS AND METHODS Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied. RESULTS The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups. CONCLUSIONS Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.
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Affiliation(s)
- Rahman Şenocak
- a Department of General Surgery , Gulhane Military Medical Faculty
| | | | - Şahin Kaymak
- a Department of General Surgery , Gulhane Military Medical Faculty
| | - Zafer Kılbaş
- a Department of General Surgery , Gulhane Military Medical Faculty
| | | | | | - Orhan Kozak
- a Department of General Surgery , Gulhane Military Medical Faculty
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11
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A minor but deadly surgery of colonic polypectomy in an elderly and fragile patient: a case report and the review of literature. World J Surg Oncol 2016; 14:252. [PMID: 27669818 PMCID: PMC5037652 DOI: 10.1186/s12957-016-1010-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/21/2016] [Indexed: 12/02/2022] Open
Abstract
Background Epithelial dysplasia and adenomatous polyps of colorectum are precancerous lesions. Surgical removal is still one of the important treatment approaches for colorectal polyps. Case presentation A male patient over 78 years was admitted due to bloody stool and abdominal pain. Colonoscopic biopsy showed a high-grade epithelial dysplasia in an adenomatous polyp of sigmoid colon. Anemia, COPD, ischemic heart disease (IHD), arrhythmias, and hypoproteinemia were comorbidities. The preoperative preparation was carefully made consisting of oral nutritional supplements (ONS), blood transfusion, cardiorespiratory management, and hemostatic therapy. However, his illness did not improve but deteriorate mainly due to polyp rebleeding during preparative period. The open polypectomy was performed within 60 min under epidural anesthesia. Postoperative treatments included oxygen inhalation, bronchodilation, parenteral and enteral nutrition, human serum albumin, antibiotics, and blood transfusion. Unluckily, these did not significantly facilitate to surgical recovery on account of severe comorbidities and complications. The most serious complications were colonic leakage and secondary abdominal severe infection. The patient finally gave up treatment due to multiple organ dysfunction syndromes. Conclusions The polypectomy for colonic polyp is a seemingly minor but potentially deadly surgery for patients with severe comorbidities, and prophylactic ostomy should be considered for the safety.
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Effects of the Oral Nutritional Supplement Containing Arginine, Glutamine, and Hydroxymethylbutyrate (Abound®) on Healing of Colonic Anastomoses in Rats. Indian J Surg 2016; 77:1242-7. [PMID: 27011545 DOI: 10.1007/s12262-015-1268-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 04/06/2015] [Indexed: 10/23/2022] Open
Abstract
We evaluated the effects of the oral nutritional supplement containing arginine, glutamine, and hydroxymethylbutyrate (Abound®) on healing of colonic anastomoses in experimental rat model. Seventy Wistar-Albino male rats were divided into seven groups. Colon transection and anastomosis were performed in all groups except for the sham group. In groups 2 and 5, rats were fed with standard rat chow after the operation. Oral nutritional supplement was added to standard nutrition for 3 days postoperatively in group 3 and 7 days in group 6 and preoperative 7 days plus postoperative 3 days in group 4 and preoperative 7 days plus postoperative 7 days in group 7. Bursting pressures were measured, adhesions were evaluated, and tissue samples were taken for measurement of tissue hydroxyproline levels and for histopathological examination. The usage of oral nutritional supplement had positive effects on bursting pressures, tissue hydroxyproline levels, and histopathological findings of anastomoses, but feeding with oral nutritional supplement both preoperatively and postoperatively had no additive effect on these parameters when compared with the groups that were fed only postoperatively. The mixture of arginine, glutamine, and hydroxymethylbutyrate may be safely used for achieving better healing results after colonic anastomoses.
