Risk factors for morbidity and mortality after colectomy for colon cancer

PURPOSE

Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers.

METHODS

The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications.

RESULTS

A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, "do not resuscitate" status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin.

CONCLUSIONS

Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

Hepatic artery thrombosis after adult liver transplantation

The incidence, clinical presentation, therapeutic options, and outcome of hepatic artery thrombosis (HAT) were analyzed in a series of 1,192 consecutive adult orthotopic liver transplantations (OLTs). HAT after OLT was observed in 30 cases, resulting in an incidence of 2.5%. The incidence of HAT increased 5.76-fold when the donor hepatic artery was reconstructed with an interposition graft to the supraceliac aorta (P <.05). Early HAT (within the first 30 days after OLT) occurred in 14 of these patients (46.7%), whereas in 16 patients (53.3%), HAT occurred beyond 30 days post-OLT. Clinical presentation of HAT ranged from an increase in serum transaminase levels with or without cholestasis to liver abscess and biliary complications, including cholangitis, bile duct stenosis or necrosis, to liver dysfunction and failure. Impairment of graft function was observed in patients with early HAT, whereas biliary tract destruction was seen more often in patients with late HAT. In only 1 patient was HAT clinically asymptomatic. Therapy consisted of recombinant plasminogen lysis with hepaticojejunostomy, liver abscess drainage, endoscopy or surveillance, and surgical thrombectomy. In 14 of 30 patients (46.7%), the occurrence of HAT required re-OLT. Nine patients with HAT died during follow-up; however, only 4 of these deaths were related to HAT, resulting in a mortality rate of 13.3%. Our results indicate that HAT is a rare but serious complication after OLT, requiring re-OLT in almost 50% of patients. In particular, conservative treatment modalities may significantly prolong graft survival, thus postponing re-OLT.

Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition

BACKGROUND

Reports of esophageal anastomotic complications often involve more gastric than colonic reconstructions and are incomplete because of fragmented followup by physicians unfamiliar with the surgical procedure.

STUDY DESIGN

Three hundred ninety-three consecutive esophagectomy patients had prevalence and risk factors determined for graft ischemia and anastomotic leak; 363 of these patients followed for more than 1 month (median 15 months) had prevalence and risk factors determined for anastomotic stricture.

RESULTS

Conduit ischemia occurred in 36 (9.2%) and anastomotic leak in 43 patients (10.9%). Risk factor for ischemia was comorbid conditions requiring therapy (Odds ratio [OR]: 2.2 [95% CI 1.1-4.3]), and for leak were ischemia (OR: 5.5 [95% CI 2.5-12.1]), neoadjuvant therapy (OR: 2.2 [95% CI 1.1-4.5]), and comorbid conditions (OR: 2.1 [95% CI 1.1-3.9]). A stricture developed in 80 patients (22.0%). Risk factors were ischemia (OR: 4.4 [95% CI 2.0-9.6]), anastomotic leak (OR: 3.8 [95% CI 1.9-7.6]), and increasing preoperative weight (p = 0.022). The prevalence of ischemia was similar after gastric (10.4%) versus colonic (7.4%) reconstruction; leak and stricture were more common (14.3% versus 6.1%, p = 0.013, 31.3% versus 8.7%, p < 0.0001, respectively) and strictures were more severe (11.2% versus 2%, p = 0.001) after gastric pull-up. Patients free of ischemia and leak who developed stricture were more likely to have had a gastric pull-up (25% versus 7%, p < 0.0001). Dilatation was effective treatment in 93% of patients.

CONCLUSIONS

After esophagectomy 10% of patients will develop conduit ischemia or an anastomotic leak and 22% will develop anastomotic stricture. Anastomotic leak and strictures are more common and the strictures are more severe after gastric pull-up compared with colon interposition. Dilatation is a safe and effective treatment.

Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis

OBJECTIVE

Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate.

DATA SOURCES

Articles published until end of March 2006 comparing PJ and PG after PD were searched.

STUDY SELECTION

Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios.

DATA EXTRACTION AND SYNTHESIS

Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG.

CONCLUSIONS

All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.

