Anastomotic Leakage Group Research Articles

Does aortic calcification really affect anastomotic leakage after rectal cancer surgery?

The purpose of the current study was to analyze whether aortic calcification had impact on the anastomotic leakage (AL) after rectal cancer (RC) surgery. We collected patients' information from January 2011 to January 2020 in a single teaching hospital. Preoperative computed tomography images were obtained. Abdominal aortic calcification (AAC), superior mesenteric aortic calcification, and inferior mesenteric aortic calcification were recorded. The difference of AL and grade C AL was calculated. A total of 2412 RC patients were included in this study. Ninety-seven (4.0%) RC patients experienced AL and 47 (1.9%) RC patients experienced grade C AL. The amount of AAC, superior mesenteric aortic calcification, and inferior mesenteric aortic calcification was 1546 (64.1%), 128 (5.3%), and 31 (1.3%). The AL group had higher portion of AAC (P = .019) than the no AL group, and the grade C AL group had higher portion of AAC (P = .016) than the no grade C AL group. In univariate logistic regression analysis, AAC was a significant potential factor for AL (P = .021, OR = 1.739, 95% CI = 1.088-2.779) and grade C AL (P = .019, OR = 2.339, 95% CI = 1.115-4.986). However, in multivariate logistic regression, AAC was not an independent predictive factor for AL (P = .157, OR = 1.443, 95% CI = 0.871-2.358) or grade C AL (P = .064, OR = 2.055, 95% CI = 0.960-4.399). AAC was associated with higher amount of AL and grade C AL, however, AAC was not an independent predictive factor for AL or grade C AL.

Anastomotic Leakage after Colorectal Surgery is Associated with a Specific Tissue-Microbiome Signature

Abstract Background Anastomotic leakage (AL) occurs in 5-15% of colorectal resections. In addition to well-known risk factors, recent evidence suggests that the gut microbiota might critically affect anastomotic healing. However, studies in humans are limited. Aims To explore differences in pre-operative microbiome of patients with or without AL and identify anastomosis-protective or damaging bacterial species. Methods Clinical records of patients undergoing left colon or rectal resection with anastomosis at our department between 2013 and 2021 were screened. AL cases were matched equally to controls by propensity score, based on common AL risk factors. The microbiome was analyzed by amplification and sequencing of the V4 region of the 16S gene of DNA extracted from formalin-fixed paraffin-embedded mucosa taken at the proximal and distal margin of the resected specimen, mixed in equal amounts. Differential abundance of identified operational taxonomic units (OTUs) in AL-cases and controls was tested by using the R-package DESeq2. Results Among 588 patients screened, 41 cases and 42 matched controls were eligible for microbiome analysis. Patient characteristics were similar except for a higher percentage of rectal resections in the AL group. Out of 5406 OTUs identified, 197 OTUs were differentially abundant between the two groups (adjusted-p value <0.05). Of those, 175 OTUs were more prevalent in the AL-group, in particular Fusobacterium periodonticum (32% vs. 5% of patients) and bacteria from the Hyphomicrobium genera (39-44% vs. 12-21%); 22 were more prevalent in the control group, in particular Akkermansia muciniphila (26 vs. 17%) and Eubacterium sireum (19 vs. 5% of patients). Conclusion Our analysis unravels AL-associated microbiome-signatures and identifies bacterial species highly prevalent in particular in patients with AL. These findings could be used for future research to develop targeted antibiotic therapy that helps prevent AL.

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy.

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Role of body mass index in anastomotic leakage after curative treatment for rectal cancer.

