Incidence Of Anastomotic Leakage Research Articles

Trends in risk factors of anastomotic leakage after colorectal cancer surgery (2011-2019), a Dutch population based study

Background: Anastomotic leakage (AL) after colon cancer (CC) and rectal cancer (RC) surgery often requires reintervention. Prevalence and morbidity may change over time with evolutions in treatment strategies and changes in patient characteristics. This nationwide study aimed to evaluate changes in the incidence, risk factors and mortality of AL during the past nine years.

Destructive colon injuries requiring resection: Is colostomy ever indicated?

The management of destructive colon injuries requiring resection has shifted from mandatory diverting stoma to liberal use of primary anastomosis. Various risk criteria have been suggested for the selection of patients for primary anastomosis or ostomy. At our center, we have been practicing a policy of liberal primary anastomosis irrespective of risk factors. The purpose of this study was to evaluate the colon-related outcomes in patients managed with this policy. This retrospective study included all colon injuries requiring resection. Data collected included patient demographics, injury characteristics, blood transfusions, operative findings, operations performed, complications, and mortality. A total of 287 colon injuries were identified, 101 of whom required resection, forming the study population. The majority (63.4%) were penetrating injuries. Furthermore, 16.8% were hypotensive on admission, 40.6% had moderate or severe fecal spillage, 35.6% received blood transfusion of >4 U, and 41.6% had Injury Severity Score of >15. At index operation, 88% were managed with primary anastomosis and 12% with colon discontinuity, and one patient had stoma. Damage-control laparotomy (DCL) with temporary abdominal closure was performed in 39.6% of patients. Of these patients with DCL, 67.5% underwent primary anastomosis, 30.0% were left with colon discontinuity, and 2.5% had stoma. Overall, after the definitive management of the colon, including those patients who were initially left in colon discontinuity, only six patients (5.9%) had a stoma. The incidence of anastomotic leaks in patients with primary anastomosis at the index operation was 8.0%, and there was no colon-related mortality. The incidence of colon anastomotic leaks in the 27 patients with DCL and primary anastomosis was 11.1%, and there was no colon-related mortality. Multivariate analysis evaluating possible risk factors identified discontinuity of the colon as independent risk factor for mortality. Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors. Therapeutic/Care Management; Level IV.

Effect of routine jejunostomy tube insertion in esophagectomy: A systematic review and meta-analysis

BackgroundRoutine feeding jejunostomy tube post esophagectomy is being revaluated because of its associated postoperative complications. We performed a systematic review and meta-analysis to evaluate the effect of routine feeding jejunostomy tube insertion on mortality and postesophagectomy outcomes. MethodsElectronic databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) were queried through December 2020. Included studies compared esophagectomy with and without postoperative feeding jejunostomy. The primary outcome was 30-day mortality. Secondary outcomes included readmission rate, length of stay, postoperative complications (sepsis, pneumonia, chyle leakage, and anastomotic leakage), and duration of surgery. Random effects pairwise meta-analysis was used to compare groups, and the risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. ResultsThe meta-analyses of 12 studies (2 randomized controlled trials, 10 observational) that enrolled 36,284 participants showed lower 30-day all-cause mortality in the jejunostomy tube group (risk ratio [RR] = 1.53 [95% CI, 1.37-1.70], P < .01; I2 = 0%, P = .80). Duration of surgery favored the no jejunostomy group (mean difference = −37.18; 95% CI, −59.48 to −14.87; P < .01). However, the 2 groups were not different in incidence of anastomotic leakage (RR = 0.88; 95% CI, 0.61-1.28; P = .50), length of stay (mean difference = −0.22; 95% CI, −1.34-0.89; P = .69), readmission (RR = 0.97; 95% CI, 0.92-1.02; P = .20), chyle leakage (RR = 1.05; 95% CI, 0.34-3.27; P = .94), sepsis (RR = 1.20; 95% CI, 0.96-1.50; P = .11), pneumonia (RR = 0.88; 95% CI, 0.75-1.03; P = .11). ConclusionsFeeding jejunostomy tube after esophagectomy might lead to lower 30-day all-cause mortality with no difference in common postesophagectomy complications. A routine insertion of a jejunostomy tube should be considered at the time of surgery for esophageal cancer resection.

