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Strobel RM, Wellner JE, Neumann K, Otto SD, Eschlboeck SM, Seifarth C, Schineis CHW, Beyer K, Kreis ME, Lauscher JC. Influence of Neoadjuvant Therapy on Success of Endoscopic Vacuum Therapy in Anastomotic Leakage after Rectal Resection Because of Rectal Cancer. J Clin Med 2024; 13:3982. [PMID: 38999546 PMCID: PMC11242140 DOI: 10.3390/jcm13133982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/21/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024] Open
Abstract
Background: For locally advanced rectal cancer, neoadjuvant therapy (NT) is an established element of therapy. Endoscopic vacuum therapy (EVT) has been a relevant treatment option for anastomotic leakage after rectal resection since 2008. The aim was to evaluate the influence of NT on the duration and success of EVT in anastomotic leakage after rectal resection for rectal cancer. Methods: This was a monocentric, retrospective cohort study including patients who underwent rectal resection with primary anastomosis because of histologically proven carcinoma of the rectum in the Department for General and Visceral Surgery of Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin over a period of ten years (2012 to 2022). Results: Overall, 243 patients were included, of which 47 patients (19.3%) suffered from anastomotic leakage grade B with consecutive EVT. A total of 29 (61.7%) patients received NT and 18 patients (38.3%) did not. The median duration of EVT until the removal of the sponge did not differ between patients with and without NT: 24.0 days (95% CI 6.44-41.56) versus 20.0 days (95% CI 17.03-22.97); p = 0.273. The median duration from insertion of EVT until complete healing was 74.0 days with NT (95% CI 10.07-137.93) versus 62.0 days without NT (95% CI 45.99-78.01); p = 0.490. Treatment failure-including early persistence and late onset of recurrent anastomotic leakage-was evident in 27.6% of patients with NT versus 27.8% without NT; p = 0.989. Ostomy was reversed in 19 patients (79.2%) with NT compared to 11 patients (68.8%) without NT; p = 0.456. Overall, continuity was restored in 75% of patients in the long term after EVT. Conclusion: This trial comprised-to our knowledge-the largest study cohort to analyze the outcome of EVT in anastomotic leakage after rectal resection for rectal cancer. We conclude that neoadjuvant therapy neither prolongs EVT nor the time to healing from anastomotic leakage. The rates of treatment failure of EVT and permanent ostomy were not higher when neoadjuvant therapy was used.
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Affiliation(s)
- Rahel M Strobel
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Julia E Wellner
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Konrad Neumann
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Susanne D Otto
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sophie M Eschlboeck
- Department of General and Visceral Surgery, St. Claraspital, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Claudia Seifarth
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christian H W Schineis
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Martin E Kreis
- Executive Board, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Johannes C Lauscher
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
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Fahmy Y, Trabia MB, Ward B, Gallup L, Froehlich M. Development of an Anisotropic Hyperelastic Material Model for Porcine Colorectal Tissues. Bioengineering (Basel) 2024; 11:64. [PMID: 38247941 PMCID: PMC10813287 DOI: 10.3390/bioengineering11010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/01/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Many colonic surgeries include colorectal anastomoses whose leaks may be life-threatening, affecting thousands of patients annually. Various studies propose that mechanical interaction between the staples and neighboring tissues may play an important role in anastomotic leakage. Therefore, understanding the mechanical behavior of colorectal tissue is essential to characterizing the reasons for this type of failure. So far, experimental data characterizing the mechanical properties of colorectal tissue have been few and inconsistent, which has significantly limited understanding their behavior. This research proposes an approach to developing an anisotropic hyperelastic material model for colorectal tissues based on uniaxial testing of freshly harvested porcine specimens, which were collected from several age- and weight-matched pigs. The specimens were extracted from the same colon tract of each pig along their circumferential and longitudinal orientations. We propose a constitutive model combining Yeoh isotropic hyperelastic material with fibers oriented in two directions to account for the hyperelastic and anisotropic nature of colorectal tissues. Experimental data were used to accurately determine the model's coefficients (circumferential, R2 = 0.9968; longitudinal, R2 = 0.9675). The results show that the proposed model can be incorporated into a finite element model that can simulate procedures such as colorectal anastomoses reliably.
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Affiliation(s)
- Youssef Fahmy
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Mohamed B. Trabia
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Brian Ward
- Department of Surgery, Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV 89154, USA; (B.W.); (M.F.)
| | - Lucas Gallup
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Mary Froehlich
- Department of Surgery, Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV 89154, USA; (B.W.); (M.F.)
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Greijdanus NG, Wienholts K, Ubels S, Talboom K, Hannink G, Wolthuis A, de Lacy FB, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rutegård M, Hompes R, Rosman C, van Workum F, Tanis PJ, de Wilt JHW. Stoma-free survival after anastomotic leak following rectal cancer resection: worldwide cohort of 2470 patients. Br J Surg 2023; 110:1863-1876. [PMID: 37819790 PMCID: PMC10638542 DOI: 10.1093/bjs/znad311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/09/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied. METHODS Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1). RESULTS Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of -1.1 (95 per cent c.i. -9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (-28 to 52) days). CONCLUSION Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kiedo Wienholts
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | | | - F Borja de Lacy
- Gastrointestinal Surgery Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Michael Solomon
- Department of Surgery, University of Sydney Central Clinical School, Camperdown, New South Wales, Australia
| | - Matteo Frasson
- Department of Surgery, Valencia University Hospital La Fe, Valencia, Spain
| | | | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Rodrigo O Perez
- Colorectal Surgery, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Tsuyoshi Konishi
- Department of Colon and Rectal Surgery, University of Texas MD Anderson Cancer Center, Anderson, Texas, USA
| | - Yves Panis
- Colorectal Surgery Centre, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly Seine, France
| | - Martin Rutegård
- Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Talboom K, Greijdanus NG, Brinkman N, Blok RD, Roodbeen SX, Ponsioen CY, Tanis PJ, Bemelman WA, Cunningham C, de Lacy FB, Hompes R. Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series. Tech Coloproctol 2023; 27:1099-1108. [PMID: 37212927 PMCID: PMC10562258 DOI: 10.1007/s10151-023-02808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/15/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR. METHODS This retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up. RESULTS Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008). CONCLUSION Proactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N G Greijdanus
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - N Brinkman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R D Blok
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S X Roodbeen
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Y Ponsioen
- Department of Gastro-Enterology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F B de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Feng W, Miao Y, Li W, Xu Z, Chen F, Lv Z, Liu W, Zheng M, Zhao J, Zong Y, Lu A. High ligation versus low ligation of the inferior mesenteric artery in laparoscopic rectal cancer surgery: a retrospective study on surgical and long-term outcome. Langenbecks Arch Surg 2023; 408:249. [PMID: 37380790 DOI: 10.1007/s00423-023-02980-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND In laparoscopic low anterior resection for rectal cancer surgery, there has been controversy to whether the inferior mesenteric artery (IMA) should be ligated at the origin of its aorta (high ligation (HL)) or below the branches of the left colonic artery (LCA) (low ligation (LL)). This study was intended to clarify oncological outcome and long-term prognosis of retrospective analysis. METHODS Analyzed the cases who underwent laparoscopic low anterior resection (LAR) in Shanghai Ruijin Hospital from January 2015 to December 2016, 357patients scheduled into 2 groups according to the level of IMA ligation: HL (n = 247) versus LL (n = 110). RESULTS The primary endpoint is long-term outcomes, and the secondary endpoint is the incidence rate of major postoperative complications. There were no significant differences in 5-year overall survival (P = 0.92) and 5-year disease-free survival (P = 0.41). There were no differences between the clinical baseline levels in each group. The incidence of low anterior resection syndrome (LARS) in the two groups was statistically significant (P = 0.037). No significant differences were observed in operative time (P = 0.092) and intraoperative blood loss (P = 0.118). In the HL group, 6 cases (2.4%) had additional colonic excision due to poor anastomotic blood supply; none of the colonic anastomosis in the low ligation group had ischemic manifestations, and length from the proximal margin (P = 0.076), length from the distal margin (P = 0.184), the total number of lymph nodes excised (P = 0.065), and anastomotic leakage incidence (P = 0.33). CONCLUSION Low ligation of the IMA which reserved LCA with vascular root lymph node dissection in laparoscopic low anterior resection for rectal cancer surgery may help protect the blood supply of the anastomosis, and will not increase postoperative complications while enhance recovery, without compromising radical excision and long-term prognosis.
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Affiliation(s)
- Wenqing Feng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yiming Miao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wenchang Li
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zifeng Xu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Fangqian Chen
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Zeping Lv
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Wangyi Liu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Minhua Zheng
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Jingkun Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Yaping Zong
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China
| | - Aiguo Lu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, China.