Total revascularization with T grafts

The T graft is constructed by anastomosing the proximal end of the free right internal thoracic artery to the side of the attached left internal thoracic artery. Besides adding considerable reach to the right internal thoracic artery, this technique allows the left anterior descending coronary artery and its branches to be bypassed with the attached left internal thoracic artery. Two hundred eight-seven patients, aged 34 to 86 years (mean age, 64.6 years) received an average of 4.4 internal thoracic artery to coronary artery anastomoses. Sixty-nine patients had left main disease, 33 were undergoing first-time reoperations, and two were reoperated on for the second time. Ejection fraction ranged from 0.20 to 0.70. Operative mortality was 1.7%. Twenty-six patients had postoperative graft visualization, and 94.7% of the grafts were open. All 45 bypass grafts from the left internal thoracic artery were patent, and 91% of those from the right internal thoracic artery were unobstructed. This procedure requires technical skill with internal thoracic arteries, but it has the potential of significantly improving long-term event-free survival and reducing the need for reoperation in patients undergoing coronary artery bypass grafting.

Leakage after resection and intraperitoneal anastomosis for colorectal malignancy: analysis of risk factors

PURPOSE

The study was designed to identify the risk factors associated with anastomotic leakage after an intraperitoneal large-bowel anastomosis in patients with colorectal malignancy.

METHODS

The prospectively collected data of patients who underwent colorectal resection for malignancy with primary anastomosis above the pelvic peritoneal reflection for malignancy between 1996 and 2004 were reviewed. Thirty-five variables were evaluated using univariate and multivariate analysis.

RESULTS

A total of 1,417 patients were studied and anastomotic leakage occurred in 25 patients (1.8 percent). Twenty-two patients (88 percent) required reoperation for anastomotic leakage. The hospital stay (28 vs. 10 days, P < 0.001) and mortality rate (32 vs. 4 percent, P < 0.001) of patients with anastomotic leakage were significantly increased compared with those without leakage. Multivariate analysis showed that American Society of Anesthesiologists Grade 3 to 5 (P = 0.04; odds ratio, 5.6; 95 percent confidence interval, 1.6-15.3) and emergency operation (P = 0.03; odds ratio, 4.6; 95 percent confidence interval, 1.9-9.8) were independent factors associated with anastomotic leakage. The risk of anastomotic leakage was 8.1 percent (odds ratio, 10.5; 95 percent confidence interval, 2.7-26.8) if both factors were present.

CONCLUSIONS

Intraperitoneal anastomosis after large-bowel resection is associated with a low leakage rate. Emergency surgery and a high American Society of Anesthesiologists grade are independent factors associated with an increased incidence of leakage. A temporary diverting stoma to protect the primary anastomosis or even avoidance of anastomosis could be considered for patients with the two risk factors present.

Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis

OBJECTIVE

The purpose of the study was to compare in prospective randomized fashion a manually sutured esophagogastric anastomosis in the neck and a stapled in the chest after esophageal resection and gastric tube reconstruction.

SUMMARY BACKGROUND DATA

Despite the fact that all reconstructions after esophagectomy will result in a cervical or a thoracic anastomosis, controversy still exists as to the optimal site for the anastomosis. In uncontrolled studies, both neck and chest anastomoses have been advocated. The only reported randomized study is difficult to evaluate because of varying routes of the substitute and different anastomotic techniques within the groups. The reported high failure rate of stapled anastomoses in the neck and the fact that most surgeons prefer to suture cervical anastomoses made us choose this technique for anastomosis in the neck. Our routine and the preference of most surgeons to staple high thoracic anastomoses became decisive for type of thoracic anastomoses.

METHODS

Between May 9, 1990 and February 5, 1996, 83 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (41 patients) or an esophagogastric anastomosis in the chest (42 patients). To evaluate selection bias, patients undergoing esophageal resection during the same period but not randomized (n = 29) were also followed and compared with those in the study (n = 83). Objective measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery. The long-term survival rates were compared with the log-rank test.

RESULTS

Two patients (1.8%) died in hospital, and the remaining 110 patients were followed until death or for a minimum of 60 months. The genuine 5-year survival rate was 29% for chest anastomoses and 30% for neck anastomoses. The overall leakage rate was 1.8% (2 cases of 112) with no relation to mortality or anastomotic method. All patients in the randomized group had tumor-free proximal and distal resection lines, but 1 patient in the nonrandomized group had tumor infiltrates in the proximal resection margin. At 3, 6, and 12 months after operation, there was no difference in anastomotic diameter between the esophagogastric anastomosis in the neck and in the thorax (P = 0.771), and both increased with time (P = 0.004, ANOVA repeated measures). Body weight development was the same in the two groups. With similar results in randomized and nonrandomized patients, study bias was eliminated.