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Netta S, Papadopoulos V, Apostolidis S, Michalopoulos A. The effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids. Hippokratia 2014; 18:350-354. [PMID: 26052203 PMCID: PMC4453810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Anastomotic failure is one of the most frequent complications in rectal surgery. The present study aims to elucidate the effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids. METHODS Fifty male Wistar rats were divided into five groups. Group A (control group, without lavage and medication), group B (lavage with saline solution and no medication), group C (lavage with SCFAs and no medication), group D (lavage with saline solution and injection of 30mg/kg methylprednisolone 7 days pre-operatively and 4 days post-operatively), group E (lavage with a SCFAs and methylprednisolone). On the 4(th) postoperative day the animals were sacrificed and bursting pressure of the anastomosis, CRP, IL-6 and TNF-a were measured. RESULTS Kruskal-Wallis variance analysis showed statistically significant differences between the groups (p<0.001). The bursting pressure of the anastomosis was lower in groups B and D, while it was higher in group C. TNF-a values displayed differences between group D and groups A, C, E. CONCLUSIONS Intraoperative lavage with SCFAs increases anastomotic strength by increasing the bursting pressure of anastomosis in rats receiving corticosteroid, while lavage with saline solution decreases it. Rectal irrigation with short-chain fatty acids may improve anastomotic healing, especially in patients receiving corticosteroids.
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Affiliation(s)
- S Netta
- 1 Propaedeutic Surgical Department, A.H.E.P.A. University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - V Papadopoulos
- 1 Propaedeutic Surgical Department, A.H.E.P.A. University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - S Apostolidis
- Department of Anatomy, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Michalopoulos
- 1 Propaedeutic Surgical Department, A.H.E.P.A. University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Jones DW, Garrett KA. Anastomotic technique—Does it make a difference? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Portilla-de Buen E, Orozco-Mosqueda A, Leal-Cortés C, Vázquez-Camacho G, Fuentes-Orozco C, Alvarez-Villaseñor AS, Macías-Amezcua MD, González-Ojeda A. Fibrinogen and thrombin concentrations are critical for fibrin glue adherence in rat high-risk colon anastomoses. Clinics (Sao Paulo) 2014; 69:259-64. [PMID: 24714834 PMCID: PMC3971357 DOI: 10.6061/clinics/2014(04)07] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/22/2013] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Fibrin glues have not been consistently successful in preventing the dehiscence of high-risk colonic anastomoses. Fibrinogen and thrombin concentrations in glues determine their ability to function as sealants, healers, and/or adhesives. The objective of the current study was to compare the effects of different concentrations of fibrinogen and thrombin on bursting pressure, leaks, dehiscence, and morphology of high-risk ischemic colonic anastomoses using fibrin glue in rats. METHODS Colonic anastomoses in adult female Sprague-Dawley rats (weight, 250-350 g) treated with fibrin glue containing different concentrations of fibrinogen and thrombin were evaluated at post-operative day 5. The interventions were low-risk (normal) or high-risk (ischemic) end-to-end colonic anastomoses using polypropylene sutures and topical application of fibrinogen at high (120 mg/mL) or low (40 mg/mL) concentrations and thrombin at high (1000 IU/mL) or low (500 IU/mL) concentrations. RESULTS Ischemia alone, anastomosis alone, or both together reduced the bursting pressure. Glues containing a low fibrinogen concentration improved this parameter in all cases. High thrombin in combination with low fibrinogen also improved adherence exclusively in low-risk anastomoses. No differences were detected with respect to macroscopic parameters, histopathology, or hydroxyproline content at 5 days post-anastomosis. CONCLUSIONS Fibrin glue with a low fibrinogen content normalizes the bursting pressure of high-risk ischemic left-colon anastomoses in rats at day 5 after surgery.