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Kim JH, Han WH, Lee DE, Kim SY, You K, Park SS, Lee DW, Seo SS, Kang S, Park SY, Lim MC. Anastomotic leakage after resection of the rectosigmoid colon in primary ovarian cancer. J Ovarian Res 2023; 16:85. [PMID: 37120533 PMCID: PMC10148549 DOI: 10.1186/s13048-023-01153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/02/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND The aim of the study is to evaluate the risk factors of anastomotic leakage (AL) and develop a nomogram to predict the risk of AL in surgical management of primary ovarian cancer. METHODS We retrospectively reviewed 770 patients with primary ovarian cancer who underwent surgical resection of the rectosigmoid colon as part of cytoreductive surgery between January 2000 to December 2020. AL was defined based on radiologic studies or sigmoidoscopy with relevant clinical findings. Logistic regression analyses were performed to identify the risk factor of AL, and a nomogram was developed based on the multivariable analysis. The bootstrapped-concordance index was used for internal validation of the nomogram, and calibration plots were constructed. RESULTS The incidence of AL after resection of the rectosigmoid colon was 4.2% (32/770). Diabetes (OR 3.79; 95% CI, 1.31-12.69; p = 0.031), co-operation with distal pancreatectomy (OR, 4.8150; 95% CI, 1.35-17.10; p = 0.015), macroscopic residual tumor (OR, 7.43; 95% CI, 3.24-17.07; p = 0<001) and anastomotic level from the anal verge shorter than 10 cm (OR, 6.28; 95% CI, 2.29-21.43; p = 0.001) were significant prognostic factors for AL on multivariable analysis. Using four variables, the nomogram has been developed to predict anastomotic leakage: https://ALnomogram.github.io/ . CONCLUSION Four risk factors for AL after resection of the rectosigmoid colon are identified from the largest ovarian cancer study cohort. The nomogram from this information provides a numerical risk probability of AL, which could be used in preoperative counseling with patients and intraoperative decision for accompanying surgical procedures and prophylactic use of ileostomy or colostomy to minimize the risk of postoperative leakage. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Ji Hyun Kim
- Center for Gynecologic Cancer, Hospital, Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Research Institute, Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Won Ho Han
- Department of Critical Care Medicine, Hospital, National Cancer Center, Goyang, South Korea
| | - Dong-Eun Lee
- Biostatistics Collaboration Team, National Cancer Center, Goyang, Republic of Korea
| | - Sun Young Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kiho You
- Center for Colorectal Cancer, Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Hospital, National Cancer Center, Goyang, South Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Hospital, National Cancer Center, Goyang, South Korea
| | - Sang-Soo Seo
- Center for Gynecologic Cancer, Hospital, Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Research Institute, Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Sokbom Kang
- Center for Gynecologic Cancer, Hospital, Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Research Institute, Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
- Department of Cancer Control & Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea
- Division of Clinical Research, Research Institute, National Cancer Center, Goyang, Republic of Korea
| | - Sang-Yoon Park
- Center for Gynecologic Cancer, Hospital, Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Research Institute, Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea
| | - Myong Cheol Lim
- Center for Gynecologic Cancer, Hospital, Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Research Institute, Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10408, Republic of Korea.
- Department of Cancer Control & Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Republic of Korea.
- Division of Clinical Research, Research Institute, National Cancer Center, Goyang, Republic of Korea.
- Rare and Pediatric Cancer Branch and Immuno-oncology Branch, Division of Rare and Refractory Cancer, Research Institute, National Cancer Center, Goyang, Republic of Korea.
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Hu X, Grinstaff MW. Advances in Hydrogel Adhesives for Gastrointestinal Wound Closure and Repair. Gels 2023; 9:282. [PMID: 37102894 PMCID: PMC10138019 DOI: 10.3390/gels9040282] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
Millions of individuals undergo gastrointestinal (GI) tract surgeries each year with common postoperative complications including bleeding, perforation, anastomotic leakage, and infection. Today, techniques such as suturing and stapling seal internal wounds, and electrocoagulation stops bleeding. These methods induce secondary damage to the tissue and can be technically difficult to perform depending on the wound site location. To overcome these challenges and to further advance wound closure, hydrogel adhesives are being investigated to specifically target GI tract wounds because of their atraumatic nature, fluid-tight sealing capability, favorable wound healing properties, and facile application. However, challenges remain that limit their use, such as weak underwater adhesive strength, slow gelation, and/or acidic degradation. In this review, we summarize recent advances in hydrogel adhesives to treat various GI tract wounds, with a focus on novel material designs and compositions to combat the environment-specific challenges of GI injury. We conclude with a discussion of potential opportunities from both research and clinical perspectives.
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Affiliation(s)
| | - Mark W. Grinstaff
- Departments of Chemistry and Biomedical Engineering, Boston University, Boston, MA 02215, USA
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Khadem S, Herzberg J, Honarpisheh H, Jenner RM, Guraya SY, Strate T. Safety profile of a multimodal fail-safe model to minimize postoperative complications in oncologic colorectal resections-a cohort study. Perioper Med (Lond) 2023; 12:5. [PMID: 36906563 PMCID: PMC10007828 DOI: 10.1186/s13741-023-00291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/07/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Despite innovations in surgical techniques, major complications following colorectal surgery still lead to a significant morbidity and mortality. There is no standard protocol for perioperative management of patients with colorectal cancer. This study evaluates the effectiveness of a multimodal fail-safe model in minimizing severe surgical complications following colorectal resections. METHODS We compared major complications in patients with colorectal cancers who underwent surgical resections with anastomosis during 2013-2014 (control group) with patients treated during 2015-2019 (fail-safe group). The fail-safe group had preoperative bowel preparation and a perioperative single dose of antibiotics, on-table bowel irrigation and early sigmoidoscopic assessment of anastomosis in rectal resections. A standard surgical technique for tension-free anastomosis was adapted in the fail-safe approach. The chi-square test measured relationships between categorical variables, t-test estimated the probability of differences, and the multivariate regression analysis determined the linear correlation among independent and dependent variables. RESULTS A total of 924 patients underwent colorectal operations during the study period; however, 696 patients had surgical resections with primary anastomoses. There were 427 (61.4%) laparoscopic and 230 (33.0%) open operations, while 39 (5.6%) laparoscopic procedures were converted. Overall, the rate of major complications (Dindo-Clavien grade IIIb-V) significantly reduced from 22.6% for the control group to 9.8% for the fail-safe group (p < 0.0001). Major complications mainly occurred due to non-surgical reasons such as pneumonia, heart failure, or renal dysfunction. The rates of anastomotic leakage (AL) were 11.8% (22/186) and 3.7% (n = 19/510) for the control and fail-safe groups, respectively (p < 0.0001). CONCLUSION We report an effective multimodal fail-safe protocol for colorectal cancer during the pre-, peri-, and postoperative period. The fail-safe model showed less postoperative complications even for low rectal anastomosis. This approach can be adapted as a structured protocol during the perioperative care of patients for colorectal surgery. TRIAL REGISTRATION This study was registered in the German Clinical Trial Register (Study ID: DRKS00023804 ).
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Affiliation(s)
- Shahram Khadem
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany.
| | - Human Honarpisheh
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Robert Maximilian Jenner
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, P. O. Box 27272, Sharjah, United Arab Emirates
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
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9
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Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications. J Clin Med 2023; 12:jcm12041489. [PMID: 36836024 PMCID: PMC9966470 DOI: 10.3390/jcm12041489] [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: 11/17/2022] [Revised: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.
