Anastomotic Leakage Research Articles

Robot-assisted laparoscopic combined with endoscopic partial gastrectomy (RALE-PG) for the treatment of gastric gastrointestinal stromal tumors in challenging anatomical locations: single-center experience

BackgroundGastric gastrointestinal stromal tumors in challenging anatomical locations are difficult to remove.MethodsThis study retrospectively analyzed the clinical data of 12 patients with gastric GISTs in challenging anatomical locations who underwent robot-assisted laparoscopic combined with endoscopic partial gastrectomy (RALE-PG) and manual suturing of the gastric wall.ResultsThis study included 12 patients with a mean age of 56.8 ± 9.8 years and a mean BMI of 23.9 ± 1.9 kg/m2. Tumors were located in the GEJ (n = 3), lesser curvature (n = 3), posterior gastric wall (n = 3) and antrum (n = 3). The cardia and pylorus were successfully preserved in all patients regardless of the tumor location. The mean tumor size was 4.5 ± 1.4 cm. The mitotic-count/50 mm2 was less than 5 in all patients (100%). There was no intraoperative tumor rupture (0%) and no conversion to open surgery (0%). The median operation time was 122 (97–240) min, and the median blood loss volume was 10 (5–30) ml. The median postoperative VAS score was 2 (2–4). The median time to first flatus was 2 (2–3) days. The median time to first fluid intake was 2 (2–3) days. The median time to first ambulation after the operation was 3 (2–4) days. No cases of anastomotic stenosis or leakage were found. The median time to drain removal for 6 patients was 5 (4–7) days. The median time to nasogastric tube removal for all patients was 2 (1–5) days. The median postoperative hospital stay was 5 (4–8) days. One patient (female/41 year) developed moderate anemia (Clavien-Dindo grade II complication). There was no unplanned readmission within 30 days after the operation. The median distance from the tumor to the resection margin was 1 (1–2) cm. R0 resection was achieved in all patients. The median follow-up period was 19 (10–25) months, and all patients survived with no recurrence or metastasis.ConclusionsRALE-PG is a safe, feasible and advantageous technique for treating GISTs in challenging anatomical locations. It can be used to accurately remove the tumor while preserving gastric function to the greatest extent, but long-term oncologic outcomes need to be evaluated in a study with a larger sample size and longer follow-up period.

Knockout Genes in Bowel Anastomoses: A Systematic Review of Literature Outcomes.

The intestinal wound healing process is a complex event of three overlapping phases: exudative, proliferative, and remodeling. Although some mechanisms have been extensively described, the intestinal healing process is still not fully understood. There are some similarities but also some differences compared to other tissues. The aim of this systematic review was to summarize all studies with knockout (KO) experimental models in bowel anastomoses, underline any recent knowledge, and clarify further the cellular and molecular mechanisms of the intestinal healing process. A systematic review protocol was performed. Medline, EMBASE, and Scopus were comprehensively searched. a total of eight studies were included. The silenced genes included interleukin-10, the four-and-one-half LIM domain-containing protein 2 (FHL2), cyclooxygenase-2 (COX-2), annexin A1 (ANXA-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and heparin-binding epidermal growth factor (HB-EGF) gene. Surgically, an end-to-end bowel anastomosis was performed in the majority of the studies. Increased inflammatory cell infiltration in the anastomotic site was found in IL-10-, annexin-A1-, and TAFI-deficient mice compared to controls. COX-1 deficiency showed decreased angiogenesis at the anastomotic site. Administration of prostaglandin E2 in COX-2-deficient mice partially improved anastomotic leak rates, while treatment of ANXA1 KO mice with Ac2-26 nanoparticles reduced colitis activity and increased weight recovery following surgery. our findings provide new insights into improving intestinal wound healing by amplifying the aforementioned genes using appropriate gene therapies. Further research is required to clarify further the cellular and micromolecular mechanisms of intestinal healing.

Early Detection and Monitoring of Anastomotic Leaks via Naked Eye-Readable, Non-Electronic Macromolecular Network Sensors.