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Affiliation(s)
- Eliseo Portilla-de Buen
- Centro de Investigación Biomédica de Occidente, IMSS, Surgical Research Division, Guadalajara, Jal, México
| | - Abel Orozco-Mosqueda
- Transplantation Department, SSG, Hospital Regional de Alta Especialidad del Bajío, León, Gto, México
| | - Caridad Leal-Cortés
- Centro de Investigación Biomédica de Occidente, IMSS, Surgical Research Division, Guadalajara, Jal, México
| | - Gonzalo Vázquez-Camacho
- Cell Biology Laboratory, Instituto Tecnológico de Estudios Superiores de Monterrey, School of Medicine, Campus Guadalajara, Jal, México
| | - Clotilde Fuentes-Orozco
- Surgical Section of the Research Unit in Clinical Epidemiology, CMNO, IMSS, Hospital de Especialidades, Guadalajara, Jal, México
| | | | - Michel Dassaejv Macías-Amezcua
- Surgical Section of the Research Unit in Clinical Epidemiology, CMNO, IMSS, Hospital de Especialidades, Guadalajara, Jal, México
| | - Alejandro González-Ojeda
- Surgical Section of the Research Unit in Clinical Epidemiology, CMNO, IMSS, Hospital de Especialidades, Guadalajara, Jal, México
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Calin MD, Bălălău C, Popa F, Voiculescu S, Scăunașu RV. Colic anastomotic leakage risk factors. J Med Life 2013; 6:420-3. [PMID: 24868253 PMCID: PMC4034302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 09/25/2013] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- MD Calin
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy,„Sf. Pantelimon” Emergency University Hospital, Bucharest
| | - C Bălălău
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy,„Sf. Pantelimon” Emergency University Hospital, Bucharest
| | - F Popa
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy,„Sf. Pantelimon” Emergency University Hospital, Bucharest
| | - S Voiculescu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, Coltea University Hospital, Bucharest
| | - RV Scăunașu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, Coltea University Hospital, Bucharest
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Morse BC, Simpson JP, Jones YR, Johnson BL, Knott BM, Kotrady JA. Determination of independent predictive factors for anastomotic leak: analysis of 682 intestinal anastomoses. Am J Surg 2013; 206:950-5; discussion 955-6. [PMID: 24070663 DOI: 10.1016/j.amjsurg.2013.07.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this study was to identify risk factors associated with intestinal anastomotic leakage in order to practically assist in surgical decision making. METHODS A retrospective review of an academic surgery database was performed over 5 years to identify patients who had intestinal (small bowel and colon) anastomoses to determine independent predictors of anastomotic leakage. RESULTS Over the study period, 682 patients were identified with intestinal anastomoses; the overall leak rate was 5.6% (38/682). In bivariate analysis, 9 factors were associated with anastomotic leaks. Of these, 3 were found to be independent predictors of anastomotic leakage using a logistic regression model: anastomotic tension (odds ratio [OR] = 10.1, 95% Confidence Interval [CI] 1.3 to 76.9), use of drains (OR = 8.9, 95% CI 4.3 to 18.4), and perioperative blood transfusion (OR = 4.2, 95% CI 1.4 to 12.3). CONCLUSIONS The recognition of factors associated with anastomotic leakage after intestinal operations can assist surgeons in mitigating these risks in the perioperative period and guide intraoperative decisions.
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Affiliation(s)
- Bryan C Morse
- Academic Department of Surgery, Division of General Surgery, Greenville Memorial Hospital, University of South Carolina School of Medicine-Greenville, 3rd Floor, 701 Grove Road, Greenville, SC 29605, USA.
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Kaur P, Karandikar SS, Roy-Choudhury S. Accuracy of multidetector CT in detecting anastomotic leaks following stapled left-sided colonic anastomosis. Clin Radiol 2013; 69:59-62. [PMID: 24156793 DOI: 10.1016/j.crad.2013.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 08/05/2013] [Accepted: 08/06/2013] [Indexed: 11/18/2022]
Abstract
AIMS To assess accuracy of multidetector computed tomography (MDCT) and individual radiological signs in the diagnosis of anastomotic leaks. MATERIALS AND METHODS Patients undergoing anterior resection with a stapled anastomosis over a 2 year period were identified. Electronic and clinical records of these patients were reviewed. Unenhanced and/or enhanced MDCT was performed with intravenous and/or per-rectal contrast medium and read by a radiologist blinded to the patients' clinical details to determine the sensitivity and specificity of specific findings at MDCT for identifying leaks. RESULTS Seventeen percent (30/170) of the anterior resections were suspected to have an anastomotic leak. Ninety-three percent (28/30) of patients underwent MDCT. Seven point six percent (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and positive and negative predictive values of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in one patient. CONCLUSIONS Presence of peri-anastomotic air is a reliable marker of anastomotic leaks at MDCT. Leakage of rectal contrast medium is highly accurate and increases confidence of diagnosis. The appearance of the staple line itself is not accurate in assessing anastomotic integrity.