Anastomotic leakage (AL) represents a severe complication after rectal surgery, leading to significant morbidity, mortality, and increased healthcare costs. Despite improvements in surgical methods and perioperative care, the challenge of AL persists. Explore the impact of body mass index (BMI) on the risk of AL following curative treatment for rectal cancer, providing insight into its predictive value. Retrospective review. Data were collected from a single tertiary center, emphasizing the specialized postoperative outcomes in a high-care setting. The study population was comprised patients who underwent sphincter-saving surgery combined with neoadjuvant chemoradiation for rectal cancer from 2001 to 2011. Patients with anastomotic stenosis were excluded. The primary outcome investigated was the occurrence of AL post-surgery. Secondary outcomes included the assessment of local cancer recurrence rates within the AL group. 224; 13 excluded. Of 237 patients who underwent surgery, 13 with anastomotic stenosis were excluded from this study. Of the remaining 224, 15 individuals (6.3%) developed AL. A potential association between higher BMI and increased AL risk was identified. Additionally, the study noted a higher incidence of local rectal cancer recurrence in the group that developed leakage. The findings suggest BMI as a significant predictive factor for AL after curative rectal cancer treatment. This emphasizes the need for heightened awareness and possible preoperative counseling for obese patients regarding their increased risk of postoperative leakage. The study was retrospective with all the inherit biases of such studies. The sample size was small and this may have introduced a type 2 statistical error.

Risk factors for anastomotic leakage after low anterior resection for obese patients with rectal cancer.

We aimed to analyze the risk factors for anastomotic leakage (AL) after low anterior resection (LAR) in obese patients (body mass index [BMI] ≥ 25kg/m2) with rectal cancer. Data were collected from four hundred two obese patients who underwent LAR for rectal cancer in 51 institutions. Forty-six (11.4%) patients had clinical AL. The median BMI (27kg/m2) did not differ between the AL and non-AL groups. In the AL group, comorbid respiratory disease was more common (p = 0.025), and the median tumor size was larger (p = 0.002). The incidence of AL was 11.5% in the open surgery subgroup and 11.4% in the laparoscopic surgery subgroup. Among the patients who underwent open surgery, the AL group showed a male predominance (p = 0.04) in the univariate analysis, but it was not statistically significant in the multivariate analysis. Among the patients who underwent laparoscopic surgery, the AL group included a higher proportion of patients with comorbid respiratory disease (p = 0.003) and larger tumors (p = 0.007). Comorbid respiratory disease and tumor size were risk factors for AL in obese patients with rectal cancer. Careful perioperative respiratory management and appropriate selection of surgical procedures are required for obese rectal cancer patients with respiratory diseases.

Predictive value of early postoperative blood lipid metabolism for anastomotic leakage after esophageal cancer surgery.

To explore the clinical value of assessing early postoperative blood lipid metabolism levels in predicting anastomotic leakage (AL) after esophageal cancer (EC) surgery. The clinical data of EC patients who underwent surgery at the Northern Jiangsu People's Hospital from May 2021 to May 2023 were retrospectively studied. Totally, 28 patients who developed AL were included in the AL group, while 110 patients who did not develop AL were included in the non-AL group. Outcomes compared between the two groups included clinical baseline data, total cholesterol (TC), triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) levels. Logistic regression analysis was performed to identify independent risk factors for postoperative AL. The predictive value of early postoperative blood lipid metabolism levels for AL was evaluated using Receiver Operating Characteristic (ROC) curves. The AL group exhibited significantly elevated levels of TC and LDL-C but significantly reduced HDL-C levels compared to the non-AL group (all P<0.05). However, there was no significant difference in triglyceride levels between the two groups (P>0.05). Logistic regression analysis revealed that low BMI (P=0.012; OR: 4.409; 95% CI: 1.391-13.976), comorbid hypertension (P=0.011; OR: 5.891; 95% CI: 1.492-23.259), comorbid diabetes (P=0.022; OR: 4.522; 95% CI: 1.238-16.521), low HDL-C (P=0.007; OR: 19.965; 95% CI: 2.293-173.809), and high LDL-C (P=0.012; OR: 4.321; 95% CI: 1.388-13.449) were independent risk factors for developing AL after EC surgery. The combined prediction model using TC, HDL-C, and LDL-C yielded an area under the curve (AUC) of 0.876, with a sensitivity of 79.09%, specificity of 85.71%, and overall accuracy of 80.44%, significantly outperforming individual lipid measurements. The combined assessment of TC, HDL-C, and LDL-C can effectively predict the occurrence of AL after EC surgery. For EC patients with relatively low BMI, hypertension, diabetes, relatively low HDL-C, and relatively high LDL-C, prioritizing weight management, hypertension and diabetes control, and lipid management can significantly reduce the risk of AL post-surgery.

Clinical value of prognostic nutritional index combined with C-reactive protein and albumin in early prediction of anastomotic leakage after radical gastric cancer surgery.