CONCLUSIONS

When performed in a standardized way, neck and chest anastomoses after esophageal resection are equally safe. The additional esophageal resection of 5 cm in the neck group did not increase tumor removal and survival; on the other hand, it did not adversely influence morbidity, anastomotic diameter, or eating as reflected by body weight development.

Timing and method of reversal of Hartmann's procedure

The outcome of 145 patients undergoing Hartmann's resection between 1973 and 1989 has been reviewed. The mortality rate of the primary procedure was 8 per cent. Eighty patients proceeded to reanastomosis. Multifactorial analysis of these patients was undertaken to determine the risk involved. The interval between the primary and secondary procedures was found to be the most important factor. Six of 12 patients had clinical evidence of a leak when this interval was < 3 months, compared with seven of 28 for 3-6 months, and none of 40 when the second operation was delayed for > 6 months. All deaths (three patients) and clinical septicaemia (four) occurred in the two 'early' groups. All colovaginal fistulae (three patients) and strictures (three) were associated with stapled anastomoses. No association was found between the complication rate following reanastomosis and the initial pathology or grade of surgeon undertaking the secondary operation.

Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial

OBJECTIVE

Using a prospective randomized study to assess postoperative morbidity and pancreatic function after pancreaticoduodenectomy with pancreaticojejunostomy and duct occlusion without pancreaticojejunostomy.

SUMMARY BACKGROUND DATA

Postoperative complications after pancreaticoduodenectomy are largely due to leakage of the pancreaticoenterostomy. Pancreatic duct occlusion without anastomosis of the pancreatic remnant may prevent these complications.

METHODS

A prospective randomized study was performed in a nonselected series of 169 patients with suspected pancreatic and periampullary cancer. In 86 patients the pancreatic duct was occluded without anastomosis to pancreatic remnant, and in 83 patients a pancreaticojejunostomy was performed after pancreaticoduodenectomy. Postoperative complications were the endpoint of the study. All relevant data concerning patient demographics and postoperative morbidity and mortality as well as endocrine and exocrine function were analyzed. At 3 and 12 months after surgery, evaluation of weight loss, stools, and the use of antidiabetics and pancreatic enzyme was repeated.

RESULTS

Patient characteristics were comparable in both groups. There were no differences in median blood loss, duration of operation, and hospital stay. No significant difference was noted in postoperative complications, mortality, and exocrine insufficiency. The incidence of diabetes mellitus was significantly higher in patients with duct occlusion.

CONCLUSIONS

Duct occlusion without pancreaticojejunostomy does not reduce postoperative complications but significantly increases the risk of endocrine pancreatic insufficiency after duct occlusion.

Life expectancy after colectomy and ileorectal anastomosis for familial adenomatous polyposis

PURPOSE

Despite the introduction of screening, surveillance, and prophylactic colectomy surgery, patients with familial adenomatous polyposis (FAP) are at risk of dying from other malignancies.

METHODS

In order to quantify this risk and identify the causes of mortality, a retrospective life table analysis was performed on 222 patients with familial adenomatous polyposis who had undergone a total colectomy and ileorectal anastomosis between 1948 and 1990. These FAP patients were compared with an age- and sex-matched group of the general population and a relative risk of dying was calculated.

RESULTS

Of 222 patients, 53 have died. In a matched group of the general population the expected number of deaths would be 15.8. The relative risk of dying is therefore 3.35. There has been no significant improvement with time and the relative risk is greatest for female patients.

CONCLUSION

The three main causes of mortality are upper gastrointestinal malignancy, desmoid disease, and perioperative complications. Further research should therefore be aimed at prevention and improved treatment of these in order to improve survival.

Laparoscopic-assisted ileocolic resections in patients with Crohn's disease: are abscesses, phlegmons, or recurrent disease contraindications?

BACKGROUND

Because of the inflammatory nature of Crohn's disease, ileocolic resections are often difficult to perform, especially if an abscess, phlegmon, or recurrent disease at a previous ileocolic anastomosis is present. Our goal was to determine whether the above factors are contraindications to a successful laparoscopic-assisted ileocolic resection.