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Affiliation(s)
- P Kaur
- Department of General Surgery, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK.
| | - S S Karandikar
- Department of General Surgery, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK
| | - S Roy-Choudhury
- Department of Radiology, Heart of England Foundation Trust, Bordesley Green East, Birmingham, UK
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Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg 2013; 257:108-13. [PMID: 22968068 DOI: 10.1097/sla.0b013e318262a6cd] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to identify patient, clinical, and surgical factors that may predispose patients to anastomotic leak (AL) after large bowel surgery. BACKGROUND Anastomotic leak is still one of the most devastating complications following colorectal surgery. Knowledge about factors predisposing patients to AL is vital to its early detection, decision making for surgical time, managing preoperative risk factors, and postoperative complications. METHODS This was a prospective observational, quality improvement study in a cohort of 616 patients undergoing colorectal resection in a single institution with the main outcome being AL within 30 days postoperatively. Some of the predictor variables were age, sex, Charlson Comorbidity Index (CCI), radiation and chemotherapy, immunomodulator medications, albumin, preoperative diagnoses, surgical procedure(s), surgical technique (laparoscopic vs open), anastomotic technique (staple vs handsewn), number of major arteries ligated at surgery, surgeon's experience, presence of infectious condition at surgery, intraoperative adverse events, and functional status using 36-Item Short Form General Health Survey. RESULTS Of the 616 patients, 53.4% were female. The median age of the patients was 63 years and the mean body mass index was 25.9 kg/m. Of them, 80.3% patients had laparoscopic surgery and 19.5% had open surgery. AL occurred in 5.7% (35) patients. In multivariate analysis, significant independent predictors for leak were anastomoses less than 10 cm from the anal verge, CCI of 3 or more, high inferior mesenteric artery ligation (above left colic artery), intraoperative complications, and being of the male sex. CONCLUSIONS Multiple risk factors exist that predispose patients to ALs. These risk factors should be considered before and during the surgical care of colorectal patients.
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Bangaru H, Veitla RMR, Pigilam M, Kunwargiri GK. Comparative Study between Staplers and Conventional(Hand-Sewn) Anastomosis in Gastrointestinal Surgery. Indian J Surg 2012; 74:462-7. [PMID: 24293900 DOI: 10.1007/s12262-012-0450-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 03/05/2012] [Indexed: 11/30/2022] Open
Abstract
Conventional (hand-sewn) technique of intestinal anastomosis has been in vogue for decades. Staplers which were developed to simplify surgery began to have significant impact. To compare staplers versus conventional anastomosis with respect to certain intra operative and post operative parameters. Prospective study from November 2008 to October 2010 in Hyderabad at OSMANIA, GANDHI, MNJ CANCER hospitals. 120 patients were divided into three groups of 40 each, depending on the surgery like posterior gastrojejunostomy, distal gastrectomy and reconstruction (Billroth II) and colorectal anastomosis. Of these 40 patients, 20 were in hand-sewn group and the other 20 in stapler group. Unpaired 't' test was used to find 'p' value . 'p' value less than 0.05 was considered statistically significant. Total operating time was shortened in stapler group. No significant difference was found in terms of restoration of intestinal function, post-operative hospital stay, post-operative complications like anastomotic leak. Staplers can expedite surgery. They have better access to difficult-to-reach areas. Thus staplers can be beneficial though one should not forget the art of conventional suturing.
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Affiliation(s)
- Himabindu Bangaru
- General Surgery, Osmania General Hospital, D/O B. Balachandra H.NO:3-12-117/140 P.S. Colony, OPP.T.V Studio, Ramantapur, Hyderabad, 500013 AP India
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LujÁN JJ, NÉMeth ZH, Barratt-Stopper PA, Bustami R, Koshenkov VP, Rolandelli RH. Factors Influencing the Outcome of Intestinal Anastomosis. Am Surg 2011. [DOI: 10.1177/000313481107700929] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Anastomotic leak (AL) is one of the most serious complications after gastrointestinal surgery. All patients aged 16 years or older who underwent a surgery with single intestinal anastomosis at Morristown Medical Center from January 2006 to June 2008 were entered into a prospective database. To compare the rate of AL, patients were divided into the following surgery-related groups: 1) stapled versus hand-sewn, 2) small bowel versus large bowel, 3) right versus left colon, 4) emergent versus elective, 5) laparoscopic versus converted (laparoscopic to open) versus open, 6) inflammatory bowel disease versus non inflammatory bowel disease, and 7) diverticulitis versus nondiverticulitis. We also looked for surgical site infection, estimated intraoperative blood loss, blood transfusion, comorbidities, preoperative chemotherapy, radiation, and anticoagulation treatment. The overall rate of AL was 3.8 per cent. Mortality rate was higher among patients with ALs (13.3%) versus patients with no AL (1.7%). Open surgery had greater risk of AL than laparoscopic operations. Surgical site infection and intraoperative blood transfusions were also associated with significantly higher rates of AL. Operations involving the left colon had greater risk of AL when compared with those of the right colon, sigmoid, and rectum. Prior chemotherapy, anticoagulation, and intraoperative blood loss all increased the AL rates. In conclusion, we identified several significant risk factors for ALs. This knowledge should help us better understand and prevent this serious complication, which has significant morbidity and mortality rates.