To evaluate the predictive value of the Prognostic Nutritional Index (PNI) combined with C-reactive protein (CRP) and albumin (ALB) for anastomotic leakage following radical gastric cancer surgery. A retrospective case-control study was conducted with 275 gastric cancer patients at the Second People's Hospital of Lanzhou City from September 2019 to October 2022. Patients were categorized into an anastomotic leakage group (n=31) or a non-leakage group. Clinical, surgical, and pathological data were analyzed using logistic regression to develop two risk models: a combined clinical-laboratory index (RISK1) and a separate laboratory index (RISK2). Model effectiveness was compared using Receiver Operating Characteristic (ROC) curves. Anastomotic leakage occurred in 11.27% of patients, predominantly in those with advanced TNM stages (P=0.006). Notably, higher operative times (P=0.049) and increased intraoperative bleeding (P=0.027) were associated with the leakage group. Significant differences in ALB, PNI, and CRP levels were observed between the groups. Both RISK1 and RISK2 identified ALB, CRP, PNI, operative time, and intraoperative bleeding as independent predictors of leakage, demonstrating high predictive accuracy (RISK1 AUC=0.937, RISK2 AUC=0.911), with no significant difference in performance between the models (P=0.245). The combination of ALB, CRP, and PNI effectively predicts the risk of anastomotic leakage in patients undergoing gastric cancer surgery. These biomarkers can significantly enhance postoperative management and improve patient outcomes.

CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study

PurposeTo determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer.MethodsWe reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden’s index using receiver operating characteristic curve analysis.ResultsIn total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66–8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L.ConclusionEarly changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study

ObjectivesThe risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address...

Time required for indocyanine green fluorescence emission for evaluating bowel perfusion in left-sided colon and rectal cancer surgery.

Indocyanine green fluorescence imaging (ICG-FI) has been reported to be useful in reducing the incidence of anastomotic leakage (AL) in colectomy. This study aimed to investigate the correlation between the required time for ICG fluorescence emission and AL in left-sided colon and rectal cancer surgery using the double-stapling technique (DST) anastomosis. This retrospective study included 217 patients with colorectal cancer who underwent left-sided colon and rectal surgery using ICG-FI-based perfusion assessment at our department between November 2018 and July 2022. We recorded the time required to achieve maximum fluorescence emission after ICG systemic injection and assessed its correlation with the occurrence of AL. Among 217 patients, AL occurred in 21 patients (9.7%). The median time from ICG administration to maximum fluorescence emission was 32s (range 25-58s) in the AL group and 28s (range 10-45s) in the non-AL group (p < 0.001). The cut-off value for the presence of AL obtained from the ROC curve was 31s. In 58 patients with a required time for ICG fluorescence of 31s or longer, the following risk factors for AL were identified: low preoperative albumin [3.4mg/dl (range 2.6-4.4) vs. 3.9mg/dl (range 2.6-4.9), p = 0.016], absence of preoperative mechanical bowel preparation (53.8% vs. 91.1%, p = 0.005), obstructive tumor (61.5% vs. 17.8%, p = 0.004), and larger tumor diameter [65mm (range 40-90) vs. 35mm (range 4.0-100), p < 0.001]. The time required for ICG fluorescence emission was associated with AL.

Non-Gastrointestinal Complications and Short-Term Outcomes in Patients With Anastomotic Leak After Colon Resection: A Propensity Matched Analysis of American College of Surgeons National Surgical Quality Improvement Program Database