Risk Factors for Anastomotic Leakage Following Total or Subtotal Colectomy

Abstract Introduction A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. The main aim of the present study was to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of AL was 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p = 0.038), in the elective-laparoscopic approach subgroup (p = 0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p = 0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgery may improve short-term outcomes.

Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015–2018 MBSAQIP

Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported. Using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics. 75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049). Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis.

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised?

BackgroundMost ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. MethodsSingle-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. ResultsThe study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. ConclusionTransanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.

Effects of Neoadjuvant Radiotherapy on Postoperative Complications in Rectal Cancer: A Meta-Analysis.

Objective Neoadjuvant radiotherapy (nRT) is an important treatment approach for rectal cancer. The relationship, however, between nRT and postoperative complications is still controversial. Here, we conducted a meta-analysis to evaluate such concerns. Methods The electronic literature from 1983 to 2021 was searched in PubMed, Embase, and Web of Science. Postoperative complications after nRT were included in the meta-analysis. The pooled odds ratio (OR) was calculated by the random-effects model. Statistical analysis was conducted by Review Manager 5.3 and STATA 14. Results A total of 23,723 patients from 49 studies were included in the meta-analysis. The pooled results showed that nRT increased the risk of anastomotic leakage (AL) compared to upfront surgery (OR = 1.23; 95% CI, 1.07–1.41; p=0.004). Subgroup analysis suggested that both long-course (OR = 1.20, 95% CI 1.03–1.40; p=0.02) and short-course radiotherapy (OR = 1.25, 95% CI, 1.02–1.53; p=0.04) increased the incidence of AL. In addition, nRT was the main risk factor for wound infection and pelvic abscess. The pooled data in randomized controlled trials, however, indicated that nRT was not associated with AL (OR = 1.01; 95% CI 0.82–1.26; p=0.91). Conclusions nRT may increase the risk of AL, wound infection, and pelvic abscess compared to upfront surgery among patients with rectal cancer.

Machine Learning-based Correlation Study between Perioperative Immunonutritional Index and Postoperative Anastomotic Leakage in Patients with Gastric Cancer

Backgrounds: The immunonutritional index showed great potential for predicting postoperative complications in various malignant diseases, while risk assessment based on machine learning (ML) methods is becoming popular in clinical practice. Early detection and prevention for postoperative anastomotic leakage (AL) play an important role in prognosis improvement among patients with gastric cancer (GC).Methods: This retrospective study included 297 patients with gastric cancer receiving gastrectomy between 2018 and 2021 in general surgery department of Xinhua Hospital. Perioperative clinical variables were collected to evaluate the predictive value for postoperative AL with 5 ML models. Then, AUROC was applied to identify the optimal perioperative clinical index and ML model for predicting postoperative AL.Results: The incidence of postoperative AL was 6.1% (n=18). After the training of 5 ML classification models, we found that immunonutritional index had significantly better classification ability than inflammatory or nutritional index alone separately (AUROC=0.87 vs. 0.83, P=0.01; AUROC=0.87 vs. 0.68, P<0.01). Next, we found that support vector machine (SVM), one of the ML methods, with selected immunonutritional index showed significantly greater classification ability than optimal univariant parameter [CRP on postoperative day 4 (AUROC=0.89 vs.0.86, P=0.02)]. Also, statistical analysis revealed multiple variables with significant relevance to postoperative AL, including serum CRP and albumin on postoperative day 4, NLR and SII etc.Conclusion: This study showed that perioperative immunonutritional index could act as an indicator for postoperative AL. Also, ML methods could significantly enhance the classification ability, and therefore, could be applied as a powerful tool for postoperative risk assessment for patients with GC.

Intracorporeal reinforcing sutures reduce anastomotic leakage in double-stapling anastomosis for laparoscopic rectal surgery.