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Affiliation(s)
- Juan J. LujÁN
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | - ZoltÁN H. NÉMeth
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
- Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey
| | | | - Rami Bustami
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | - Vadim P. Koshenkov
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
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Karatepe O, Kurtulus I, Yalcin O, Battal M, Kamali G, Aydin T. Adrenomedulline improves ischemic left colonic anastomotic healing in an experimental rodent model. Clinics (Sao Paulo) 2011; 66:1805-10. [PMID: 22012055 PMCID: PMC3181232 DOI: 10.1590/s1807-59322011001000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/04/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Leakage from colonic anastomosis is a major complication causing increased mortality and morbidity. Ischemia is a well-known cause of this event. This study was designed to investigate the effects of adrenomedullin on the healing of ischemic colon anastomosis in a rat model. METHODS Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats that were divided into four groups. To mimic ischemia, the mesocolon was ligated 2 cm from either side of the anastomosis in all of the groups. The control groups (1 and 2) received no further treatment. The experimental groups (3 and 4) received adrenomedullin treatment. Adrenomedullin therapy was started in the perioperative period in group 3 and 4 rats (the therapeutic groups). Group 1 and group 3 rats were sacrificed on postoperative day 3. Group 2 and group 4 rats were sacrificed on postoperative day 7. After careful relaparotomy, bursting pressure, hydroxyproline, malondialdehyde, interleukin 6, nitric oxide, vascular endothelial growth factor, and tumor necrosis factor alpha levels were measured. Histopathological characteristics of the anastomosis were analyzed. RESULTS The group 3 animals had a significantly higher bursting pressure than group 1 (p<0.05). Hydroxyproline levels in group 1 were significantly lower than in group 3 (p<0.05). The mean bursting pressure was significantly different between group 2 and group 4 (p<0.05). Hydroxyproline levels in groups 3 and 4 were significantly increased by adrenomedullin therapy relative to the control groups (p<0.05). When all groups were compared, malondialdehyde and nitric oxide were significantly lower in the control groups (p<0.05). When vascular endothelial growth factor levels were compared, no statistically significant difference between groups was observed. Interleukin 6 and tumor necrosis factor alpha were significantly decreased by adrenomedullin therapy (p<0.05). The healing parameters and inflammatory changes (e.g., granulocytic cell infiltration, necrosis, and exudate) were significantly different among all groups (p<0.05). CONCLUSION Adrenomedullin had positive effects on histopathologic anastomotic healing in this experimental model of ischemic colon anastomosis.
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Affiliation(s)
- Oguzhan Karatepe
- Department of Surgery, Okmeydani Education and Research Hospital, Okmeydani, Istanbul, Turkey.
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Abstract
PURPOSE Use of biosutures in animal models of colonic anastomoses is associated with decreased adhesions without affecting anastomotic strength. This study aimed to evaluate the effect of biosutures on colonic anastomoses kept free of adhesions by peritoneal instillation of icodextrin 4%. METHODS Three types of colonic anastomoses were compared: group 1, anastomoses without icodextrin 4% and control suture; group 2, anastomoses with icodextrin 4% (adhesion-free anastomoses) and control suture; and group 3, anastomoses with icodextrin 4% (adhesion-free anastomoses) and biosutures. Dehiscence, adhesion formation, and anastomotic strength were evaluated on day 4 after the operation. RESULTS When peritoneal icodextrin 4% was used in anastomoses with conventional sutures, a decrease in the adhesion index (P = 0.01) and a lower bursting pressure (P = 0.15) were observed. When adhesion-free anastomoses were compared, those performed with biosutures had a higher bursting pressure (P = 0.008) and a similar pattern of adhesion index (P = 0.48). CONCLUSIONS Biosutures improve the strength of adhesion-free colonic anastomoses.