Introduction: Anastomotic leak is a devastating complication after colorectal surgery. There is paucity of data on non-gastrointestinal complications after anastomotic leak in this population. We aimed to investigate non-gastrointestinal complications, as well as causes of major morbidity and mortality following anastomotic leak after colorectal resection and hypothesized that non-gastrointestinal complications after anastomotic leak are a sizable proportion of the overall morbidity and mortality in this population. Methods: We used the ACS NSQIP database, and searched for CPT codes for colorectal procedures with primary anastomosis between 2015-2019. The cohorts (anastomotic leak vs. no-leak) were aligned using propensity score matching, and 30-day mortality, length of stay, and readmission outcomes were compared. Results: We identified 4881 patients with anastomotic leak and 150331 patients with no-leak. The overall leak rate was 3.14%. Anastomotic leak group had an 85% longer length-of-stay. Predicted mean (95% CI) length-of-stay for the leak group was 10.2 (9.9-10.5) days vs. 5.5 (5.4-5.7) days for the no-leak group. Anastomotic leak was associated with a higher 30-day risk of unplanned return to the operating room (OR 34.5; 95% CI 27.2-43.8), and thirty-day mortality (OR 2.8; 95% 2.2-3.5). Anastomotic leak was associated with a higher incidence of pulmonary complications including: pneumonia (OR 4.4; 95% CI 3.5-5.6), unplanned intubation (OR 6.3; 95% CI 4.8-8.3), mechanical ventilation (OR 6.3; 95% CI 5.1-8.0), and pulmonary embolism (OR 4.3; 95% CI 2.6-7.0); cardiac complications, including myocardial infarction (OR 2.9 (95% CI 2.0-4.2) and cardiac arrest (OR 3.2; 95% CI 2.1-4.9); and new-onset renal failure requiring dialysis (OR 3.8; 95% CI 2.6-5.5). There was no significant difference in risk of acute kidney injury (OR 1.1; 95% CI 0.6-2.0), and stroke (OR 1.8; 95% CI 0.9-3.6). Conclusion: Colorectal anastomotic leak independently lengthens length-of-stay, and is associated with increased mortality (2.7% vs. 7.2%) after colorectal surgery with an enteric anastomosis.

Anastomotic leakage following bowel resection in radical cytoreductive surgery for ovarian cancer: A subgroup analysis of the prospective AGO-OVAR.OP3/LION.

5566 Background: Anastomotic leakage (AL) is an important and severe complication following bowel resection in cytoreductive surgery (CRS) for ovarian cancer (OC). Identifying patients (pts) at risk for AL could improve clinical management and reduce frequency and severity of complications. Methods: AGO-OVAR.OP3/LION intraoperatively randomized 647 pts with advanced OC (FIGO IIB-IV) following complete cytoreduction with unsuspicious lymph nodes to either undergo systematic pelvic and paraaortic lymphadenectomy (LNE) or not. All pts who underwent bowel resection were included in this analysis. Potential prognostic impact of AL was analyzed by Kaplan-Meier method and log-rank tests regarding progression-free (PFS) and overall survival (OS). Risk factors for AL in a subset of clinicopathological parameters were evaluated by calculating odds ratio (OR) with 95% confidence interval (CI) in univariate and multivariate logistic regression models. A stepwise variable selection algorithm using the Akaike Information Criteria (AIC) for identification of the final logistic regression model was applied. P values presented were two-tailed, and P&lt;0.05 was considered as statistically significant. Results: Among all 647 randomized pts, AL was noted in 24 (3.7 %) pts. The AL rate of the 336 pts with bowel surgery during CRS (median age 61.3 years; 316 large bowel, 94 small bowel resections) was 7.1% (24/336 pts). Pts following stoma formation had an AL rate of 5.5% (3/55 pts) compared to 7.5% (21/281 pts) in pts without stoma. Median PFS was 18 months in pts with AL versus 19 months in the no-AL-group (hazard ratio (HR) 0.86; 95% CI 0.5 to 1.4, P=0.53), median OS was 31 months in the AL group and 58 months in the no-AL-group (HR 0.69; 95% CI 0.4 to 1.2, P=0.17). The clinicopathological characteristics “volume of blood loss” (OR 1.05 per 100cc; 95% CI 1.01-1.10) and “LNE vs non-LNE” (OR 4.10; 95% CI 1.60-12.62) were identified as factors potentially predictive for AL in univariate analysis, and both factors (volume of blood loss [OR 1.04 per 100cc, 95% CI 1.0001-1.09], LNE vs non-LNE [OR 3.67, 95% CI 1.41-11.39]) remained a significant independent factor in multivariate analysis. Conclusions: Considering the high surgical complexity in this large prospective surgical trial, the overall rate of AL following bowel surgery was relatively low and had no significant impact on PFS or OS. While protective stoma formation was not identified as protective factor in this cohort, volume of blood loss and LNE procedure were clinical parameters associated with higher risk of AL. Being potential surrogates for extensive surgery, these factors should be considered in perioperative management in pts with advanced OC. Further specific factors predicting AL were not identified. Clinical trial information: NCT00712218 .