Anastomotic leakage (AL) is the leaking of non-sterile gastrointestinal contents into a patient's abdominal cavity. AL is one of the most dreaded complications following gastrointestinal surgery, with mortality rates reaching up to 27%. The current diagnostic methods for anastomotic leaks are limited in sensitivity and specificity. Since the timing of detection directly impacts patient outcomes, developing new, fast, and simple methods for early leak detection is crucial. Here, a naked eye-readable, electronic-free macromolecular network drain fluid sensor is introduced for continuous monitoring and early detection of AL at the patient's bedside. The sensor array comprises three different macromolecular network sensing elements, each tailored for selectivity toward the three major digestive enzymes found in the drainage fluid during a developing AL. Upon digestion of the macromolecular network structure by the respective digestive enzymes, the sensor produces an optical shift discernible to the naked eye. The diagnostic efficacy and clinical applicability of these sensors are demonstrated using clinical samples from 32 patients, yielding a Receiver Operating Characteristic Area Under the Curve (ROC AUC) of 1.0. This work has the potential to significantly contribute to improved patient outcomes through continuous monitoring and early, low-cost, and reliable AL detection.

A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis.

Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection. A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort. 72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer. We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.

Enhanced perioperative care for the prevention of anastomotic leakage – DOUBLE CHECK: study protocol for an international, multicenter open-label trial with historical controls

Background: Colorectal anastomotic leakage (CAL) remains a severe complication after bowel surgery. Recent research has identified several modifiable perioperative CAL risk factors. The aim of this study is to implement an enhanced perioperative care protocol, to optimize the intraoperative condition of the patient and minimalize exposure to modifiable CAL risk factors. Secondly, this study will investigate whether implementation of this new protocol results in a decreased CAL rate. Methods: The DOUBLE CHECK study will be performed using an open-label, international, multicenter design in 11 participating hospitals. The aim is to include an intervention group of 943 adult patients that underwent a colorectal resection with creation of a primary anastomosis. The patients in the intervention group will be treated according to an enhanced perioperative care protocol focusing on optimizing the intraoperative condition of the patient by minimalizing exposure to the following perioperative factors: anemia, hyperglycemia, hypothermia, epidural anesthesia, vasopressor drug administration, and incorrect or lack of antibiotic prophylaxis. The control group will consist of 1562 historical patients that were treated with standard perioperative practice (LekCheck study cohort). The patient’s intraoperative condition defined by exposure to the six perioperative risk factors, compliance to the DOUBLE CHECK study protocol, 30-day and 90-day CAL and other postoperative complications, length of hospital-stay, and ICU stay, hospital readmission and 30-day mortality will be measured. Discussion: The strength of this study is that it is an implementation study of an enhanced perioperative practice protocol for patients that are scheduled for colorectal resection in combination with a comparative study. This protocol could be a tool for other hospitals that want to improve their perioperative care pathway.

Machine learning-based preoperative analytics for the prediction of anastomotic leakage in colorectal surgery: a swiss pilot study

BackgroundAnastomotic leakage (AL), a severe complication following colorectal surgery, arises from defects at the anastomosis site. This study evaluates the feasibility of predicting AL using machine learning (ML) algorithms based on preoperative data.MethodsWe retrospectively analyzed data including 21 predictors from patients undergoing colorectal surgery with bowel anastomosis at four Swiss hospitals. Several ML algorithms were applied for binary classification into AL or non-AL groups, utilizing a five-fold cross-validation strategy with a 90% training and 10% validation split. Additionally, a holdout test set from an external hospital was employed to assess the models' robustness in external validation.ResultsAmong 1244 patients, 112 (9.0%) suffered from AL. The Random Forest model showed an AUC-ROC of 0.78 (SD: ± 0.01) on the internal test set, which significantly decreased to 0.60 (SD: ± 0.05) on the external holdout test set comprising 198 patients, including 7 (3.5%) with AL. Conversely, the Logistic Regression model demonstrated more consistent AUC-ROC values of 0.69 (SD: ± 0.01) on the internal set and 0.61 (SD: ± 0.05) on the external set. Accuracy measures for Random Forest were 0.82 (SD: ± 0.04) internally and 0.87 (SD: ± 0.08) externally, while Logistic Regression achieved accuracies of 0.81 (SD: ± 0.10) and 0.88 (SD: ± 0.15). F1 Scores for Random Forest moved from 0.58 (SD: ± 0.03) internally to 0.51 (SD: ± 0.03) externally, with Logistic Regression maintaining more stable scores of 0.53 (SD: ± 0.04) and 0.51 (SD: ± 0.02).ConclusionIn this pilot study, we evaluated ML-based prediction models for AL post-colorectal surgery and identified ten patient-related risk factors associated with AL. Highlighting the need for multicenter data, external validation, and larger sample sizes, our findings emphasize the potential of ML in enhancing surgical outcomes and inform future development of a web-based application for broader clinical use.