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Irkorucu O, Ucan BH, Cakmak GK, Tascilar O, Emre AU, Ofluoglu E, Bahadir B, Karakaya K, Demirtas C, Pasaoglu H, Ankarali H, Comert M. Effect of 2-Octyl-Cyanoacrylate on Ischemic Anastomosis of the Left Colon. J INVEST SURG 2009; 22:188-94. [DOI: 10.1080/08941930902866261] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Irkorucu O, Ucan BH, Cakmak GK, Emre AU, Tascilar O, Ofluoglu E, Bahadir B, Karakaya K, Demirtas C, Ankarali H, Kertis G, Pasaoglu H, Comert M. Does sildenafil reverse the adverse effects of ischemia on ischemic colon anastomosis: yes, 'no'. Int J Surg 2008; 7:39-43. [PMID: 19022713 DOI: 10.1016/j.ijsu.2008.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 09/27/2008] [Accepted: 10/10/2008] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Sildenafil may lead an improvement in anastomotic healing of ischemic left colon anastomosis. METHODS Thirty-six male Wistar albino rats were randomized into four experimental groups (n=9 in each group). In group 1, a well-perfused left colonic segment was transected, and free ends were anatomosed. In groups 2, 3 and 4 animals underwent a standardized surgical procedure to induce ischemic left colon anastomosis. Group 2 animals received only tap water. In groups 3 and 4 animals received 10mg/kg/body-weight and 20mg/kg/body-weight sildenafil, single dose a day during 4 days, respectively. Rats were sacrificed on day 4 following operation. Anastomotic integrity, intra-peritoneal adhesion scores, anastomotic bursting pressures and tissue hydroxyproline levels were recorded. Histopathological examination of the anastomosis was also performed. RESULTS There was no statistically significant difference among groups with respect to anastomotic integrity (p=0.142) but ischemia decreased the anastomotic bursting pressure. The mean bursting pressure values were 78.8+/-24.1, 43.3+/-26, 55.1+/-32.4, and 43.3+/-20.4 in groups 1, 2, 3, and 4, respectively. Group 1 had the highest values whereas; there was no statistically significant difference between groups 1 and 3. There was no statistically significant difference among groups 2, 3, and 4 with respect to tissue hydroxyproline levels, adhesion scores and the Chiu scores. The highest inflammatory cell presence in the granulation tissue was detected in group 2, whereas the lowest was detected in group 4 (p=0.0001). The highest fibroblast infiltration in the granulation tissue was detected in group 1 (p=0.045). DISCUSSION Our results showed that 10mg/kg sildenafil decreased the adverse effects of ischemia on the healing of ischemic left colon anastomosis. Additional investigations are needed to confirm the effects of phosphodiesterase-5 inhibitors in ischemic colon anastomosis models.
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Affiliation(s)
- Oktay Irkorucu
- Department of General Surgery, Zonguldak Karaelmas University, School of Medicine, Kozlu, Zonguldak, Turkiye.
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Lemmens L, van Zelm R, Vanhaecht K, Kerkkamp H. Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery. J Eval Clin Pract 2008; 14:880-7. [PMID: 19018922 DOI: 10.1111/j.1365-2753.2008.01079.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A systematic review on clinical pathways for gastrointestinal surgery was performed. The aim was to study indicators that are used to evaluate these clinical pathways and to study which effects of clinical pathways are reported. METHODS A search was performed for the period from January 2000 to November 2006 in MEDLINE, EMBASE and CINAHL. The Leuven Clinical Pathway Compass was used to categorize the indicators reported in literature. RESULTS Twenty-three studies were selected, of which 16 were controlled studies. The studies assessed most frequently complication rates, re-admissions, mortality and length of stay. More specific indicators like time to start defecation and time to return to enteral feeding were reported as well. None of the studies reported adverse effects in any of the domains of the Clinical Pathway Compass. CONCLUSION Clinical pathways for gastrointestinal surgery can enhance efficiency of care without adverse effects on outcome. Specific indicators to evaluate these clinical pathways are time to return to enteral feeding and time to defecate. Furthermore, additional to complication rates, number of re-admissions, mortality and length of stay, indicators such as the number of re-operations, pain scores and intensive care unit admission can be assessed to monitor effectiveness and patient safety of the clinical pathways.