IntroductionIn rectal surgery, double-stapled anastomosis is one of the most common techniques. However, the crossing of the staple line is considered a weakness of this method and could lead to anastomotic leakage (AL), which is one of the major complications of rectal cancer surgery.AimTo investigate the usefulness of laparoscopic intracorporeal reinforcement suturing for preventing AL in laparoscopic rectal surgery.Material and methodsA total of 153 patients with rectal cancer underwent laparoscopic rectal resection with anastomosis using the double-stapling technique between January 2015 and December 2018. Patient characteristics, surgical data, and outcomes were recorded and retrospectively analysed. Patients who received intracorporeal reinforcing sutures (n = 72) were compared with those who did not receive the reinforcing sutures (n = 81).ResultsAL was observed in 11 (7.2%) cases overall and in only 1 case in the group with intracorporeal reinforcing sutures. There were no associations between clinicopathological factors and the use of reinforcing sutures. Multivariate analysis revealed that a distance from the anal verge of less than 6.5 cm, diabetes mellitus, and the non-use of reinforcing sutures were independent risk factors for AL.ConclusionsLaparoscopic intracorporeal reinforcing sutures reduced the incidence of AL. Therefore, laparoscopic reinforcing sutures for double-stapled anastomoses seem useful for the prevention of AL.

Neoadjuvant chemoradiotherapy, chemotherapy, and radiotherapy do not significantly increase the incidence of anastomotic leakage after esophageal cancer surgery: a meta-analysis.

This study investigated whether neoadjuvant therapies, such as neoadjuvant chemoradiotherapy (NCRT), neoadjuvant chemotherapy (NCT), and neoadjuvant radiotherapy (NRT), would affect the incidence of anastomotic leakage (AL) after esophageal cancer surgery. Published randomized controlled trials were reviewed, and the incidence of AL after esophageal cancer was statistically analyzed in each study. Meta-analysis was performed using Revman and Stata software. A total of 17 randomized controlled trials with 2874 patients were reviewed showing that, in general, preoperative neoadjuvant therapies were not significant risk factors for AL after esophageal cancer surgery (relative risk [RR] = 0.82, 95% CI = 0.64-1.04). NCRT and NRT did not significantly increase the risk of postoperative AL in patients with esophageal cancer (RR = 0.81, 95% CI = 0.63-1.05; RR = 0.64, 95% CI = 0.14-2.97, respectively). Moreover, NCT has no significant correlation with the occurrence of AL (RR = 1.01, 95% CI = 0.57-1.80). NCRT, NCT, and NRT do not significantly increase the incidence of gastroesophageal AL after esophageal cancer surgery.

Effect of peritoneum reconstruction on postoperative complications after laparoscopic low anterior resection for rectal cancer

Objective: To determine the effect of peritoneum reconstruction on postoperative complications after laparoscopic low anterior resection (LAR) for rectal cancer. Methods: Retrospective cohort study and propensity score matching were conducted. Case inclusion criteria: (1) pathologically confirmed rectal adenocarcinoma; (2) 18 to 80 years; (3) patients with middle to low rectal cancer undergoing laparoscopic LAR; (4) patients staging cT1-4aN0-2M0 or ycT1-4aN0-2M0 after neoadjuvant therapy; (5) the distance of 4-10 cm from tumor low margin to anal verge. Exclusion criteria: (1) abdominal surgery history (except appendicitis, cholecystitis, ectopic pregnancy); (2) anastomosis above the peritoneal reflection; (3) tumor distant metastasis or clinical staging of T4b during surgery; (4) conversion to open surgery; (5) severe incapacitating disease (American Society of Anesthesiologists classification IV or V, ASA). A total of 666 patients with middle to low rectal cancer undergoing laparoscopic LAR in The First Affiliated Hospital of Army Medical University from January 2017 to June 2020 were enrolled. There were 473 males and 193 females with the median age of 59 (18-80) years. Laparoscopic LAR with peritoneum reconstruction was performed in 188 cases (PR group), and laparoscopic LAR without peritoneum reconstruction was performed in 478 cases (NPR group). After 1:1 propensity score matching according to 1:1 based on age, gender, body mass index, TNM staging, ASA classification, intraoperative blood loss, distance from tumor low margin to anal edge, 153 cases were included in each group. Postoperative complications were classified according to Clavien-Dindo classification. Anastomotic leakage was defined and graded according to the International Study Group of Rectal Cancer (ISGRC) criteria. Results: After propensity score matching, there were no significant differences in baseline demographic characteristics between the 2 groups (all P>0.05), indicating that these two groups were comparable. (1) Operative conditions: All the patients in both groups completed operation successfully. Compared with the NPR group, the PR group had longer operation time [(181.3±60.3) minutes vs. (168.9±51.5) minutes, t=2.185, P=0.029], shorter postoperative median hospital stay [8 (7, 10) days vs. 9 (7, 11) days, Z=-2.282, P=0.022], and the differences were statistically significant (P<0.05). (2) Postoperative complications: The overall morbidity of postoperative complication in PR group and NPR group was 20.3% (31/153) and 24.2% (37/153) respectively, and the incidence of anastomotic leakage was 9.8% (15/153) and 11.1%(17/153) respectively, whose differences were not statistically significant (both P>0.05). Compared with NPR group, PR group had lower morbidity of grade III to IV complications [3.9% (6/153) vs. 11.1% (17/153), χ(2)=5.688, P=0.017] and lower secondary operation rate [1.3% (2/153) vs. 5.9% (9/153), χ(2)=4.621, P=0.032], the differences were statistically significant (both P<0.05). Though PR group had lower incidence of grade C anastomoic leakage [1.3% (2/153) vs. 3.9% (6/153), χ(2)=2.054, P=0.152], but the differences were not statistically significant. (3) Postoperative inflammation: The difference of the procalcitonin level of both PR and NPR groups at postoperative 1-d, 3-d, and 5-d was statistically significant (F=5.222, P=0.010) in time-dependent manner, while the difference was not significant in the interaction effect (P>0.05). No statistically significant differences in the C-reactive protein level between two groups at postoperative 1-d, 3-d, and 5-d were found (all P>0.05). Conclusion: Peritoneum reconstruction in laparoscopic LAR can decrease the morbidity of postoperative complication of grade III to IV and the reoperation rate, and plays an important role in controlling the inflammatory reaction, which has great clinical value.