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10
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Emile SH, Horesh N, Freund MR, Garoufalia Z, Gefen R, Silva-Alvarenga E, Wexner SD. A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score. Surgery 2023; 173:342-349. [PMID: 36473745 DOI: 10.1016/j.surg.2022.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/15/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer. METHODS This was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival. RESULTS A total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9-7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed. CONCLUSION Comorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, Mansoura University Hospitals, Egypt. https://twitter.com/dr_samehhany81
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Tel Aviv University, Israel. https://twitter.com/nirhoresh
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel. https://twitter.com/mikifreund
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/ZGaroufalia
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem. https://twitter.com/RachelGefen
| | - Emanuela Silva-Alvarenga
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL. https://twitter.com/EmanuelaSilvaA1
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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11
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Saraswat NB, Brill SA, Wise WE. Management of Low-Rectal Anastomotic Sinus With Transanal Minimally Invasive Septotomy. Am Surg 2023; 89:322-324. [PMID: 33170744 DOI: 10.1177/0003134820952827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Scott A Brill
- Section of Colon and Rectal Surgery, Riverside Methodist Hospital, Columbus, OH, USA
| | - William E Wise
- Section of Colon and Rectal Surgery, Riverside Methodist Hospital, Columbus, OH, USA
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12
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Ostapenko A, Liechty S, Kleiner D. Endoluminal vacuum therapy for rectal anastomosis is safe and does not increase risk of strictures in a swine model. J Clin Transl Res 2022; 8:453-464. [PMID: 36452003 PMCID: PMC9706313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/28/2022] [Accepted: 07/27/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Endoluminal vacuum therapy has been experimentally used in patients with esophageal, rectal, and Roux-en-Y bypass surgery. Yorkshire pigs are good animal models for studying the safety and efficacy of endoluminal vacuum therapy and prior studies have employed these devices in rectal anastomotic defects, as rescue therapy for early anastomotic leaks, as well as prophylactic therapy as a means of protecting high risk anastomosis. AIM The objective of this study is to assess the effects of a prophylactic vacuum assist device on bowel tissue surrounding an intact anastomosis at 30 days post device removal. METHODS A total of seven pigs underwent a rectal resection with primary anastomosis: five experimental pigs with a prophylactic endoluminal vacuum device in place for 5 days post-surgery and two control pigs with no device. All animals were euthanized on the 35th post-operative day and subjected to a necropsy with a histopathological evaluation of the rectal anastomosis. RESULTS No significant difference in inflammation or strictures was observed between the anastomosis of animals with the endoluminal vacuum devices and controls. CONCLUSION We, therefore, conclude that endoluminal vacuum therapy is safe for prophylactic use in pigs undergoing low anterior resection and does not cause significant strictures. RELEVANCE FOR PATIENTS Anastomotic leak is a feared complication resulting in increased costs, length of stay, and emotional distress. Endoluminal negative pressure vacuum therapy is a new technology that has been used in experimental models in both animals and humans for prevention and treatment of anastomotic leak. In this series we demonstrate endoluminal vacuum therapy is safe in a porcine model and does not result in stricture or increased adhesion formation. We expect endoluminal vacuum therapy to become more widely used in the future in both prevention and treatment of anastomotic leaks.
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Affiliation(s)
| | - Shawn Liechty
- Department of General Surgery, Nuvance Health, CT, USA
| | - Daniel Kleiner
- Department of General Surgery, Waterbury Hospital, CT, USA
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13
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Schultzel M, Ghazaryan N, Schultzel M. Rectocutaneous Fistula Presenting as an Insect Bite at the Distal Posterior Thigh: A Multidisciplinary Approach. Perm J 2022; 26:114-119. [PMID: 36530051 PMCID: PMC9761277 DOI: 10.7812/tpp/22.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Mark Schultzel
- 1United Medical Doctors, San Diego, CA, USA,Mark Schultzel, MD, MBA
| | - Nelli Ghazaryan
- 2Department of Obstetrics and Gynecology, UCSF Fresno, Fresno, CA, USA
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14
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Liu RQ, Elnahas A, Tang E, Alkhamesi NA, Hawel J, Alnumay A, Schlachta CM. Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery. Surg Endosc 2022; 36:9281-9287. [PMID: 35290507 DOI: 10.1007/s00464-022-09166-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. METHODS A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. RESULTS The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. CONCLUSION Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.
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Affiliation(s)
- Rachel Q Liu
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Ahmad Elnahas
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Ephraim Tang
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Nawar A Alkhamesi
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada
| | - Abdulaziz Alnumay
- Department of Surgery, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Christopher M Schlachta
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada.
- CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, University Hospital, 339 Windermere Road Room B7-216, London, ON, N6A 5A5, Canada.
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15
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Talboom K, Greijdanus NG, Ponsioen CY, Tanis PJ, Bemelman WA, Hompes R. Endoscopic vacuum-assisted surgical closure (EVASC) of anastomotic defects after low anterior resection for rectal cancer; lessons learned. Surg Endosc 2022; 36:8280-8289. [PMID: 35534735 PMCID: PMC9613741 DOI: 10.1007/s00464-022-09274-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Endoscopic vacuum-assisted surgical closure (EVASC) is an emerging treatment for AL, and early initiation of treatment seems to be crucial. The objective of this study was to report on the efficacy of EVASC for anastomotic leakage (AL) after rectal cancer resection and determine factors for success. METHODS This retrospective cohort study included all rectal cancer patients treated with EVASC for a leaking primary anastomosis after LAR at a tertiary referral centre (July 2012-April 2020). Early initiation (≤ 21 days) or late initiation of the EVASC protocol was compared. Primary outcomes were healed and functional anastomosis at end of follow-up. RESULTS Sixty-two patients were included, of whom 38 were referred. Median follow-up was 25 months (IQR 14-38). Early initiation of EVASC (≤ 21 days) resulted in a higher rate of healed anastomosis (87% vs 59%, OR 4.43 [1.25-15.9]) and functional anastomosis (80% vs 56%, OR 3.11 [1.00-9.71]) if compared to late initiation. Median interval from AL diagnosis to initiation of EVASC was significantly shorter in the early group (11 days (IQR 6-15) vs 70 days (IQR 39-322), p < 0.001). A permanent end-colostomy was created in 7% and 28%, respectively (OR 0.18 [0.04-0.93]). In 17 patients with a non-defunctioned anastomosis, and AL diagnosis within 2 weeks, EVASC resulted in 100% healed and functional anastomosis. CONCLUSION Early initiation of EVASC for anastomotic leakage after rectal cancer resection yields high rates of healed and functional anastomosis. EVASC showed to be progressively more successful with the implementation of highly selective diversion and early diagnosis of the leak.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nynke G Greijdanus
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Cancer Centre Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
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16
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Anastomotic leakage following restorative rectal cancer resection: treatment and impact on stoma presence 1 year after surgery-a population-based study. Int J Colorectal Dis 2022; 37:1161-1172. [PMID: 35469107 DOI: 10.1007/s00384-022-04164-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leakage (AL) continues to be a challenge after restorative rectal resection (RRR). Various treatment options of AL are available; however, their long-term outcomes are uncertain. We explored the impact of AL on the risk of stoma presence 1 year after RRR for rectal cancer and described treatment of AL after RRR including impact on the probability of receiving adjuvant chemotherapy and stoma presence following different treatment options of AL. METHODS We included 859 patients undergoing RRR in Central Denmark Region between 2013 and 2019. Stoma presence was calculated as the proportion of patients with stoma 1 year after RRR. Multivariable logistic regression was conducted to estimate the impact of AL on stoma presence adjusting for potential predictors. Descriptive data of outcomes were stratified for various treatment options of AL. RESULTS The risk of stoma presence 1 year after surgery was 9.8% (95% CI 7.98-12.0). Predictors for having stoma 1 year after RRR were AL (OR 8.43 (95% CI 4.87-14.59)) and low tumour height (OR 3.85 (95% CI 1.22-13.21)). For patients eligible for adjuvant chemotherapy, the probability of receiving it was 42.9% (95% CI 21.8-66.0) if treated with endo-SPONGE and 71.4% (95% CI 47.8-88.7) if treated with other anastomosis preserving treatment options. The risk of having stoma 1 year after RRR was 33.9% (95% CI 21.8-47.8) for patients treated with endo-SPONGE and 13.5% (95% CI 5.6-25.8) for patients treated with other anastomosis preserving treatment options (p = 0.013). CONCLUSION AL is a strong predictor for stoma presence 1 year after RRR. Patients treated with endo-SPONGE seem to have worse outcomes compared to other anastomosis preserving treatment options.
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17
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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18
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Chen YC, Tsai YY, Ke TW, Fingerhut A, Chen WTL. Transanal endoluminal repair for anastomotic leakage after low anterior resection. BMC Surg 2022; 22:24. [PMID: 35081948 PMCID: PMC8793212 DOI: 10.1186/s12893-022-01484-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is still no consensus on the management of colorectal anastomotic leakage after low anterior resection. The goal was to evaluate the outcomes of patients who underwent transanal endoluminal repair + laparoscopic drainage ± stoma vs. drainage only ± stoma. METHODS Retrospective chart review of patients sustaining anastomotic leakage after laparoscopic low anterior resection between January 2013 and September 2020 who required laparoscopic reoperation. RESULTS Forty-nine patients were included, 22 patients underwent combined laparoscopy and transanal endoluminal repair and 27 patients had drainage with a stoma (n = 16) or drainage alone (n = 11), without direct anastomotic repair. The overall morbidity rate was 30.6% and the mortality rate was 2%. Combined laparoscopic lavage/drainage and transanal endoluminal repair of anastomotic leakage was associated with a lower complication rate (13.6% vs. 44.4%, p = 0.03) and fewer intraabdominal infections (4.5% vs. 29.6%, p = 0.03) compared with no repair. CONCLUSIONS Combined laparoscopic lavage/drainage and transanal endoluminal repair is effective in the management of colorectal anastomosis leakage and was associated with lower morbidity-in particular intraabdominal infection-compared with no repair. However, our results need to be confirmed in larger, and ideally randomized, studies.