A prospective single-center, single-arm, open-label, phase II study of sintilimab and anlotinib combined with chemotherapy in neoadjuvant treatment of resectable esophageal cancer.

Antiangiogenic treatment and immunochemotherapy effectively treat patients with advanced esophageal cancer. However, there remains a dearth of studies concerning neoadjuvant therapy for resectable esophageal cancer. The study focused on patients with T2-4NxM0 resectable esophageal carcinoma. Neoadjuvant treatment involved administering anlotinib (10 mg orally, once a day, 2 weeks on and 1 week off) for antiangiogenesis and sintilimab (200 mg) and chemotherapy for three cycles. Surgical treatment was performed 4-6 weeks after the last chemotherapy cycle was completed. The primary endpoints assessed were pathological complete response (pCR) and safety. Out of the 34 screened patients, 17 were successfully enrolled in the study, and 14 completed the entire treatment process. The pCR was 35.3% (6/17). However, two patients experienced mortality. The occurring rate of grade 3 or higher complications after the surgery was 78.6% (11/14) according to Clavien-Dindo classification. Specifically, anastomotic leakage was observed in 57.1% (8/14) of the patients. Compared to neoadjuvant chemotherapy, the current regimen demonstrated improved pCR. However, it did not show significant improvement compared to immunochemotherapy. It is essential to exercise caution when using this treatment approach in patients with esophageal cancer as it might increase postoperative complications, especially anastomotic leakage.

Complications Rate and Related Factors After Laparoscopic Sphincter-Preserving Total Mesorectal Excision for Low Rectal Cancer: A Single-Center Study in Vietnam.

Colorectal cancer is a significant health concern. Surgery remains a critical component of the multimodal treatment strategy. The laparoscopic sphincter-preserving total mesorectal excision (TME) is increasingly utilized and effective, offering enhanced quality of life for patients compared to previous traditional methods. This study aims to determine the rate of complications and the related factors associated with complications following laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer. This retrospective study was conducted at the University Medical Center of Ho Chi Minh City from March 2022 to March 2023. It included patients aged 18 years and older diagnosed with low rectal cancer who underwent laparoscopic sphincter-preserving total mesorectal excision. Data on patient demographics, surgical details, and postoperative complications were retrospectively collected and analyzed. Follow-ups were conducted up to six months after surgery. Of the 83 patients included, the postoperative complications rate was 14.5%. The complications observed included surgical wound infections (five cases), anastomotic leaks (five cases, including three recto-vaginal fistulas and two pelvic abscesses), urinary retention (one case), and pneumonia (one case). A significant finding was the higher rate of distant metastases in patients with complications compared to those without (p=0.033). Laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer is safe and effective, with a high success rate and low complication rate during or after surgery. Anastomotic leakage remains the most significant complication. Despite advancements in surgery, modern suturing tools, and preoperative patient optimization, complications are avoidable. Therefore, understanding the related factors and implementing preventive interventions is crucial.

Intraoperative left-sided colorectal anastomotic testing in clinical practice: a multi-treatment machine-learning analysis of the iCral3 prospective cohort.