METHODS

Between 1992 and 1996, 46 laparoscopic-assisted ileocolic resections were attempted. Fourteen patients had an abscess or phlegmon treated with bowel rest before operation (group I), 10 patients had recurrent Crohn's disease at the previous ileocolic anastomosis (group II), and 22 patients had no previous operation and no phlegmon or abscess associated with their disease (group III). These groups were compared with each other and with 70 consecutive open ileocolic resections for Crohn's disease during the same time period (group IV).

RESULTS

Operative blood loss and time were greater in group IV than in groups I, II, and III (245 versus 151, 131, and 195 ml, respectively, and 202 versus 152, 144, and 139 minutes, respectively). Conversion to open procedure occurred in 5 patients (group I, 1 [7%]; group II, 2 [20%]; group III, 2 [9%]). Morbidity was highest in group IV (21% versus 0%, 10%, and 10%, respectively). Only one patient died (group IV, 1%). Length of hospital stay was longest in group IV (7.9 versus 4.8, 3.9, and 4.5 days, respectively).

CONCLUSIONS

The laparoscopic-assisted approach to Crohn's disease is feasible and safe with good outcomes. Co-morbid preoperative findings such as abscess, phlegmon, or recurrent disease at the previous ileocolic anastomosis are not contraindications to a successful laparoscopic-assisted ileocolic resection in select patients.

Surgical and postoperative factors influencing short-term survival of horses following small intestinal resection: 92 cases (1994-2001)

Although short-term survival rates following small intestinal resection reportedly range from 48-88%, there is little information on predicting which horse may or may not survive small intestinal (SI) resection and anastomosis. The aim of this study was to identify factors that contribute to nonsurvival in horses following small intestinal resection. Medical records of horses which recovered from anaesthesia following SI resection were reviewed. Clinical and surgical variables were evaluated for their association with short-term survival using logistic regression and were reported as odds ratios (OR), including the 95% confidence interval (CI), indicating the likelihood of horses not surviving to hospital discharge. Ninety-two records met the criteria for inclusion. Thirty-six (81.8%) of the horses that underwent jejunojejunostomy (JJ) and 34 (70.8%) of the horses that underwent jejunocaecostomy (JC) survived to discharge. Multiple logistic analysis indicated that postoperative ileus (OR = 29.7; 95% CI 2.5-354.6), repeat celiotomy (OR = 18; CI 1.7-187.6), and an elevated heart rate of > or = 60 beats/min (OR = 5.6; CI 1.5-20.6) were the principal factors associated with nonsurvival. A low total plasma protein of <55 g/l (OR = 1.8; CI 0.-7.6) was incorporated in the final model because its inclusion improved the overall validity of the model, Clinicians should be aware of the factors associated with the greatest likelihood of nonsurvival following small intestinal resection, so that they can institute aggressive treatment and accurately inform owners on the likelihood of survival.

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

BACKGROUND

Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.

METHODS

A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).

RESULTS

We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).

CONCLUSIONS

Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Fate of the pouch in 151 pediatric patients after ileal pouch anal anastomosis

BACKGROUND/PURPOSE

Ileal pouch anal anastomosis (IPAA) offers many pediatric patients a surgical cure for mucosal ulcerative colitis (MUC) with preservation of anal continence. However, some patients incur serious problems after surgery including chronic pouchitis and pouch failure. The goal of this study is to identify clinical and pathologic factors that are associated with an adverse outcome of IPAA.

METHODS

A retrospective analysis of outcome was performed in 151 consecutive patients < or = 21 years of age who underwent IPAA with a mean follow-up of 7.24 years (range, 2 to 15 years). Patients were categorized into 4 outcome groups: A, no pouchitis; B, mild, acute pouchitis; C, chronic refractory pouchitis; and D, pouch failure. Pairwise comparisons were used to test the association between the groups and clinical and pathologic variables including age, sex, duration of symptoms, perianal disease, colonoscopic histology, terminal ileitis, operation type, staged versus unstaged IPAA, colonic specimen histology, early postoperative complications defined as less than 31 days postsurgery, late postoperative complications defined as 31 or more days postsurgery, and pouch fistulae. Crohn's disease as a definitive diagnosis and indeterminant colitis, a histologic diagnosis, also were tested for association with the above variables and outcome groups.