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Affiliation(s)
- Yi-Chang Chen
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yuan-Yao Tsai
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tao-Wei Ke
- Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, People's Republic of China.,Medical University Hospital of Graz, Graz, Austria
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Abstract
Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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20
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Bloomfield I, Dobson B, Von Papen M, Clark D. Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience. ANZ J Surg 2021; 92:146-150. [PMID: 34791754 DOI: 10.1111/ans.17359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site. METHOD A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure. RESULTS A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group. DISCUSSION The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.
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Affiliation(s)
- Ian Bloomfield
- Medical and Health Sciences, Logan Hospital, Griffith University, Meadowbrooks, Queensland, Australia
| | | | | | - David Clark
- Royal Brisbane Hospital, Brisbane, Queensland, Australia
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21
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Kim YY, Seo N, Lee KY, Kim NK, Lim JS. Contrast-enhanced abdominal computed tomography to evaluate anastomotic integrity before ileostomy closure in postoperative colorectal cancer patients. Abdom Radiol (NY) 2021; 46:4130-4137. [PMID: 34019143 DOI: 10.1007/s00261-021-03118-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE To investigate the usefulness of contrast-enhanced abdominal computed tomography (CECT) to predict clinically significant anastomotic leakage (CSAL) in patients who received colorectal cancer surgery with diverting ileostomy. METHODS In this retrospective cohort study, patients who underwent colorectal cancer surgery with diverting ileostomy from January 2014 to May 2018 and postoperative CECT were included. The performance of significant CECT features, identified using multivariable logistic regression, to predict CSAL was calculated. In subgroup analysis, the areas under the receiver operating characteristic curve (AUROCs) were compared between CECT and water-soluble contrast enema (WSCE) using DeLong's method. RESULTS Of 325 patients (median age, 58 years; 213 men), CECT was routinely performed to evaluate cancer status in 307 (94.5%), and CSAL was observed in 28 (8.6%). After multivariable adjustment, anastomotic mural defect (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.77-15.51; p = 0.003), perianastomotic air (OR 7.28; 95% CI 1.82-29.17; p = 0.007) and ischemic colitis (OR 3.30; 95% CI 1.13-9.61; p = 0.029) were significantly associated with CSAL. The sensitivity, specificity, accuracy, and positive and negative predictive values of significant CECT features were 60.7%, 88.2%, 85.9%, 32.7%, and 96.0%, respectively. In subgroup analysis of 144 patients, the AUROC using significant CECT features (optimal sensitivity/specificity, 50.0%/90.4%) was comparable to that using WSCE (optimal sensitivity/specificity, 12.5%/97.8%) to predict CSAL (0.704 vs. 0.552, p = 0.085). CONCLUSION CECT performed after colorectal cancer surgery may be useful to assess anastomotic integrity before ileostomy closure, especially to negatively predict CSAL. In the presence of anastomotic mural defect, perianastomotic air, or ischemic colitis, WSCE may be recommended to exclude CSAL.
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22
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Pallan A, Dedelaite M, Mirajkar N, Newman PA, Plowright J, Ashraf S. Postoperative complications of colorectal cancer. Clin Radiol 2021; 76:896-907. [PMID: 34281707 DOI: 10.1016/j.crad.2021.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 12/12/2022]
Abstract
Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.
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Affiliation(s)
- A Pallan
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.
| | - M Dedelaite
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - N Mirajkar
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - P A Newman
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - J Plowright
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - S Ashraf
- Department of Colorectal Surgery, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
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23
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Kienle P, Magdeburg JR. [Chronic anastomotic leak after low rectal resection-an unsolved problem?]. Chirurg 2021; 92:605-611. [PMID: 33852017 DOI: 10.1007/s00104-021-01400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 11/27/2022]
Abstract
There is no generally accepted definition of a chronic anastomotic leak, which often presents as a chronic sinus. The corresponding time interval required from primary anastomotic construction ranges from 2 months to 12 months. Between 2% and 16% of all patients develop this complication after low anterior rectal resection. Due to the heterogeneous presentation and configuration of chronic leaks there are no valid comparable data on how to manage this problem. A variety of therapeutic options are used, sometimes combined or additively. The choice of therapeutic option depends very much on the individual case. The following options are used: debridement of the persisting cavity/fistula system, wide deroofing of the cavity into the lumen, endosponge with vacuum, stent implantation, advancement flap with simultaneous drainage of the cavity, fibrin glue instillation and as a last resort a redo low anastomosis. The healing rate in the available literature is generally over 70%. In selected cases a stoma reversal can be done for persisting cavities (wide entry of the cavity into the neorectum, no relevant distal stenosis). Overall, the available poor to moderate evidence suggests that 70-85% of patients with a chronic anastomotic leak, defined as stoma reversal, are treated successfully; however, there is some concern of a relevant publication bias of the published data so that the results may be less impressive in the clinical reality.
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Affiliation(s)
- Peter Kienle
- Allgemein-und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik gGmbH, Bassermannstraße 1, 68165, Mannheim, Deutschland.
| | - Jörn Richard Magdeburg
- Allgemein-und Viszeralchirurgie, Theresienkrankenhaus und St. Hedwig-Klinik gGmbH, Bassermannstraße 1, 68165, Mannheim, Deutschland
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24
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Siragusa L, Sensi B, Vinci D, Franceschilli M, Pathirannehalage Don C, Bagaglini G, Bellato V, Campanelli M, Sica GS. Volume-outcome relationship in rectal cancer surgery. Discov Oncol 2021; 12:11. [PMID: 35201453 PMCID: PMC8777490 DOI: 10.1007/s12672-021-00406-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hospital centralization effect is reported to lower complications and mortality for high risk and complex surgery operations, including colorectal surgery. However, no linear relation between volume and outcome has been demonstrated. Aim of the study was to evaluate the increased surgical volume effect on early outcomes of patient undergoing laparoscopic restorative anterior rectal resection (ARR). METHODS A retrospective analysis of all consecutive patients undergoing ARR with primary anastomosis between November 2016 and December 2020 after centralization of rectal cancer cases in an academic Centre. Short-term outcomes are compared to those of patients operated in the same unit during the previous 10 years before service centralization. The primary outcome was estimated anastomotic leak rate. Mean operative time, need of conversion, postoperative use of blood transfusion, radicality, in-hospital stay, number and type of complications, readmission and reoperation rate, mortality and 1-year and stoma persistence rates were evaluated as secondary outcomes. RESULTS 86 patients were operated in the study period and outcomes compared to those of 101 patients operated during the previous ten years. Difference in volume of surgery was significant between the two periods (p 0.019) and the estimated leak rate was significantly lower in the higher volume unit (p 0.047). Mean operative time, need of conversion, postoperative use of blood transfusion and in-hospital stay (p < 0.05) were also significantly reduced in Group A. CONCLUSION This study suggests that the shift toward higher volume in rectal cancer surgery is associated to decreased anastomotic leak rate. Potentiation of lower volume surgical units may yield optimal perioperative outcomes.
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Affiliation(s)
- L Siragusa
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | - B Sensi
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - D Vinci
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - M Franceschilli
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - C Pathirannehalage Don
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - G Bagaglini
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - V Bellato
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - M Campanelli
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - G S Sica
- Department of Surgical Science, University Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
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25
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van Workum F, Talboom K, Hannink G, Wolthuis A, de Lacy BF, Lefevre JH, Solomon M, Frasson M, Rotholtz N, Denost Q, Perez RO, Konishi T, Panis Y, Rosman C, Hompes R, Tanis PJ, de Wilt JHW. Treatment of anastomotic leakage after rectal cancer resection: The TENTACLE-Rectum study. Colorectal Dis 2021; 23:982-988. [PMID: 33169512 PMCID: PMC8246753 DOI: 10.1111/codi.15435] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/25/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
AIM Anastomotic leakage is a severe complication after low anterior resection (LAR) for rectal cancer and occurs in up to 20% of patients. Most research focuses on reducing its incidence and finding predictive factors for anastomotic leakage. There are no robust data on severity and treatment strategies with associated outcomes. The aims of this work were (1) to investigate the factors that contribute to severity of anastomotic leakage and to compose an anastomotic leakage severity score and (2) to evaluate the effects of different treatment approaches on prespecified outcome parameters, stratified for severity score and other leakage characteristics. METHOD TENTACLE-Rectum is an international multicentre retrospective cohort study. Patients with anastomotic leakage after LAR for primary rectal cancer between 1 January 2014 and 31 December 2018 will be included by each centre. We aim to include 1246 patients in this study. The primary outcome is 1-year stoma-free survival (i.e. patients alive at 1 year without a stoma). Secondary outcomes include number of reinterventions and unplanned readmissions within 1 year, total length of hospital stay, total time with a stoma, the type of stoma present at 1 year (defunctioning, permanent), complications related to secondary leakage and mortality. For aim (1) regression models will be used to create an anastomotic leakage severity score. For aim (2) the effectiveness of different treatment strategies for leakage will be tested after correction for severity score and leakage characteristics, in addition to other potential related confounders. CONCLUSION TENTACLE-Rectum will be an important step towards drawing up evidence-based recommendations and improving outcomes for patients who experience severe treatment-related morbidity.