Current evidence about intraoperative anastomotic testing after left-sided colorectal resections is still controversial. The aim of this study was to analyze the impact of Indocyanine Green fluorescent angiography (ICG-FA) and air-leak test (ALT) over standard assessment on anastomotic leakage (AL) rates according to surgeon's perception of anastomosis perfusion and/or integrity in clinical practice. A database of 2061 patients who underwent left-sided colorectal resections was selected from patients enrolled in a prospective multicenter study. It was retrospectively analyzed through a multi-treatment machine-learning model considering standard visual assessment (NW; No. = 899; 43.6%) as the reference treatment arm, compared to ICG-FA alone (WP; No. = 409; 19.8%), ALT alone (WI; No. = 420; 20.4%) or both (WPI; No. = 333; 16.2%). Twenty-four covariates potentially affecting the outcomes were included and balanced into the model within the subgroups. The primary endpoint was AL, the secondary endpoints were overall morbidity (OM), major morbidity (MM), reoperation for AL, and mortality. All the results were reported as odds ratio (OR) with 95% confidence intervals (95%CI). The WPI subgroup showed significantly higher AL risk (OR 1.91; 95% CI 1.02-3.59; p 0.043), MM risk (OR 2.35; 95% CI 1.39-3.97; p 0.001), and reoperation for AL risk (OR 2.44; 95% CI 1.12-5.31; p 0.025). No other significant differences were recorded. This study showed that the surgeons' perception of both anastomotic perfusion and integrity (WPI subgroup) was associated to a significantly higher risk of AL and related morbidity, notwithstanding the extensive use of both ICG-FA and ALT testing.

Short-term outcomes of robotic tumor-specific mesorectal resection of rectal cancer: surgical techniques in mesorectal division using rolling division of the mesorectum.

This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division of the mesorectum, and to elucidate short-term outcomes at a single institution. Tumor-specific mesorectal excision (TSME) is commonly performed for resection of a tumor located in the upper rectum. However, especially in a narrow pelvis, it is difficult to perform appropriate mesorectal division at an adequate distance from the tumor in robot-assisted laparoscopic anterior resection. Retrospective case series of patients with rectal cancer who underwent robot-assisted TSME using rolling division of mesorectum. Patient characteristics, perioperative clinical results, surgical and pathological details were recorded. A total of 198 patients underwent robot-assisted TSME for rectal cancer using rolling division of mesorectum between May 2019 and December 2023.The tumor was located in the upper rectum in 45 patients, middle rectum in 115 patients and lower rectum in 38 patients. The types of resections were 40 high anterior resection and 158 low anterior resections. The median operation time was 175 (range 109-310) min, and median mesorectal division time was 24 (range 15-45) min. Median blood loss was 3 (range 0-20) ml; no patients required blood transfusion. The overall complication rate of Clavien-Dindo classification grades I-IV was 7.1%. Anastomotic leakage was observed in two patients (1.0%) with grade III. There was no surgical mortality in this series. This robotic technique for anterior resection is a feasible and reliable procedure for achieving sufficient and safe TSME in this cohort.

Thoracoscopic external traction suture elongation for the management of long-gap oesophageal atresia: a two-centre experience.

Van der Zee (VdZ) described a technique to elongate the oesophagus in long-gap oesophageal atresia (LGOA) by thoracoscopic placement of external traction sutures (TPETS). Here, we describe our experience of using this technique. Retrospective review of all LGOA + / - distal tracheo-oesophageal fistula (dTOF) cases where TPETS was used in our institutions. Data are given as medians (IQR). From 01/05/2019 to 01/03/2023, ten LGOA patients were treated by the VdZ technique. Five had oesophageal atresia (Gross type A or B, Group 1) and five had OA with a dTOF (type C, Group 2) but with a long gap precluding primary anastomosis. Age of first traction procedure was Group 1 = 53 (29-55) days and Group 2 = 3 (1-49) days. Median number of traction procedures = 3; time between first procedure and final anastomosis was 6days (4-7). Four cases were converted to thoracotomy at the third procedure. Three had anastomotic leaks managed conservatively. Follow-up was 12-52months. All patients achieved oesophageal continuity and were orally fed; no patient required an oesophagostomy. In this series, TPETS in LGOA facilitated delayed primary anastomoses and replicated the good results previously described but, in addition, was successful in cases with dTOF. We believe traction suture placement and tensioning benefit from being performed thoracoscopically because of excellent visualisation and the fact that the tension does not change when the chest is closed. Surgical and anaesthetic planning and expertise are crucial. It is now our management of choice in OA patients with a long gap with or without a distal TOF.