Efficacy of side-to-end anastomosis to prevent anastomotic leakage after anterior resection for rectal cancer.

The present study aimed to investigate whether side-to-end anastomosis could provide an improved surgical outcome, such as lower anastomotic leakage rate, compared with end-to-end anastomosis, following anterior resection for rectal and rectosigmoid cancer. This retrospective study included 162 patients with rectal cancer who underwent elective anterior resection between January 2012 and October 2019 at a single institution. Patients with double cancers or colonic J-pouch were excluded. Anastomotic leakage was defined clinically and radiologically. Side-to-end anastomosis was introduced in the International University of Health and Welfare Mita Hospital in January 2017. Side-to-end anastomosis was performed in 63 patients, while end-to-end anastomosis was performed in 99 patients. Tumors tended to be located lower in the rectum in the side-to-end anastomosis group than in the end-to-end anastomosis group. No significant differences were observed in other patient characteristics. The incidence of anastomotic leakage was significantly lower in the side-to-end anastomosis group than in the end-to-end anastomosis group (3/63, 4.8% vs. 18/99, 18.2%, respectively, P=0.02). No significant differences were observed in the incidence rates of other complications. Univariate and multivariate analyses revealed that a smoking habit (P=0.04) and side-to-end anastomosis (P=0.02) were significantly associated with anastomotic leakage. In conclusion, side-to-end anastomosis using a double-stapling technique following anterior resection for rectal cancer may prevent anastomotic leakage.