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Affiliation(s)
- Frans van Workum
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands,Department of Surgery and cancerImperial CollegeLondonUK
| | - Kevin Talboom
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Gerjon Hannink
- Department of Operating RoomsRadboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Jeremie H. Lefevre
- Department of Digestive SurgerySorbonne Université, AP‐HPHôpital Saint AntoineParisFrance
| | - Michael Solomon
- Department of SurgeryUniversity of Sydney Central Clinical SchoolCamperdownNew South WalesAustralia
| | - Matteo Frasson
- Department of SurgeryValencia University Hospital La FeValenciaSpain
| | | | - Quentin Denost
- Department of SurgeryBordeaux University HospitalBordeauxFrance
| | | | - Tsuyoshi Konishi
- Department of Gastroenterological SurgeryCancer Institute Hospital of the Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yves Panis
- Colorectal DepartmentBeaujon Hospital, Clichy, and University of ParisClichyFrance
| | - Camiel Rosman
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
| | - Roel Hompes
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryAmsterdam University Medical CentersUniversity of AmsterdamThe Netherlands
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26
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Clifford RE, Fowler H, Manu N, Sutton P, Vimalachandran D. Intra-operative assessment of left-sided colorectal anastomotic integrity: a systematic review of available techniques. Colorectal Dis 2021; 23:582-591. [PMID: 32978892 DOI: 10.1111/codi.15380] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/26/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
AIM Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer-related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought. METHOD A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990-2020. Additional papers were detected by scanning references of relevant papers. RESULTS A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air-leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra-operatively provides the opportunity for either suture reinforcement or formal takedown with or without re-do of the anastomosis and consideration of diversion. Suture repair alone of a positive air-leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future. CONCLUSION Although over reliance on any assessment tool should be avoided, intra-operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra-operatively for mechanical failure, particularly distal anastomoses.
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Affiliation(s)
| | - Hayley Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Nicola Manu
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Paul Sutton
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Dale Vimalachandran
- Institute of Cancer Medicine, University of Liverpool, Liverpool, UK.,Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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27
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Abstract
Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.
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Affiliation(s)
- Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
| | - David Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
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28
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Thiruvengadam NR, Hamerski C, Nett A, Bhat Y, Shah J, Bernabe J, Kane S, Binmoeller K, Watson RR. Effectiveness of combination endoscopic therapy for colonic anastomotic leaks. Endoscopy 2020; 52:886-890. [PMID: 32521549 DOI: 10.1055/a-1176-0967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colonic anastomotic leaks are associated with significant morbidity and mortality. Whereas small case series suggest that fully covered self-expandable metal stents (FCSEMS) are effective, no larger studies have examined the impact of combination endoscopic therapy on colonic anastomotic leaks. METHODS Our retrospective cohort study reviewed 51 patients undergoing endoscopic therapy for colonic anastomotic leaks between 2011 and 2018. Patients receiving combination therapy involving FCSEMS plus local closure (n = 24) were compared with patients receiving FCSEMS alone (n = 18) or endoscopic suturing alone (n = 9). The primary outcomes were technical and clinical success (resolution of leak, removal of percutaneous drains, avoidance of surgical reoperation, and reversal of temporary diversion). RESULTS Clinical success was achieved in 55 % of patients. Clinical success was achieved in 18/24 patients (75 %) with combination therapy compared with 6/18 patients receiving FCSEMS alone (33 %, adjusted risk ratio [RR] 2.16, 95 % confidence interval [CI] 1.10 - 4.24; P = 0.02) and 4 /9 patients undergoing endoscopic suturing alone (44 %, RR 1.91, 95 %CI 0.84 - 4.31; P = 0.10). Stent migration occurred in 40 % of patients. CONCLUSIONS This large series demonstrates that combination therapy was associated with a higher rate of clinical success, and future prospective studies are warranted.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology, UCSF Medical Center, San Francisco, California, United States
| | - Christopher Hamerski
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Yasser Bhat
- Division of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, California, United States
| | - Janak Shah
- Division of Gastroenterology, Ochsner Medical Center, Louisiana, United States
| | - Jona Bernabe
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Steven Kane
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
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29
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Weréen A, Dahlberg M, Heinius G, Pieniowski E, Saraste D, Eklöv K, Nygren J, Pekkari K, Everhov ÅH. Long-Term Results after Anastomotic Leakage following Rectal Cancer Surgery: A Comparison of Treatment with Endo-Sponge and Transanal Irrigation. Dig Surg 2020; 37:456-462. [PMID: 32829324 DOI: 10.1159/000508935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/19/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE We aimed to evaluate long-term results in patients from regular health care treated with endoscopic transanal closure system, that is, endoscopic vacuum-assisted closure system (EVAC) compared to transanal irrigation. METHODS In this retrospective, medical chart-based, observational study, we included patients with anastomotic leakage after low anterior resection for rectal cancer from 3 Stockholm hospitals 2006-2016 and compared time to first stoma closure in a Kaplan-Meier model and the proportion of patients who were stoma-free at end of follow-up. RESULTS Anastomotic leakage was found in 81 patients who were followed up in median 5.9 years (min-max: 0.53-13). EVAC was used on 14 (17%) patients and transanal irrigation on 34 (42%) patients. The remaining 33 (41%) patients either got a permanent colostomy or were treated only with antibiotics and percutaneous drainage. Treatment with EVAC or transanal irrigation led to similar rates of stoma closure, both when comparing all patients, and when comparing patients with similar defects. At the end of follow-up, 43% of patients treated with EVAC and 50% of patients treated with repeated irrigation were stoma-free (p = 0.75). CONCLUSIONS We found no evidence of better outcomes in patients treated with EVAC. The study was, however, limited by small sample size.
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Affiliation(s)
- Alice Weréen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Göran Heinius
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Emil Pieniowski
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Deborah Saraste
- Department of Molecular Medicine and Surgery, Karolinska Instistutet, Stockholm, Sweden
| | - Karolina Eklöv
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Surgery, Ersta Hospital & Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa H Everhov
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, .,Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,
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30
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Spinelli A, Anania G, Arezzo A, Berti S, Bianco F, Bianchi PP, De Giuli M, De Nardi P, de Paolis P, Foppa C, Guerrieri M, Marini P, Persiani R, Piazza D, Poggioli G, Pucciarelli S, D'Ugo D, Renzi A, Selvaggi F, Silecchia G, Montorsi M. Italian multi-society modified Delphi consensus on the definition and management of anastomotic leakage in colorectal surgery. Updates Surg 2020; 72:781-792. [PMID: 32613380 DOI: 10.1007/s13304-020-00837-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/21/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice. METHODS A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark "totally disagree", "partially agree" or "totally agree" for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting. RESULTS Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds. CONCLUSIONS This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.