Is preoperative hypoalbuminemia or hypoproteinemia a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery in an enhanced recovery after surgery (ERAS) program?

PurposePreoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL).MethodsThe Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis, was interrogated. Preoperative serum albumin and protein levels (measured within 1 week of surgery) were plotted on receiver operating characteristic curves (ROC curves) and statistically analyzed for cutoff values, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).ResultsThe incidence of AL was 4.4% (16/361). Overall mortality was 1.4% (5/361), 6.3% (1/16) in the AL group, and 1.2% (4/345) in the no AL group. The median preoperative albumin and protein level in the AL group were 39 g/L and 75 g/L, respectively. The median preoperative albumin and protein level in the no AL group were 38 g/L and 74 g/L, respectively. The Mann–Whitney U test showed no statistically significant difference in albumin levels (p = 0.4457) nor protein levels (p = 0.6245) in the AL and no AL groups. ROC curves demonstrated that preoperative albumin and protein levels were not good predictors of anastomotic leak. Cutoff values for albumin (38 g/L) and protein (75 g/L) both had poor PPV for AL (4.8% and 3.8% respectively).ConclusionIn patients undergoing elective colorectal surgery as part of an ERAS program, preoperative serum albumin and protein levels are not reliable in predicting AL. This may be because of nutritional supplementation provided as part of an ERAS program may correct nutritional deficits to protect against AL or that low albumin/protein is not as robust a marker of AL as previously reported.

Perfusion assessment by fluorescence time curves in esophagectomy with gastric conduit reconstruction: a prospective clinical study

BackgroundIntraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications.MethodsThis prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T0, Tmax, Fmax, slope, Time-to-peak) as outflow parameters (T90% and T80%). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL.ResultsOne hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as Tmax were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3–2.5) and 1.7 (IQR 1.0–3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T90% 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that Tmax might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%.ConclusionThis study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction.A significant predictive value remains to be determined in future studies.

Microbiota Phenotype Promotes Anastomotic Leakage in a Model of Rats with Ischemic Colon Resection.

Anastomotic leakage (AL) is a major cause of morbidity and mortality after colorectal surgery, but the mechanism behind this complication is still not fully understood. Despite the advances in surgical techniques and perioperative care, the complication rates have remained steady. Recently, it has been suggested that colon microbiota may be involved in the development of complications after colorectal surgery. The aim of this study was to evaluate the association of gut microbiota in the development of colorectal AL and their possible virulence strategies to better understand the phenomenon. Using 16S rRNA sequencing of samples collected on the day of surgery and the sixth day following surgery, we analyzed the changes in tissue-associated microbiota at anastomotic sites created in a model of rats with ischemic colon resection. We discovered a trend for lower microbial diversity in the AL group compared to non-leak anastomosis (NLA). There were no differences in relative abundance in the different types of microbial respiration between these groups and the high abundance of the facultative anaerobic Gemella palaticanis is a marker species that stands out as a distinctive feature.

Curable leakage in stapled IPAA has little effect on the long-term pouch function.

This study aimed to evaluate the frequency and grade of anastomotic leakage (AL) in stapled ileal pouch-anal anastomosis (IPAA) and its long-term impact on the pouch functions. A longitudinal cohort study was conducted on UC patients who underwent stapled IPAA at Yokohama City University Medical Center between 2007 and 2018. The diagnosis and grading of AL were performed in accordance with the recommendations of the International Study Group of Rectal Cancer. We assessed the functional pouch rate, late complication, pouch survival rate, bowel function (bowel movements per day, soiling, spotting, difficulty in distinguishing feces from flatus) and pouch inflammation (pouchitis disease activity index; PDAI) in the long-term period. Two hundred seventy-six patients were analyzed. Twenty-three (8.3%; grade B/C; 13/10) patients were diagnosed with AL, but a functional pouch was achieved in all the twenty-three patients. Anastomotic stricture was significantly more common in patients with AL (AL group) than in patients without AL (non-AL group; AL/non-AL: 13.0/3.2%, p = 0.020). There were no differences in other late complications. Furthermore, the pouch survival rate did not differ between the AL and non-AL groups (100.0/97.9%/10years, p = 0.494). There were no differences between the groups in bowel movements per day, spotting, soling, difficulty in distinguishing feces from flatus, or PDAI postoperatively. Curable AL may not affect late complications (except anastomotic stricture), pouch survival, the bowel function, or pouch inflammation over the long term. Perioperative management to prevent the severity of AL is as important as preventing its occurrence.