Safety analysis of definitive surgery for chronic radiation intestinal injury

Objective: To investigate the safety of definitive surgery for chronic radiation intestinal injury. Methods: A descriptive case series study was performed. Clinical data of 105 patients who were diagnosed as chronic radiation intestinal injury, had complete data and received definitive surgery (the radiation-induced intestinal segment and digestive tract reconstruction) at Department of Gastrointestinal Surgery of Beijing Tsinghua Changgung Hospital from June 2016 to May 2020 were retrospectively analyzed. There were 30 males (28.6%) and 75 females (71.4%) with the median age of 58 years (P25, P75: 52, 64 years). Patients who had tumor recurrence or refused surgical treatment were excluded. According to the preoperative evaluation and clinical manifestations, to select the resection range. Outcome parameters: (1) preoperative evaluation (nutrition risk assessment and status of obstruction or fistula); (2) clinical manifestations and treatment strategies; (3) details of surgical parameters; (4) postoperative complications, and Clavien-Dindo classification III to V was defined as main moderate-severe complication. Results: (1) Preoperative evaluation: Eighty-eight patients (83.8%) developed symptoms of chronic radiation intestinal injury more than 1 year after the end of radiotherapy. Ninety-eight patients (93.3%) had preoperative NRS-2002 score ≥3, 74 patients (70.5%) received preoperative parenteral nutritional support, and the median time of nutritional support was 10.5 (7.0, 16.0) days. Sixteen patients (15.2%) received small intestinal decompression tube implantation due to severe obstruction. (2) Clinical manifestations and treatment strategies: Among 105 patients, 87 (82.9%) presented with obstruction and received definitive resection of the radiation-induced intestinal segment plus one-stage digestive tract reconstruction; 18 (17.1%) presented with intestinal fistula and all of them received definitive resection of the radiation-induced intestinal segment, intestinal fistula plus one-stage digestive tract reconstruction. Among above 18 patients with fistula, 3 patients with ileorectal stump fistula received pedicled pelvic closure of greater omentum at the same time; 4 patients had ileal vesical fistula, of whom 2 patients received cystectomy and bladder repair due to preoperative nephrostomy decompression, and the other 2 patients received transection of the small intestine proximal and distal to the fistula and anastomosis of the intestinal loop without fistula resection, intestinal fistula or bladder fistula repair. (3) The details of surgical parameters: Median operative time and intraoperative blood loss was 230 (180, 300) minutes and 50 (20, 50) ml respectively. Ninety-two patients (92/105, 87.6%) underwent ileocolonic anastomosis, and anastomosis on the hepatic flexure or splenic flexure colon were performed in 88 (83.8%) and 4 (3.8%) patients respectively. Ileoileal anastomosis was performed in 13 patients (12.4%). The anastomotic site of 92 patients (87.6%) was strictly located in the contralateral quadrant of the radiation field, and the anastomotic site of 13 patients (12.4%) was far from the radiation field. Nine patients (8.6%) had more than one anastomosis, 5 patients (4.8%) had less than 180 cm of residual small intestine, 7 patients (6.7%) underwent retrograde intestinal permutation, 4 patients (3.8%) underwent abdominal wall reconstruction surgery due to abdominal wall defects, and 87 patients (82.9%) had severe abdominal pelvic adhesions (grade 3-4 adhesions). Intraoperative complications occurred in 3 patients (2.9%), which were found in time and handled properly. The median postoperative hospital stay was 13.0 (12.0, 24.5) days, and all the patients had resumed oral feeding upon discharge. (4) Postoperative complications: Fourteen patients (13.3%) had 18 major complications (grade III to V). The incidence of postoperative anastomotic leakage was 5.7% (6/105), and the incidence of anastomotic leakage for ileocolon anastomosis and ileoileal anastomosis was 2.2% (2/92) and 4/13, respectively (χ(2)=17.29, P<0.001). The incidence of postoperative anastomotic leakage of intestinal fistula and intestinal obstruction was 3/18 and 3.4% (3/87), respectively (χ(2)=4.84, P=0.028). The mortality at 30 days after operation was 1.0% (1/105), after abdominal infection and septic shock caused by postoperative anastomotic leakage resulting in multiple organ failure. Conclusion: For chronic radiation intestinal injury patients with obstruction or fistula, definitive surgical treatment is feasible and safe with acceptable major complications.

Clinical comparison between thoracoscopic and thoracotomy repair of Gross type C esophageal atresia

BackgroundTo compare the clinical outcomes between thoracoscopic approach and thoracotomy surgery in patients with Gross type C Esophageal atresia (EA) and tracheoesophageal fistula (TEF).MethodsPatients with Gross type C EA/TEF who underwent surgery from January 2007 to January 2020 at Beijing Children’s Hospital were retrospectively analyzed. The patients were divided into two groups according to surgical approaches. The perioperative factors and postoperative complications were compared among the two groups.ResultsOne hundred and ninety patients (132 boys and 58 girls) with a median birth weight of 2975 (2600, 3200) g were included. The primary operations were performed via thoracoscopic (n = 62) and thoracotomy (n = 128) approach. After comparison of clinical characteristics between the two groups, we found that there were statistically significant differences in associated anomalies, method of fistula closure, duration of mechanical ventilation after surgery, feeding option before discharge, management of pneumothorax, and prognosis (all P < 0.05). To a certain extent, thoracoscopic surgery reduced the incidence of anastomotic leakage and increased the incidence of anastomotic stricture in this study. However, there were no statistically significant differences between the two groups in terms of operative time, postoperative pneumothorax, anastomotic leakage, anastomotic stricture, and recurrent tracheoesophageal fistula (all P > 0.05).ConclusionsThoracoscopy surgery for Gross type C EA/TEF is a safe and effective, minimally invasive technique with comparable operative time and incidence of postoperative complications.