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Affiliation(s)
- Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Gabriele Anania
- Dipartimento di Scienze Mediche-Università di Ferrara, Azienda Ospedaliero Universitaria S. Anna, Ferrara, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Stefano Berti
- S.C. Chirurgia Generale, Dipartimento Chirurgico, ASL 5 Spezzino-POLL-Regione Liguria, La Spezia, Italy
| | - Francesco Bianco
- General and Colo-Rectal Surgery Unit, S. Leonardo-ASL Naples 3 Hospital, C.mare di Stabia, Naples, Italy
| | - Paolo Pietro Bianchi
- UOC di Chirurgia Generale e Mini-Invasiva, Dipartimento di Chirurgia Generale e Specialistiche, ASL Toscana Sud-Est. Ospedale Misericordia, Grosseto, Italy
| | - Maurizio De Giuli
- Department of Oncology, Head, Digestive and Surgical Oncology, University of Torino, and San Luigi University Hospital, Orbassano, Italy
| | - Paola De Nardi
- Gastrointestinal Surgery, Scientific Institute San Raffaele Hospital, Milan, Italy
| | | | - Caterina Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Mario Guerrieri
- Clinica Chirurgica Generale e d'urgenza, Università Politecnica delle Marche, Ancona, Italy
| | | | - Roberto Persiani
- Minimally-Invasive Surgical Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Diego Piazza
- U.O.C. Chirurgia Oncologica, ARNAS Garibaldi, Catania, Italy
| | - Gilberto Poggioli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Salvatore Pucciarelli
- Dipartimento di Scienze Chirurgiche Oncologiche e Gastroenterologiche-DISCOG, Università di Padova, Padova, Italy
| | - Domenico D'Ugo
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Adolfo Renzi
- Department of General Surgery, Fatebenefratelli Hospital, Naples, Italy
| | - Francesco Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Gianfranco Silecchia
- Deparment of Medico-Surgical Science and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Surgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
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Chorti A, Stavrou G, Stelmach V, Tsaousi G, Michalopoulos A, Papavramidis TS, Kotzampassi K. Endoscopic repair of anastomotic leakage after low anterior resection for rectal cancer: A systematic review. Asian J Endosc Surg 2020; 13:141-146. [PMID: 31297989 DOI: 10.1111/ases.12733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re-operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over-The-Scope-Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy. METHOD A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed. RESULTS The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70-68.76), the male-to-female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03-6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39-74.90). Vacuum-assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum-assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%). CONCLUSION Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results.
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Affiliation(s)
- Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Veronica Stelmach
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonios Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Kayano H, Nomura E, Ueda Y, Machida T, Uda S, Mukai M, Yamamoto S, Makuuchi H. Short-term outcomes of OTSC for anastomotic leakage after laparoscopic colorectal surgery. MINIM INVASIV THER 2020; 30:369-376. [PMID: 32196402 DOI: 10.1080/13645706.2020.1742743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC.Material and methods: Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated.Results: The average distance from the anal verge of the anastomosis site was 12 (5-18) cm. The average diameter of the dehiscent part was 10.9 (9.3-14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5-22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9-5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone.Conclusion: AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management.
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Affiliation(s)
- Hajime Kayano
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Eiji Nomura
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yasuhiko Ueda
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takashi Machida
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shuji Uda
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masaya Mukai
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Seiichiro Yamamoto
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroyasu Makuuchi
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
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Short-term and Long-term Outcome of Endoluminal Vacuum Therapy for Colorectal or Coloanal Anastomotic Leakage: Results of a Nationwide Multicenter Cohort Study From the French GRECCAR Group. Dis Colon Rectum 2020; 63:371-380. [PMID: 31842165 DOI: 10.1097/dcr.0000000000001560] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The indications and efficacy of endoluminal vacuum therapy for the management of colorectal/coloanal anastomotic leakage are not well defined. OBJECTIVE This study aimed to evaluate the efficacy and to define adequate indications of endoluminal vacuum therapy to treat colorectal/coloanal anastomotic leakage. DESIGN The retrospective cohort evaluated in this study is based on a prospectively maintained database. SETTINGS This study was conducted in 8 centers from the French GRECCAR study group. PATIENTS Patients with colorectal/coloanal anastomotic leakage treated with endoluminal vacuum therapy were included. MAIN OUTCOME MEASURES The primary outcome measured was the success rate of endoluminal vacuum therapy defined by the complete healing of the perianastomotic sepsis and a functional anastomosis. The predictive factors of success of endoluminal vacuum therapy and long-term functional result (low anterior resection syndrome score) were also analyzed. RESULTS Among 62 patients treated for an anastomotic leakage of colorectal/coloanal anastomosis from 2012 to 2017, 47 fulfilled the inclusion criteria. The patients had a mean of 6.6 (±5.8) replacements for a total of 27 (±34) days treatment duration, associated with diverting stoma in 81%. After 37 months median follow-up, a successful treatment of anastomotic leakage using endoluminal vacuum therapy could be achieved in 26 patients (55%). The success rate was improved in patients undergoing primary endoluminal vacuum therapy compared to salvage endoluminal vacuum therapy (73% vs 33%, p = 0.006) and when endoluminal vacuum therapy was initiated within 15 days compared to more than 15 days after the diagnosis of anastomotic leakage (72.4% vs 27.8%, p = 0.003). At 12 months, 53% of patients who responded had minor low anterior resection syndrome and only 3 necessitated anastomotic stricture dilation. LIMITATIONS This was a noncomparative cohort study. CONCLUSION Endoluminal vacuum therapy appears to be effective to treat colorectal anastomotic leakage especially when it is used as primary treatment of the fistula. Long-term functional outcome of patients undergoing conservative management of anastomotic leakage may be improved with endoluminal vacuum therapy. See Video Abstract at http://links.lww.com/DCR/B103. RESULTADOS A CORTO Y LARGO PLAZO DE LA TERAPIA DE VACÍO ENDOLUMINAL PARA LA FUGA ANASTOMÓTICA COLORRECTAL O COLOANAL: RESULTADOS DE UN ESTUDIO DE COHORTE MULTICÉNTRICO A NIVEL NACIONAL DEL GRUPO FRANCÉS GRECCAR: Las indicaciones y la eficacia de la terapia de vacío endoluminal para el tratamiento de la fuga anastomótica colorrectal / coloanal no están bien definidas.Evaluar la eficacia y definir indicaciones adecuadas de la terapia de vacío endoluminal para tratar la fuga anastomótica colorrectal / coloanal.Cohorte retrospectivo basada en una base de datos mantenida prospectivamente.Este estudio se realizó en 8 centros del grupo de estudio Francés GRECCAR.Se incluyeron pacientes con fuga anastomótica colorrectal / coloanal tratados con terapia de vacío endoluminal.Tasa de éxito de la terapia de vacío endoluminal definida por la curación completa de la sepsis perianastomótica y una anastomosis funcional. También se analizaron los factores predictivos del éxito de la terapia de vacío endoluminal y el resultado funcional a largo plazo (puntaje bajo del síndrome de resección anterior).Entre 62 pacientes tratados por una fuga anastomótica de anastomosis colorrectal / coloanal de 2012 a 2017, 47 cumplieron los criterios de inclusión. Los pacientes tuvieron una media de 6.6 (±5.8) reemplazos para un total de 27 (±34) días de duración del tratamiento, asociado con estoma de desvio en el 81%. Después de una mediana de seguimiento de 37 meses, se pudo lograr un tratamiento exitoso de la fuga anastomótica usando terapia de vacío endoluminal en 26 pacientes (55%). La tasa de éxito mejoró en pacientes sometidos a terapia de vacío endoluminal primaria en comparación con la terapia de vacío endoluminal de rescate (73% frente a 33%, p = 0.006) y cuando la terapia de vacío endoluminal se inició dentro de los 15 días en comparación con más de 15 días después del diagnóstico de fuga anastomótica (72.4% vs 27.8%, p = 0.003). A los 12 meses, el 53% de los pacientes que respondieron tenían síndrome de resección anterior baja leve y solo 3 necesitaban dilatación de estenosis anastomótica.Estudio de cohorte no comparativo.La terapia de vacío endoluminal parece ser efectiva para tratar la fuga anastomótica colorrectal, especialmente cuando se usa como tratamiento primario de la fístula. El resultado funcional a largo plazo de los pacientes sometidos a un tratamiento conservador de la fuga anastomótica puede mejorarse con la terapia de vacío endoluminal. Consulte Video Resumen en http://links.lww.com/DCR/B103.
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Rosendorf J, Horakova J, Klicova M, Palek R, Cervenkova L, Kural T, Hosek P, Kriz T, Tegl V, Moulisova V, Tonar Z, Treska V, Lukas D, Liska V. Experimental fortification of intestinal anastomoses with nanofibrous materials in a large animal model. Sci Rep 2020; 10:1134. [PMID: 31980716 PMCID: PMC6981151 DOI: 10.1038/s41598-020-58113-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/09/2020] [Indexed: 12/14/2022] Open
Abstract
Anastomotic leakage is a severe complication in gastrointestinal surgery. It is often a reason for reoperation together with intestinal passage blockage due to formation of peritoneal adhesions. Different materials as local prevention of these complications have been studied, none of which are nowadays routinely used in clinical practice. Nanofabrics created proved to promote healing with their structure similar to extracellular matrix. We decided to study their impact on anastomotic healing and formation of peritoneal adhesions. We performed an experiment on 24 piglets. We constructed 3 hand sutured end-to-end anastomoses on the small intestine of each pig. We covered the anastomoses with a sheet of polycaprolactone nanomaterial in the first experimental group, with a sheet of copolymer of polylactic acid with polycaprolactone in the second one and no fortifying material was used in the Control group. The animals were sacrificed after 3 weeks of observation. Clinical, biochemical and macroscopic signs of anastomotic leakage or intestinal obstruction were monitored, the quality of the scar tissue was assessed histologically, and a newly developed scoring system was employed to evaluate the presence of adhesions. The material is easy to manipulate with. There was no mortality or major morbidity in our groups. No statistical difference was found inbetween the groups in the matter of level of peritoneal adhesions or the quality of the anastomoses. We created a new adhesion scoring system. The material appears to be safe however needs to be studied further to prove its' positive effects.