RESULTS

One hundred and fifty-one pediatric patients underwent IPAA utilizing mucosectomy and hand-sewn S or J (n = 44) and stapled J or S-W anastomosis (n = 107) with 0% mortality rate and outcome as follows: group A, n = 54; group B, n = 73; group C, n = 11; group D, n = 13. Variables strongly associated with poor outcome, groups C and D, were duration of symptoms (P =.03), perianal disease (P =.03), late complications (P <.001), pouch fistulae (P <.001), and Crohn's disease (P <.0001). Furthermore, Crohn's disease was associated strongly with female gender (P =.01), perianal disease (P =.004), early (P =.006) and late (P <.001) complications, and pouch fistula (P <.001). The findings of indeterminant colitis, terminal ileitis, and early postoperative complications did not show significant differences between the 4 outcome groups.

CONCLUSIONS

Crohn's disease appears to be an important determinant of postoperative complications, chronic pouchitis, and pouch failure and occurred in 15% of the authors' patients after IPAA. Indeterminant colitis and the intraoperative findings of terminal ileitis are not associated with Crohn's disease or adverse outcome after IPAA in pediatric patients. Operation type and stage do not alter the clinical course after IPAA in pediatric patients.

Restoration of intestinal continuity following Hartmann's procedure: the Lothian experience 1987-1992

Restoration of intestinal continuity following Hartmann's procedure is associated with high morbidity (anastomotic leak rates 4-16 per cent) and mortality (0-4 per cent) rates. A total of 178 patients, under the care of seven different surgical units, underwent reversal of Hartmann's procedure during a 5-year period, representing the largest series yet reported. The mortality rate of the study group was 0.6 per cent, the anastomotic leak rate was 3.9 per cent and the incidence of anastomotic stricture was 6.7 per cent. The median time interval between resection and reversal was 92 days and no relation was found between timing and complications. Anastomotic stricture occurred significantly more commonly in stapled than in sutured anastomoses (P < 0.05); however, leaks were equally common in both types. The mean age of the patients who developed major complications was not statistically different from that of the rest of the study group and there was no difference in premorbid state. The authors believe that the low complication rates reported in this series may be attributable to the high level of operator experience in performing this technically difficult procedure, which was done by a consultant in 66 per cent of cases and by a senior registrar in 33 per cent.

The interleukin 1 receptor antagonist gene allele 2 as a predictor of pouchitis following colectomy and IPAA in ulcerative colitis

BACKGROUND & AIMS

The interleukin 1 receptor antagonist gene allele 2 has been suggested as a determinant of both disease susceptibility and extent in ulcerative colitis. The aim of this study was to assess the allele as a predictor of both the indication for colectomy and the occurrence of pouchitis after ileal pouch-anal anastomosis formation.

METHODS

Genotyping for the +2018 single nucleotide polymorphism in the interleukin 1 receptor antagonist gene was performed in 109 patients who had undergone colectomy, including 82 patients who had been followed prospectively after ileal pouch-anal anastomosis formation.

RESULTS

Patients with pouchitis had a higher allele 2 carriage rate compared with those without pouchitis (72% vs. 45%) and Kaplan-Meier survival analysis showed that allele 2 carriers had a significantly increased incidence of pouchitis compared with noncarriers (log-rank test, 6.5). After adjustment for confounding covariates in a Cox proportional hazards model, the relative hazard was 3.1 (95% confidence interval [CI], 1.2-7.8; P = 0.02). Although there was a higher allele 2 carriage rate in patients with chronic refractory compared with acute severe ulcerative colitis (63% vs. 48%), this difference was not significant (odds ratio, 1.9; 95% CI, 0.9-4.1; P = 0.1).

CONCLUSIONS

The interleukin 1 receptor antagonist gene allele 2 predicts pouchitis after ileal pouch-anal anastomosis in ulcerative colitis.

Intrathoracic leaks following esophagectomy are no longer associated with increased mortality

OBJECTIVES

Assess outcomes following intrathoracic leaks after esophagectomy from 1970 to 2004 to evaluate the impact of evolving surgical and perioperative techniques on leak-associated mortality (LAM).

SUMMARY BACKGROUND DATA

An intrathoracic leak following esophagectomy has historically been considered a catastrophic event, with mortality as high as 71%. Concerns about this complication often affect choice of surgical approach for esophagectomy.

METHODS

A retrospective review of all esophagectomies for cancer from 1970 to 2004 (n = 1223) was performed. Outcomes following intrathoracic anastomoses (n = 621) were analyzed by era: historical 1970-1986 (n = 145) and modern 1987-2004 (n = 476).