The economic impact of anastomotic leakage after colorectal surgery: a systematic review

BackgroundAnastomotic leakage (AL) remains a burdensome complication following colorectal surgery, with increased morbidity, oncological compromise, and mortality. AL may impose a substantial financial burden on hospitals and society due to extensive resource utilization. Estimated costs associated with AL are important when exploring preventive measures and treatment strategies. The purpose of this study was to systematically review the existing literature on (socio)economic costs associated with AL after colorectal surgery, appraise their quality, compare reported outcomes, and identify knowledge gaps.MethodsHealth economic evaluations reporting costs related to AL after colorectal surgery were identified through searching multiple online databases until June 2023. Pairs of reviewers independently evaluated the quality using an adapted version of the Consensus on Health Economic Criteria list. Extracted costs were converted to 2022 euros (€) and also adjusted for purchasing power disparities among countries.ResultsFrom 1980 unique abstracts, 59 full-text publications were assessed for eligibility, and 17 studies were included in the review. The incremental costs of AL after correcting for purchasing power disparity ranged from €2250 (+39.9%, Romania) to €83,633 (+ 513.1%, Brazil). Incremental costs were mainly driven by hospital (re)admission, intensive care stay, and reinterventions. Only one study estimated the economic societal burden of AL between €1.9 and €6.1 million.ConclusionsAL imposes a significant financial burden on hospitals and social care systems. The magnitude of costs varies greatly across countries and data on the societal burden and non-medical costs are scarce. Adherence to international reporting standards is essential to understand international disparities and to externally validate reported cost estimates.

Biological therapy of bariatric surgery complications

In recent years, the number of performed bariatric interventions has increased significantly. Despite the high effectiveness of this method of treatment, the occurrence of complications is not uncommon. The most common complications are stapler line leaks, occurring in 1.5–2.4% of cases; anastomotic leakage after One Anastomosis Gastric Bypass – in 2.2–8% of cases. The problem with all methods is the increased duration of treatment and the need to go without food for significant periods of time, which means starting parenteral nutrition and risking malnutrition. The article demonstrates the effectiveness of biological therapy for complications of bariatric surgery in a series of clinical cases. Clinical cases of 2 patients with anastomotic leakage after One Anastomosis Gastric Bypass are described; also 2 patients with incompetent staple line after laparoscopic Sleeve Gastrectomy. PRP therapy, stromal vascular fraction (SVF) and fibrin glue were used. Platelet-rich plasma is an autologous blood serum containing high concentrations of platelets and growth factors. As a result, after 4 courses of PRP therapy, the patient with the failure of the upper third of the stapler line received an application of twocomponent fibrin glue “Kriofit” with a positive effect. In addition, positive dynamics was observed in the patient with the use of threecomponent therapy of anastomotic leakage. Based on the above facts, it can be concluded, that biological therapy demonstrates great potential value in the treatment of bariatric surgery complications such as stapler line leaks, and anastomotic leakage.

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.

Reconstruction Techniques and Associated Morbidity after Minimally Invasive Gastrectomy for Cancer – Insights from the GastroBenchmark and GASTRODATA databases