High amylase concentration in drainage liquid can early predict proximal and distal intestinal anastomotic leakages: A prospective observational study.

Anastomotic leak (AL) is a serious complication in digestive surgery. Early diagnosis might allow clinicians to anticipate appropriate management. The aim of this study was to assess the predictive value of amylase concentration in drain fluid for the early diagnosis of digestive tract AL. Hundred and fourteen consecutive patients "at risk" of AL, in whom a flexible drainage was placed by surgeon's choice after digestive anastomosis were included. Patients with eso-gastric, bilio-digestive, and pancreatic anastomoses were excluded. Drain amylase measurement (DAM) was routinely performed on postoperative day (POD) 1, 3, 5-7. DAM values were compared between patients with postoperative AL versus patients without AL. A receiver-operating curve (ROC) with calculation of the areas under the ROC curves area under curves was performed and a cutoff value of DAM was calculated. AL occurred in 25 patients (AL group) and 89 patients did not present AL (C group). The mean DAM was significantly higher in AL group versus C Group on POD 1, 3, and 5. A cutoff value of 307 IU/L predicted the occurrence of AL with a sensitivity and specificity of 91% and 100%, respectively. Positive and negative predictive values were 100% and 97.5%, respectively. Patients with AL had an elevated DAM prior to the appearance of any clinical signs of AL. High level DAM could accurately predict AL for proximal and distal digestive tract anastomoses. This simple, noninvasive, and low-cost method can accurately predict early AL and help physicians to perform appropriate imaging and treatment.

Application value of continuous seromuscular layer sutures in the reinforcement of esophagojejunostomy in total gastrectomy for gastric cancer: a retrospective comparative cohort study

The development process of gastrointestinal anastomosis is from complex to simple, from two layers to one layer, from extramucosal anastomosis to seromuscular anastomosis. With the rapid development of anastomosis instruments, the anastomosis process becomes more and more convenient. However, relevant studies have shown that related complications such as anastomotic leakage still occur. This study sought to investigate the feasibility and safety of seromuscular layer sutures in the reinforcement of esophagojejunostomy after open radical total gastrectomy. This study retrospectively analyzed patients who underwent Roux-en-Y esophagojejunostomy after open radical total gastrectomy at The Third Department of Surgery, The Fourth Hospital of Hebei Medical University from April 2019 to May 2020. The inclusion criteria of patients were between 18 and 80 years old; pathology confirmed gastric adenocarcinoma; preoperative imaging showed no distant metastasis and did not receive neoadjuvant therapy; no complex infectious diseases; no blood transfusion was performed before operation. A total of 192 patients were included according to the inclusion criteria. They were divided into the following 2 groups based on whether seromuscular layer suturing of the anastomosis was performed: (I) group A (the simple anastomosis group, n=76); (II) and group B (the seromuscular layer suture group, n=116). The baseline data, surgical data and postoperative complications were compared between the two groups. All patients underwent esophagojejunostomy Roux-en-Y anastomosis after open radical total gastrectomy, and no perioperative deaths occurred. There was no significant difference in baseline data between the two groups. Group B had an earlier time to liquid diet than group A (4.23±0.76 vs. 4.57±0.58 days, P<0.001). The incidence of postoperative anastomotic leakage in group B (1.72%) was lower than that in group A (9.21%), and the difference was statistically significant (P=0.03). The incidence of pleural effusion was lower in group B (15.52%) than group A (32.89%), and the difference was statistically significant (P=0.005). Compared to the simple anastomosis, seromuscular layer sutures after esophagojejunostomy may decrease the rates of postoperative anastomotic leakage and pleural effusion. This suture method is feasible and may provide a new option to increase surgical safety.