RESULTS

There was no difference in the frequency of leak between the time intervals (4.8% versus 6.3%, P = 0.5). Despite a significant increase in the use of preoperative chemoradiation (1% versus 42%, P < 0.001) in the historical versus modern era, the overall mortality decreased from 11% to 2.5% (P < 0.001). The LAM was markedly reduced from 43% to 3.3% (P = 0.016). Factors associated with LAM included failure to use enteral nutrition (HR 13.22, CI 1.8-96.8) and era in which the surgery was performed (HR 18.3, 1.9-180). Other differences included an increased proportion of successful reoperations for leak control (11/30 versus 0/7, P = 0.08) and use of reinforcing muscle flaps (7/11). In the modern era, perioperative mortality is not significantly different for patients with or without intrathoracic leaks (3.3% versus 2.5%, P = 0.55), nor is long-term survival (P = 0.16).

CONCLUSIONS

Modern surgical management of intrathoracic leaks results in no increased mortality and has no impact on long-term survival. Clinical decisions regarding the use of intrathoracic anastomoses should not be affected by concerns of increased mortality from leak.

Population-based cohort study of the impact on postoperative mortality of anastomotic leakage after anterior resection for rectal cancer

Background

Anastomotic leakage following anterior resection for rectal cancer may result in death. The aim of this study was to yield an updated, population-based estimate of postoperative mortality and evaluate possible interacting factors.

Methods

This was a retrospective national cohort study of patients who underwent anterior resection between 2007 and 2016. Data were retrieved from a prospectively developed database. Anastomotic leakage constituted exposure, whereas outcome was defined as death within 90 days of surgery. Logistic regression analyses, using directed acyclic graphs to evaluate possible confounders, were performed, including interaction analyses.

Results

Of 6948 patients, 693 (10·0 per cent) experienced anastomotic leakage and 294 (4·2 per cent) underwent reintervention due to leakage. The mortality rate was 1·5 per cent in patients without leakage and 3·9 per cent in those with leakage. In multivariable analysis, leakage was associated with increased mortality only when a reintervention was performed (odds ratio (OR) 5·57, 95 per cent c.i. 3·29 to 9·44). Leaks not necessitating reintervention did not result in increased mortality (OR 0·70, 0·25 to 1·96). There was evidence of interaction between leakage and age on a multiplicative scale (P = 0·007), leading to a substantial mortality increase in elderly patients with leakage.

Conclusion

Anastomotic leakage, in particular severe leakage, led to a significant increase in 90-day mortality, with a more pronounced risk of death in the elderly.

Is simultaneous hepatectomy and intestinal anastomosis safe?

BACKGROUND

To assess the safety of simultaneous, "one-stage," hepatectomy and intestinal anastomosis, we retrospectively studied 53 patients who underwent such a procedure, with 76 digestive tract sutures. They represented 80% of all the cases eligible for one-stage procedures among 332 liver resections for malignant tumors.

METHODS

The medical records of the patients were retrospectively analyzed to assess details of the surgical procedures, postoperative mortality and morbidity, and postoperative liver function, with special attention being paid to the prothrombin time and the bilirubin value on days 1, 2, 3, and 7.

RESULTS

No postoperative mortality occurred and the postoperative morbidity rate was 19%. Only 2 cases of digestive tract anastomotic leakage occurred, which led to reoperation. Hepatectomy-related complications were noted in 5 patients (3 biliary fistulas, 1 hemorrhage and 1 transient liver failure), and pulmonary infections occurred 3 times. The technical difficulties of the one-stage procedure are discussed, focusing on the choice of the incision, the risk of sepsis for the liver if there is an intestinal aperture, possible repercussions of liver impairment and hepatic pedicle clamping on bowel suture healing, and the risk of digestive fistula according to the location of the bowel suture.

CONCLUSION

It appears that this one-stage procedure is safe if the bowel is systematically cleaned before the operation, if an appropriate Rio-Branco incision is used, and if the risk of postoperative liver failure is low. It seems preferable to use intermittent hepatic pedicle clamping rather than continuous clamping (when feasible), and to temporarily protect a low rectal anastomosis with a colostomy.