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Affiliation(s)
- Jachym Rosendorf
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic. .,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic.
| | - Jana Horakova
- Department of Nonwovens, Faculty of Textile Engineering, Technical University in Liberec, Liberec, Czech Republic
| | - Marketa Klicova
- Department of Nonwovens, Faculty of Textile Engineering, Technical University in Liberec, Liberec, Czech Republic
| | - Richard Palek
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic.,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Lenka Cervenkova
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Tomas Kural
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Petr Hosek
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Tomas Kriz
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Vaclav Tegl
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic.,Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Pilsen, Czech Republic
| | - Vladimira Moulisova
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Zbynek Tonar
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic.,Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Vladislav Treska
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - David Lukas
- Department of Nonwovens, Faculty of Textile Engineering, Technical University in Liberec, Liberec, Czech Republic
| | - Vaclav Liska
- Department of Surgery, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic.,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
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Baloyiannis I, Perivoliotis K, Diamantis A, Tzovaras G. Virtual ileostomy in elective colorectal surgery: a systematic review of the literature. Tech Coloproctol 2019; 24:23-31. [PMID: 31820192 DOI: 10.1007/s10151-019-02127-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature. METHODS A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy. RESULTS In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases. CONCLUSIONS VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made.
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Affiliation(s)
- I Baloyiannis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece.
| | - K Perivoliotis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
| | - A Diamantis
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
| | - G Tzovaras
- Department of Surgery, University Hospital of Larissa, Biopolis, Mezourlo, 41110, Larissa, Greece
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Creavin B, Ryan ÉJ, Kelly ME, Moynihan A, Redmond CE, Ahern D, Kennelly R, Hanly A, Martin ST, O'Connell PR, Brophy DP, Winter DC. Minimally invasive approaches to the management of anastomotic leakage following restorative rectal cancer resection. Colorectal Dis 2019; 21:1364-1371. [PMID: 31254432 DOI: 10.1111/codi.14742] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 05/18/2019] [Indexed: 12/12/2022]
Abstract
AIM Management of anastomotic leakage (AL) following rectal resection has evolved with increasing use of less invasive techniques. The aim of this study was to review the management of AL following restorative rectal cancer resection in a tertiary referral centre. METHOD A retrospective review of a prospectively maintained database was performed. The primary outcome was successful management of AL. The secondary outcome was the impact of AL on oncological outcome. RESULTS Five hundred and two restorative rectal cancer resections were performed during the study period. The incidence of AL was 9.9% (n = 50). AL occurred more commonly following neoadjuvant chemoradiotherapy (n = 31/252, 12.3%) than in those who did not receive neoadjuvant chemoradiotherapy (n = 19/250, 7.6%; P = 0.107); however, this was not statistically significant. Successful minimally invasive drainage was achieved in 28 patients (56%, radiological n = 24, surgical n = 4). Trans-rectal drainage was the most common drainage method (n = 14). The median duration of drainage was longer in the neoadjuvant group (27 vs 18 days). Surgical intervention was required in 11 patients, with anastomotic takedown and end-colostomy formation was most commonly required. Successful management of AL with drainage (maintenance of the anastomosis without the need for further intervention) was achieved in 26 of the 28 patients. There were no significant differences in overall or disease-free survival when patients with AL were compared with patients without AL (69.4% vs 72.6%, P = 0.99 and 78.7% vs 71.3%, P = 0.45, respectively). CONCLUSION In selected patients, AL following restorative rectal resection can be effectively controlled using minimally invasive radiological or surgical drainage without the need for further intervention.
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Affiliation(s)
- B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - É J Ryan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - M E Kelly
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - A Moynihan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - C E Redmond
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
| | - D Ahern
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - R Kennelly
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - A Hanly
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - S T Martin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - P R O'Connell
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D P Brophy
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - D C Winter
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection. Dis Colon Rectum 2019; 62:1458-1466. [PMID: 31567923 DOI: 10.1097/dcr.0000000000001483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted in a tertiary referral center. PATIENTS All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES Primary end points were procedural characteristics and 90-day major complications. RESULTS In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS A limitation of this study is the relatively small sample size. CONCLUSIONS This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis.El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica.Este es un estudio de cohorte retrospectiva.Este estudio se realizó en un centro de referencia terciario.Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018.La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional.Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días.En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente.La limitación de este estudio es el tamaño relativamente pequeño de la muestra.Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.
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Agostinho N, Hamilton AE, Young CJ. Could it be an anastomotic leak? A pelvic abscess of unknown aetiology. ANZ J Surg 2019; 90:1169-1171. [PMID: 31578785 DOI: 10.1111/ans.15443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nelson Agostinho
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Auerilius E Hamilton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Fuchs KH, Schulz T, Broderick R, Breithaupt W, Babic B, Varga G, Horgan S. Transanal hybrid colon resection: techniques and outcomes for benign colorectal diseases. Surg Endosc 2019; 34:3487-3495. [PMID: 31559574 DOI: 10.1007/s00464-019-07126-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 09/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages. METHODS A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life. RESULTS From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24-80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p < 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18 months follow-up. CONCLUSIONS ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.
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Affiliation(s)
- Karl-Hermann Fuchs
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, 9500 Gilman Drive, MC:0740, La Jolla, CA, 92093, USA.
| | - Thomas Schulz
- Department of General- and Viszeral-Surgery, AGAPLESION Markus Krankenhaus, Frankfurt am Main, Germany
| | - Ryan Broderick
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, 9500 Gilman Drive, MC:0740, La Jolla, CA, 92093, USA
| | - Wolfram Breithaupt
- Department of General- and Viszeral-Surgery, AGAPLESION Markus Krankenhaus, Frankfurt am Main, Germany
| | - Benjamin Babic
- Department of Surgery, University of Mainz, Mainz, Germany
| | - Gabor Varga
- Department of General- and Viszeral-Surgery, AGAPLESION Markus Krankenhaus, Frankfurt am Main, Germany
| | - Santiago Horgan
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, 9500 Gilman Drive, MC:0740, La Jolla, CA, 92093, USA
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Tonolini M, Bareggi E, Salerno R. Endoscopic stenting of malignant, benign and iatrogenic colorectal disorders: a primer for radiologists. Insights Imaging 2019; 10:80. [PMID: 31456127 PMCID: PMC6712200 DOI: 10.1186/s13244-019-0763-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/28/2019] [Indexed: 02/08/2023] Open
Abstract
In recent years, endoscopic placement of intraluminal stents is increasingly used to manage a widening range of colorectal disorders. Self-expanding metal stents represent an established alternative to surgery for the palliation of unresectable carcinomas and currently allow a "bridge-to-surgery" strategy to relieve large bowel obstruction and optimise the patients' clinical conditions before elective oncologic resection. Additionally, intraluminal stents represent an appealing option to manage obstructing extracolonic tumours and selected patients with benign conditions such as refractory anastomotic strictures and post-surgical leaks.This educational paper reviews the technical features and current indications of colorectal stenting and presents the expected and abnormal radiographic, CT and MRI appearances observed during the endoscopic management of malignant, benign and iatrogenic colonic disorders with stents. The aim is to provide radiologists with a thorough familiarity with stent-related issues, which is crucial for appropriate reconstruction of focused CT images, correct interpretation of early post-procedural studies and elucidation of stent-related complications such as misplacement, haemorrhage, perforation, migration and re-obstruction.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Emilia Bareggi
- Digestive Endoscopy, ASST Fatebenefratelli Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Raffaele Salerno
- Digestive Endoscopy, ASST Fatebenefratelli Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
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Vu L, Penter C, Platell C. Long‐term significance of an anastomotic leak in patients undergoing an ultra‐low anterior resection for rectal cancer. ANZ J Surg 2019; 89:1291-1295. [DOI: 10.1111/ans.15373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/01/2019] [Accepted: 06/22/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Linda Vu
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
| | - Cheryl Penter
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
| | - Cameron Platell
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
- Department of SurgeryThe University of Western Australia Perth Western Australia Australia
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Ghoz H, Brahmbhatt B, Odah T, Foulks C, Woodward TA. Endoscopic identification and clipping of an anastomotic leak after colorectal surgery by use of methylene blue dye and over-the-scope clipping system. VideoGIE 2019; 4:476-477. [PMID: 31709335 PMCID: PMC6831911 DOI: 10.1016/j.vgie.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Tarek Odah
- Division of General Internal Medicine, MetroWest Medical Center, Framingham, Massachusetts, USA
| | - Carla Foulks
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Řezáč T, Stašek M, Zbořil P, Vomáčková K, Bébarová L, Hanuliak J, Neoral Č. Necrotizing pelvic infection after rectal resection. A rare indication of endoscopic vacuum-assisted closure therapy. A case report. Int J Surg Case Rep 2019; 61:44-47. [PMID: 31315075 PMCID: PMC6630029 DOI: 10.1016/j.ijscr.2019.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Anastomotic leak after colorectal surgery is a major problem associated with higher morbidity and mortality. In most cases of contained leaks, treatment recommendations are clear and effective. However, in rare cases like necrotizing pelvic infection, there is no clear treatment of choice, despite the mortality rate almost 21%. We present successful management with endoscopic vacuum-assisted closure therapy. THE PRESENTATION OF A CASE A 68-year-old female patient with BMI 26, hypothyroidism and high blood pressure was indicated to low anterior rectal resection because of high-risk neoplasia of lateral spreading tumor type of the upper rectum. Four days after the primary operation, sepsis (SOFA 12) with diffuse peritonitis and unconfirmed leak according to CT led to surgical revision with loop ileostomy. On postoperative days 6-10, swelling, inflammation and subsequent necrosis of the right groin and femoral region communicating with the leak cavity developed. The endoscopy confirmed a leak of 30% of the anastomotic circumference with the indication of debridement and endoscopic vacuum-assisted closure therapy. EVAC sessions with 3-4 day intervals healed the leak cavity. Secondary healing of the skin defects required 4 months. CONCLUSION Necrotizing pelvic infection after a leak of the colorectal anastomosis is a very rare complication with high morbidity and mortality. Endoscopic vacuum-assisted closure therapy should be implemented in the multimodal therapeutic strategy in case of major leaks, affecting up to 270° of the anastomotic circumference.