Abstract Background Various anastomotic and reconstruction techniques are used to restore intestinal continuity after minimally invasive total (TG) and subtotal distal gastrectomy (DG). Aims Their effects on anastomotic leakage and postoperative morbidity have not been extensively studied. Methods Patients after minimally invasive TG and DG were selected from a cohort of 9356 oncological gastrectomies performed between 2017-2021 in 44 specialized centers. Results Three anastomotic techniques (circular stapled (CS, 3.7%); linear stapled (LS, 93.8%); hand sewn (HS, 2.5%)) and three types of bowel reconstruction (Roux (RX, 51.5%); Billroth I (BI, 23.1%); Billroth II (BII, 25.4%)) were identified after TG (n=878) and DG (n=3334). Postoperative morbidity was higher after TG compared to DG (AL 5.2% vs. 1.1%, p≤0.001; 90-day mortality 1.6% vs. 0.4%, p≤0.001; overall morbidity 28.6% vs. 16.3%, p≤0.001; major morbidity 15.4% vs. 8.0%, p≤0.001). Anastomotic leakage rate in the TG cohort was higher after CS (13.1%) and HS (7.9%) than after LS anastomoses (1.9%, p<0.001). Similarly, overall (CS: 43.9%, HS: 28.6%, LS: 23.1%) and major complications rates (CS: 25.2%, HS: 11.1%, LS: 12.0%) as well as mortality (CS: 4.7%, HS: 2.2%, LS: 0.8%) were higher after CS. Multivariate analysis confirmed anastomotic technique as a predictive factor for anastomotic leakage (Fig. 1), but not for occurrence of mortality, overall and major complications. In the DG cohort, most (98.7%), outcomes were similar for all types of bowel reconstruction: Anastomotic leakage (BI: 1.4%, BII 0.8%, RX 1.2%, p=0.440), 90-day mortality (BI: 0%, BII 0.1%, RY: 1.1%%, p=0.109), overall (BI: 14.5%, BII: 15.0%, RX: 18.7%, p=0.208) and major morbidity (BI: 7.9%, BII: 9.1%, RX: 7.2%, p=0.219). Conclusion In suitable situations, DG should be preferred to TG, as postoperative morbidity is significantly lower. In addition, LS should be the preferred method of anastomosis after TG. Conversely, the techniques for bowel reconstruction can be chosen according to the surgeon's preference.

Randomised Controlled Pilot Trial on GHOST Ileostomy versus Conventional Loop Ileostomy in Patients Undergoing low Anterior Resection for Rectal Cancer

Abstract Background Anastomotic leakage is the most important complication after colorectal surgery. In patients undergoing low anterior resection with total mesorectal excision (LAR/TME) a loop ileostomy is fashioned to protect the low anastomosis. Ghost ileostomy is a pre-stage ileostomy, which can be converted to a diverting ileostomy, if anastomotic leakage is suspected. If there are no signs of anastomotic leakage an actual ileostomy can be avoided. Aims The objective was to evaluate whether ghost ileostomy is a safe alternative to a conventional loop ileostomy. Methods GHOST was a randomised controlled pilot trial without formal hypothesis. Patients undergoing LAR/TME for rectal cancer were intraoperatively randomised to receive a ghost ileostomy or loop ileostomy. Patients were followed prospectively for 6 months. Comprehensive complication index, transformation of ghost ileostomy into loop ileostomy, presence of an ostomy at 6 months, Wexner score and quality of life were assessed. Results Thirty patients were equally randomised. The CCI was 30.7 (± 17.7) in the ghost ileostomy group compared to 29.7 (± 18.6) in the loop ileostomy group at 6 months (p=0.889). The ghost ileostomy was converted into a loop ileostomy in 6 of 15 (40.0%) patients. At 6 months after low anterior resection, 6 (40.0%) patients in the ghost ileostomy group and 7 (46.7%) patients in the ileostomy group still had an ileostomy. There was no mortality and no need for creation of a terminal ostomy within the trial. Neither postoperative function assessed by the Wexner score, nor the overall quality of life showed significant differences. Conclusion Ghost ileostomy seems to be a viable and safe option to a more selective approach regarding creation of an ileostomy in patients undergoing LAR/TME. However, the difficult patient selection with exclusion of patients at high risk of anastomotic leakage limits its widespread application and should be optimised in future trials.

Technical feasibility and oncological outcomes of robotic esophagectomy compared with conventional thoracoscopic esophagectomy for clinical T3 or T4 locally advanced esophageal cancer: a propensity-matched analysis.