Acute diverticulitis. A complicated problem in the immunocompromised patient

We reviewed the records of 209 patients with acute diverticulitis treated from 1984 through 1989 to determine if immunocompromised patients have a worse prognosis than nonimmunocompromised patients. Forty immunocompromised patients and 169 nonimmunocompromised patients with acute diverticulitis were identified. Free perforation into the peritoneal cavity occurred in 43% (17/40) of immunocompromised patients and 14% (24/169) of nonimmunocompromised patients. Operations were performed in 58% (23/40) of immunocompromised patients and 33% (55/169) of nonimmunocompromised patients. Postoperative morbidity was 65% (15/23) in immunocompromised patients and 24% (13/55) in nonimmunocompromised patients; postoperative mortality was 39% (9/23) and 2% (1/55), respectively. We conclude that acute diverticulitis in the immunocompromised patient is a complicated problem; there is a greater risk of free perforation and need for surgery than in the nonimmunocompromised patient. Furthermore, the prognosis for immunocompromised patients who undergo surgery is worse than that for nonimmunocompromised patients.

Impact of Anastomotic Airway Complications After Lung Transplantation

BACKGROUND

Because improper airway healing continues as a source of morbidity after lung transplantation, we determined prevalence and risk factors for anastomotic complications and examined their impact on survival.

METHODS

From January 1997 to January 2004, 272 patients undergoing pulmonary transplantation were studied for anastomotic airway complications. Complications were categorized as necrosis or obstruction and treatment as none, endoscopic (stenting, bronchoplasty, ablation), or open repair. Survival impact was assessed by follow-up (mean, 3.0 +/- 2.2 years) using competing-risks nonproportional hazards methodology in the context of repeated events.

RESULTS

By 24 months, 94 anastomotic airway complications (26 necrotic, 67 obstructive, 1 torsion) had developed in 48 patients (18%), and 23 (8.5% overall; 48% of affected patients) underwent intervention. Risk of necrotic complications preceded obstruction. Risk factors were telescoping anastomosis (p < 0.0001), more recent transplant (p < 0.0001), donor-recipient size mismatch (p = 0.008), and previously treated anastomotic airway complication (p < 0.0001). Seventy-eight interventions were performed for 60 of the 94 complications. Compared with patients experiencing no anastomotic airway complications, those with treated complications had equivalent early survival (82% versus 80% at 12 months, p = 0.9) but worse late survival (60% versus 27% at 48 months, p = 0.03), and those with untreated complications had worse early survival (82% versus 62% at 12 months, p = 0.004) but equivalent late survival (p = 0.4).

CONCLUSIONS

Anastomotic airway complications occur in about one fifth of patients after lung transplantation and are formidable and persistent problems. Early complications are necrosis, followed by obstruction. Few risk factors are modifiable. Because these complications importantly affect survival, improving efficacy of intervention strategies should improve outcome.

The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions

OBJECTIVE

Over the last 15 years we have managed patients with malignant pleural effusion, using a single procedure with thoracoscopy and talc pleurodesis or shunt as appropriate. Talc pleurodesis remains our primary treatment option but in those patient shown to have the 'trapped lung syndrome', in whom pleurodesis would fail, we have been using a pleuroperitoneal shunt.

METHODS

This retrospective review was undertaken to evaluate the mortality and morbidity of pleuroperitoneal shunts in the management of malignant pleural effusions and to assess their long-term results. Three hundred and sixty patients were treated for malignant effusions during the period 1983-1998, 160 (44.4%) of whom had a pleuroperitoneal shunt inserted. There were no intraoperative deaths and the hospital mortality was three patients (1.87%). Follow up was available for 88.1% of patients. The median survival of all malignant cases was 7.7 months (range 1-72 months). Mesothelioma patients survived somewhat longer with a median survival of 10.1 months.

RESULTS

Shunt complication occurred in 21 patients (14.8%). Twelve patients developed shunt occlusion, requiring revision in five and replacement in seven. The shunt was removed in eight patients due to skin erosion in one patient and infection in seven patients. The distal limb of shunt was broken in one patient and the shunt was replaced. One patient developed malignant seeding along the chest wall at the site of shunt insertion but there were no incidences of peritoneal deposits. Effective palliation was achieved in 95% of patients.

CONCLUSIONS

Pleuroperitoneal shunt insertion provides effective and safe palliation for malignant pleural effusion when associated with the 'trapped lung syndrome'. There are however complications which require revision or shunt removal. There is no evidence that peritoneal deposits result from pleuroperitoneal shunting.