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Affiliation(s)
- Tomáš Řezáč
- Department of Surgery I, University Hospital Olomouc, Olomouc 77900, Czech Republic.
| | - Martin Stašek
- Department of Surgery I, University Hospital Olomouc, Olomouc 77900, Czech Republic.
| | - Pavel Zbořil
- Department of Surgery I, University Hospital Olomouc, Olomouc 77900, Czech Republic.
| | - Katherine Vomáčková
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc 77900, Czech Republic.
| | - Linda Bébarová
- Department of Surgery I, University Hospital Olomouc, Olomouc 77900, Czech Republic.
| | - Jan Hanuliak
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc 77900, Czech Republic.
| | - Čestmír Neoral
- Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc 77900, Czech Republic.
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Olavarria OA, Kress RL, Shah SK, Agarwal AK. Novel technique for anastomotic salvage using transanal minimally invasive surgery: A case report. World J Gastrointest Surg 2019; 11:271-278. [PMID: 31171958 PMCID: PMC6536885 DOI: 10.4240/wjgs.v11.i5.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/18/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anastomotic leak (AL) after low anterior resection (LAR) can be a highly morbid complication. The incidence of AL ranges from 5% to 20% depending on patient characteristics and the distance of the anastomosis from the anal verge. Low anastomoses and leaks pose technical challenges for endoscopic treatment. The aim of this report was to describe the use of a commercially available laparoscopic energy device through a transanal minimally invasive surgery (TAMIS) port for the management of a symptomatic leak not requiring relaparotomy (grade B) after a LAR with diverting loop ileostomy.
CASE SUMMARY A TAMIS GelPOINT Path port was inserted into the anus to access the distal rectum. Pneumorectum was achieved with AirSeal insufflation and a 30 degree laparoscope was introduced through a trocar. A LigaSureTM Retractable L-Hook device was then used to perform a septotomy of the chronic sinus tract identified posterior to the coloproctostomy. The procedure was then repeated twice in three weeks intervals with ultimate resolution of the chronic leak cavity. Several months after serial TAMIS septotomies, barium enema demonstrated a patent anastomosis with no evidence of persistent leak or stricture. The patient subsequently underwent ileostomy reversal and has had no significant post-operative issues.
CONCLUSION TAMIS septotomy with the LigaSureTM Retractable L-Hook is a feasible and effective, minimally invasive salvage technique for the treatment of grade B ALs. Larger studies are needed to assess the generalizability and long-term results of this technique.
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Affiliation(s)
- Oscar A Olavarria
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77033, United States
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, TX 77033, United States
| | - Robert L Kress
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, TX 77033, United States
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, TX 77033, United States
| | - Amit K Agarwal
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, TX 77033, United States
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de Moura DTH, de Moura BFBH, Manfredi MA, Hathorn KE, Bazarbashi AN, Ribeiro IB, de Moura EGH, Thompson CC. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11:329-344. [PMID: 31205594 PMCID: PMC6556487 DOI: 10.4253/wjge.v11.i5.329] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Ahmad N Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
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Abstract
BACKGROUND Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage. OBJECTIVE There is an absence of further technical development of the standardized material from 2007 for the lower GI tract. MATERIAL AND METHODS New strategies and new materials for endoscopic vacuum therapy are presented. RESULTS Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects. CONCLUSION The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.
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47
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Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA. Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Affiliation(s)
- R E Clifford
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK.
| | - H Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - N Govindarajah
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - D Vimalachandran
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - P A Sutton
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open 2018; 3:153-160. [PMID: 30957061 PMCID: PMC6433422 DOI: 10.1002/bjs5.50124] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
Background Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. Methods A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. Results Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. Conclusion EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.
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Affiliation(s)
- M Shalaby
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of General Surgery Rome Tor Vergata University Rome Italy
| | - S Emile
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - H Elfeki
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt.,Department of Surgery, Colorectal Surgery Unit Aarhus University Aarhus Denmark
| | - A Sakr
- Department of General Surgery, Colorectal Surgery Unit Mansoura University Mansoura Egypt
| | - S D Wexner
- Department of Colorectal Surgery Cleveland Clinic Florida Weston Florida USA
| | - P Sileri
- Department of General Surgery Rome Tor Vergata University Rome Italy
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Shalaby M, Thabet W, Buonomo O, Lorenzo ND, Morshed M, Petrella G, Farid M, Sileri P. Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection. Ann Coloproctol 2018; 34:317-321. [PMID: 30572421 PMCID: PMC6347340 DOI: 10.3393/ac.2017.10.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/18/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). Methods Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. Results Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20–35 kg/m2). The median tumor distance from the anal verge was 8 cm (range, 4–12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. Conclusion These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy.,Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Waleed Thabet
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Oreste Buonomo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Di Lorenzo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mosaad Morshed
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Giuseppe Petrella
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mohamed Farid
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
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50
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Fonseca AZ, Uramoto E, Santos-Rosa OM, Santin S, Ribeiro M. COLOSTOMY CLOSURE: RISK FACTORS FOR COMPLICATIONS. ACTA ACUST UNITED AC 2018; 30:231-234. [PMID: 29340543 PMCID: PMC5793137 DOI: 10.1590/0102-6720201700040001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Background : The restoration of intestinal continuity is an elective procedure that is not free of complications; on the contrary, many studies have proven a high level of morbidity and mortality. It is multifactorial, and has factors inherent to the patients and to the surgical technique. Aim : To identify epidemiological features of patients that underwent ostomy closure analyzing the information about the surgical procedure and its arising complications. Method : It was realized a retrospective analysis of medical records of patients who underwent ostomy closure over a period of seven years (2009-2015). Results : A total of 39 patients were included, 53.8% male and 46.2% female, with mean age of 52.4 years. Hartmann´s procedure and ileostomy were the mainly reasons for restoration of intestinal continuity, representing together 87%. Termino-terminal anastomosis was performed in 71.8% of cases, by using mainly the manual technique. 25.6% developed complications, highlighting anastomotic leakage; there were three deaths (7.6%). The surgical time, the necessity of ICU and blood transfusion significantly related to post-operative complications. Conclusion : It was found that the majority of the patients were male, with an average age of 52 years. It was observed that the surgical time, the necessity of blood transfusion and ICU were factors significantly associated with complications.
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Affiliation(s)
| | - Edson Uramoto
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | | | - Stephanie Santin
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
| | - Marcelo Ribeiro
- Department of Surgery, University of Santo Amaro, São Paulo, SP, Brazil
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