Minimally invasive esophagectomy is the first-line approach for esophageal cancer; however, there has recently been a paradigm shift toward robotic esophagectomy (RE). We investigated the clinical outcomes of patients who underwent RE compared with those of patients who underwent conventional minimally invasive thoracoscopic esophagectomy (TE) for locally advanced cT3 or cT4 esophageal cancer using a propensity-matched analysis. Overall, 342 patients with locally advanced cT3 or cT4 esophageal cancer underwent transthoracic esophagectomy with total mediastinal lymph node dissection between 2018 and 2022. The propensity-matched analysis was performed to assign the patients to either RE or TE by covariates of histological type, tumor location, and clinical N factor. Overall, 87 patients were recruited in each of the RE and TE groups according to the propensity-matched analysis. The total complication rate and the rates of the three major complications (recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia) were not significantly different between the RE and TE groups. However, the peak C-reactive protein concentration on postoperative day 3, rate of surgical site infection, and intensive care unit length of stay after surgery were significantly shorter in the RE group than in the TE group. No significant differences were observed in the harvested total and mediastinal lymph nodes. The total operation time was significantly longer in the RE group, while the thoracic operation time was shorter in the RE group than in the TE group. There was no significant difference between the two groups in the recurrence rate of oncological outcomes after surgery. RE may facilitate early recovery after esophagectomy with total mediastinal lymph node dissection and has the same technical feasibility and oncological outcomes as TE.

Low rectal resection for low rectal endometriosis and rectal adenocarcinoma: Are we discussing the same risks?

To evaluate the rate and risk factors for anastomosis leakage in patients undergoing colorectal resection with low anastomosis for rectal endometriosis and rectal adenocarcinoma. A retrospective cohort study evaluating prospectively collected data was conducted. Patients undergoing colorectal resection for rectal endometriosis and rectal adenocarcinoma with low anastomosis (<7 cm from the anal verge [AV]) from September 2018 to January 2023 were included in the analysis. The main outcome was the rate of anastomosis leakage. A multivariate logistic regression was conducted to evaluate risk factors for anastomosis leakage in both groups. A total of 159 patients underwent colorectal resection with low anastomosis due to rectal endometriosis (n = 99) and rectal adenocarcinoma (n = 60). Patients with endometriosis were significantly younger than those with adenocarcinoma (35.7 ± 5.1 vs 63.7 ± 12.6; P = 0.001). The leakage rate was similar between the endometriosis (n = 12, 12.1%) and adenocarcinoma (n = 9, 15.0%) patients (P = 0.621). The anastomosis height less than 5 cm from the AV (adjusted odds ratio [aOR] 12.12, 95% confidence interval [CI] 2.24-23.54) was significantly associated with the anastomosis leakage. Protective stoma was associated with the decrease of the leakage risk (aOR 0.12, 95% CI 0.01-0.72). The type of disease (rectal endometriosis or adenocarcinoma) was not associated with the anastomosis leakage (aOR 2.87, 95% CI 0.34-21.23). Despite the different pathogenesis, the risk of anastomotic leakage was found to be similar between patients with low rectal endometriosis and those with rectal adenocarcinoma. These results must be considered by the gynecologist and colorectal surgeon to deliver proper information before rectal surgery for endometriosis.

Evaluation of the blood flow in reconstructed gastric tube and its relation to anastomosis leakage

ObjectivesAnastomotic leakage in esophageal cancer surgery may be reduced by evaluating the blood flow to the reconstructed organ, but quantitative evaluation of arterial and venous blood flow is difficult. This study aimed to quantitatively assess blood flow using a new technique, as well as determine the relationship between the blood flow in the gastric tube and anastomotic leakage using near-infrared spectroscopy.MethodsThis single-center, observational study included 50 patients aged 51–82 years who underwent radical esophagectomy with gastric tube reconstruction for esophageal cancer between June 2022 and January 2023. Regional tissue oxygen saturation was measured at the antrum (point X), the anastomotic point (point Z), and the midpoint between points X and Z (point Y) before and after gastric tube formation. These three points of oxygen saturation were investigated in relation to anastomotic leakage.ResultsWhen comparing the presence of leakage to its absence, regional tissue oxygen saturation at points X and Z after gastric tube formation was significantly lower (X: p = 0.03, Z: p = 0.02), with the decreasing rate significantly higher at point Z (p = 0.01). There was no significant difference in the decreasing rate of regional tissue oxygen saturation between points X and Y (X: p = 0.052, Y: p = 0.83).ConclusionRegional tissue oxygen saturation levels may be useful for measuring blood flow and could be a predictor of anastomotic leakage.

Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10year experience from a Nordic center.

Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55days vs. 29.5days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.