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Affiliation(s)
- Lidwien Lemmens
- Department of Perioperative and Emergency Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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28
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Kozol RA, Hyman N, Strong S, Whelan RL, Cha C, Longo WE. Minimizing risk in colon and rectal surgery. Am J Surg 2007; 194:576-87. [PMID: 17936417 DOI: 10.1016/j.amjsurg.2007.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 08/07/2007] [Indexed: 01/11/2023]
Affiliation(s)
- Robert A Kozol
- Department of Surgery, University of Connecticut School of Medicine, 236 Farmington Ave, Farmington, CT 06030, USA
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Smith S, McGeehin W, Kozol RA, Giles D. The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis. BMC Surg 2007; 7:15. [PMID: 17683526 PMCID: PMC1950862 DOI: 10.1186/1471-2482-7-15] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 08/02/2007] [Indexed: 12/11/2022] Open
Abstract
Background Intraoperative testing of colonic anastomoses is routine in assuring anastamotic integrity. We sought to determine the efficacy of the methylene blue enema (MBE) as an intraoperative test for anastomotic leaks. Methods This study is a retrospective review of consecutive colonic operations performed from January 2001 to December 2004 in a community hospital setting by a general surgical group that uses the MBE exclusively. All operations featuring a colonic anastomosis and an intraoperative MBE were studied (n = 229). Intraoperative MBE via a rectal tube was used as the diagnostic test. Intraoperative leak (IOL) rate and clinically significant postoperative leak (POL) rate were the outcome measures. Results The IOL rate was 4.5% for proximal anastomoses, 8% for distal anastomoses, and 7% of total anastomoses. The POL rate was 3% of anastomosis. There were no other testing methods employed. There were no POLs in cases where an IOL led to concomitant intraoperative repair. POL rate for proximal anastomosis was 0.8% and for distal 3%, for stapled 1% and hand sewn 5%. Conclusion MBE IOL rate is comparable to published IOL rates for other methods of intraoperative testing. The MBE can be applied to proximal and distal anastomosis. Patients who were found to have an IOL, and underwent immediate repair, did not develop a clinical POL.
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Affiliation(s)
- Stanton Smith
- University of Connecticut School of Medicine, Farmington, CT, USA.
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30
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Roig JV, García-Armengol J, Alós R, Solana A, Rodríguez-Carrillo R, Galindo P, Fabra MI, López-Delgado A, García-Romero J. Preparar el colon para la cirugía. ¿Necesidad real o nada más (y nada menos) que el peso de la tradición? Cir Esp 2007; 81:240-6. [PMID: 17498451 DOI: 10.1016/s0009-739x(07)71312-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mechanical bowel preparation is a traditional procedure for preparing patients for colorectal surgery. This practice aims to reduce the risk of postoperative infectious complications since colonic fecal content has classically been related to stool spillage during surgery and anastomotic disruption. However, increasing evidence against its routine use can be found in experimental studies, clinical observations, prospective studies, and meta-analyses. We performed a review of the literature on mechanical bowel preparation and its consequences. There is no clear evidence that preoperative bowel cleansing reduces the septic complications of surgery and routine use of this procedure may increase anastomotic leaks and morbidity. Therefore, the results suggest that mechanical preparation is not required in elective colon and rectal surgery and that its use should be restricted to specific indications such as small nonpalpable tumors to aid their localization during laparoscopic procedures or to enable intraoperative colonoscopy. The role of mechanical bowel preparation in rectal surgery is not well defined and further trials with a larger number of patients are required.
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Affiliation(s)
- José V Roig
- Servicio de Cirugía General y Digestiva, Consorcio Hospital General Universitario de Valencia, Valencia, España.
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