Reversal of Hartmann's procedure: timing and operative technique

A review of closure of Hartmann's colostomy was undertaken to establish guidelines for the timing and technique of reversal. Between 1984 and 1990 there were 69 reversals; 48 patients originally had diverticular disease and 21 had carcinoma. One-third underwent reversal before 4 months and two-thirds after this time. The operative mortality rate was 3 per cent and the anastomotic leak rate 4 per cent. Significant morbidity occurred in 30 per cent. There was no advantage in delayed closure. Complications occurred in 24 per cent of patients undergoing reversal before and 35 per cent undergoing reversal after 4 months. Thirty-five anastomoses were hand-sewn and 34 stapled. There were no differences in operating time for the two techniques, but a greater number were stapled after 4 months than before (P less than 0.05), which may reflect increased rectal stump shrinkage with time. There were no differences in complication rates whether the anastomosis was hand-sewn (34 per cent) or stapled (26 per cent). Closure of Hartmann's colostomy is a safe procedure but has a significant morbidity in nearly one-third of cases. On the basis of these results, there is no indication to delay closure after 4 months have elapsed, and earlier reversal, when the rectal stump is most accessible, is recommended.

Risk factors for clinical anastomotic leakage and postoperative mortality in elective surgery for rectal cancer

BACKGROUND AND AIMS

Clinical anastomotic leakage remains a major problem after anterior or low anterior resection for rectal cancer. The aim of this study was to assess the association between risk factors and anastomotic leakage and postoperative mortality.

MATERIALS AND METHODS

Two hundred seventy-six elective anterior or low anterior resections with anastomosis were performed and documented on-line from January 1995 to December 2004. Univariate and multivariate analyses with Bonferroni adjustment were carried out to identify relevant risk factors.

RESULTS

The rate of anastomotic leakage was 14.9% (41 of 276 patients) with a mortality of 12.2% (5 of 41 patients). Overall mortality was 2.5% (7 of 276 patients). Multiple regression analysis showed that smokers had an increased risk of anastomotic leakage [odds ratio (OR), 6.42; 95% confidence interval (CI), 2.68-15.36] as well as patients with coronary heart disease (OR, 7.79; 95% CI, 2.52-24.08). Smokers (OR, 13.20; 95% CI, 2.48-7.24) and patients with coronary heart disease (OR, 23.46; 95% CI, 4.33-27.04) also had an increased risk of postoperative mortality in the univariate analysis as well as patients with anastomotic leakage (OR, 16.25; 95% CI, 3.04-16.92).

CONCLUSIONS

Smoking and coronary heart disease are important risk factors for anastomotic leakage and postoperative mortality after elective resection for rectal cancer.

Comparison of stapled and hand-sewn esophagogastric anastomoses

BACKGROUND

Esophagogastric anastomotic leaks continue to be a major source of morbidity and mortality after esophagectomy. Leaks usually result from technical errors or occult ischemia of the mobilized gastric fundus. The introduction of stapled esophagogastric anastomoses was initially very promising; leak rates appeared to be reduced.

DATA SOURCES

The English language medical literature was searched for publications comparing stapled and hand-sewn esophagogastric anastomoses. We reviewed data from four randomized trials and seven nonrandomized comparative studies to determine if stapling was superior to hand suturing for esophagogastric anastomoses.

RESULTS

Pooled data from randomized trials comparing stapled with hand-sewn esophagogastric anastomoses showed no significant difference for leaks (stapled 9%, hand-sewn 8%, P <0.67), but a higher incidence of strictures in stapled anastomoses (stapled 27%, hand-sewn 16%, P < 0.02). In nonrandomized studies, stapled anastomoses had a lower leak rate (stapled 6%, hand-sewn 11%, P < 0.0001), but strictures were more frequent (stapled 31%, hand-sewn 16%, P < 0.0001). A major source of bias in the nonrandomized studies was the comparison of contemporary stapled experience and earlier hand-sewn experience. This bias was not present in three of seven nonrandomized studies that featured prospective data collection. Pooled data from these three studies showed no difference in anastomotic leak rate (stapled 4%, hand-sewn 6%, P < 0.28).

CONCLUSIONS

Stapled and hand-sewn esophagogastric anastomotic techniques have equivalent anastomotic leak rates, but strictures are more common in stapled anastomoses. Irrespective of which technique is used, surgical experience and meticulous attention to detail are required to prevent anastomotic complications. Anastomotic technical modifications alone are unlikely to eliminate the problem of leaks, since they do not address the problem of gastric fundal ischemia.