Comprehensive abdominal composition evaluation of rectal cancer patients with anastomotic leakage compared with body mass index-matched controls.

Anastomotic leakage (AL) is a fatal complication in patients with rectal cancer after undergoing anterior resection. However, the role of abdominal composition in the development of AL has not been studied. To investigate the relationship between abdominal composition and AL in rectal cancer patients after undergoing anterior resection. A retrospective case-matched cohort study was conducted. Complete data for 78 patients with AL were acquired and this cohort was defined as the AL group. The controls were matched for the same sex and body mass index (± 1 kg/m2). Parameters related to abdominal composition including visceral fat area (VFA), subcutaneous fat area (SFA), subcutaneous fat thickness (SFT), skeletal muscle area (SMA), skeletal muscle index (SMI), abdominal circumference (AC), anterior to posterior diameter of abdominal cavity (APD), and transverse diameter of abdominal cavity (TD) were evaluated based on computed tomography (CT) images using the following Hounsfield Unit (HU) thresholds: SFA: -190 to -30, SMA: -29 to 150, and VFA: -150 to -20. The significance of abdominal composition-related parameters was quantified using feature importance analysis; an artificial intelligence method was used to evaluate the contribution of each included variable. Two thousand two hundred and thirty-eight rectal cancer patients who underwent anterior resection from 2010 to 2020 in a large academic hospital were investigated. Finally, 156 cases were enrolled in the study. Patients in the AL group showed longer operative time (225.03 ± 55.29 vs 207.17 ± 40.80, P = 0.023), lower levels of preoperative hemoglobin (123.32 ± 21.17 vs 132.60 ±1 6.31, P = 0.003) and albumin (38.34 ± 4.01 vs 40.52 ± 3.97, P = 0.001), larger tumor size (4.07 ± 1.36 vs 2.76 ± 1.28, P < 0.001), and later cancer stage (P < 0.001) compared to the controls. Patients who developed AL exhibited a larger VFA (125.68 ± 73.59 vs 97.03 ± 57.66, P = 0.008) and a smaller APD (77.30 ± 23.23 vs 92.09 ± 26.40, P < 0.001) and TD (22.90 ± 2.23 vs 24.21 ± 2.90, P = 0.002) compared to their matched controls. Feature importance analysis revealed that TD, APD, and VFA were the three most important abdominal composition-related features. AL patients have a higher visceral fat content and a narrower abdominal structure compared to matched controls.

Quantitative Analysis of Colonic Perfusion Using ICG Fluorescence Angiography and Its Consequences for Anastomotic Healing in a Rat Model.

Simple SummaryAlthough indocyanine green (ICG) fluorescence angiography has been widely used to prevent anastomotic leakage (AL) in recent years, its usefulness remains unclear. The purpose of this study was to investigate whether quantitative analysis of colonic perfusion using ICG angiography could predict AL in a rat AL model. In the quantitative assessment, the following five parameters were calculated: Fmax (fluorescence difference between maximum and baseline), Tmax (time from onset to maximum), T1/2 (time from onset to half of maximum), Slope (Fmax/Tmax), and TR (T1/2/Tmax). Using a rat AL model, we found that there was a significant difference between the AL group and non-AL group in terms of Fmax, Tmax, T1/2, and Slope. In particular, Slope could be useful to predict AL.Forty-three rats were randomly assigned to the following four groups: non-ischemic group (Control Group), 1 cm-long ischemic group (Group 1), 2 cm-long ischemic group (Group 2), and 3 cm-long ischemic group (Group 3). The rates of AL were 0% (0/10) in the Control Group, 22.2% (2/9) in Group 1, 25% (2/8) in Group 2, and 50% (4/8) in Group 3. The bursting pressure of the Control Group was significantly higher than that of the other groups (p < 0.01). Regarding the pathological findings, the granulation thickness and the number of blood vessels at the anastomosed site were significantly higher in the Control Group than in Group 3 (p < 0.05). Receiver operating characteristics analysis revealed that Slope was the most significant predictor of AL, with an area under the curve of 0.861. When the cutoff value of Slope was 0.4, the sensitivity and specificity for the prediction of AL were 75% and 81.4%, respectively. Quantitative analysis of ICG fluorescence angiography could predict AL in a rat model.