Anastomosis oversewing technique to prevent leakage after oesophagectomy: a propensity score-matched analysis.

Oesophagogastric anastomosis is a core part of oesophagectomy, and anastomotic leakage is among its main concerns. We used the oversewing technique to reinforce the anastomosis created with a circular stapler. This study investigated the use of oversewing to reduce the incidence of anastomotic leakage without increasing morbidity. This study enrolled 1734 patients who underwent oesophagectomy for oesophageal cancer between April 2012 and December 2019. Using propensity score-matched analysis, the clinical results of postoperative complications were compared between anastomotic-oversewn and -unsewn oesophagectomies. Of the 1734 patients, 661 were included in the anastomotic-unsewn group and 661 in the anastomotic-oversewn group after propensity score matching. The clinical characteristics did not differ between the 2 groups, but the frequency of anastomotic leakage was significantly higher in the anastomotic-unsewn group than in the anastomotic-oversewn group (10.3% vs 4.7%, P < 0.001). Multivariable logistic analysis showed oversewn anastomosis and smoking history as the independent factors associated with anastomotic leakage (odds ratios, 0.399 and 2.383; P < 0.001 and P = 0.012, respectively). On the sub-group analysis, the relative risk for anastomotic leakage was significantly higher with unsewn than with oversewn anastomosis in patients <65 years old, those with American Association of Anesthesiologists score II, those who had middle segment oesophageal cancer and those who have undergone the McKeown approach and cervical anastomosis. Anastomosis oversewing technique may be a practical method to reduce anastomotic leakage, especially in younger patients and those who have undergone the McKeown approach and cervical anastomosis.

Anastomotic leakage and chronic presacral sinus after transanal total mesorectal excision (taTME) for rectal cancer: A comparative study to laparoscopic TME

BackgroundSeveral studies have shown that there are no significant differences in anastomotic leakage associated with Transanal total mesorectal excision (taTME) versus laparoscopic TME (lapTME) for rectal cancer; however, little is known about late anastomotic leakage, such as that primarily found in the chronic presacral sinus. We aimed to compare the occurrence of anastomotic leakage and chronic presacral sinus in rectal cancer for taTME and lapTME. MethodsIn this retrospective cohort study, data were collected for patients with rectal cancer who underwent surgery between January 2009 and September 2019. Of the 220 patients included in this study, 182 were in the lapTME group and 38 in the taTME group. We compared factors associated with anastomotic leakage and chronic presacral sinus formation between the two groups. A binary-logistic model was used to determine the risk factors for chronic presacral sinus. ResultsAnastomotic leakage occurred in six patients (15.8%) in the taTME group and 36 patients (19.7%) in the lapTME group. Chronic presacral sinus occurred in three patients (7.9%) in the taTME group and 15 patients (8.2%) in the lapTME group. There was no significant difference in anastomotic leakage or chronic presacral sinus between groups (P = 0.569 and P = 1.000, respectively). Pathologic stage III or higher was significantly associated with chronic presacral sinus formation (P = 0.006). ConclusionThere were no significant differences between taTME and lapTME regarding the incidence of anastomotic leakage or chronic presacral sinus. Almost one-third of anastomotic leakages developed into chronic presacral sinus.

Fluorescent angiography in colorectal surgery, the influence of augmented reality in the operating room on the anastomotic leakage after low rectal resection

Near-infrared (NIR) fluorescence angiography (FA) is an augmented reality (AR) technique. When used in the operating room, it allows colorectal surgeons to visualize and evaluate intestinal blood flow in real time, identify lymph nodes, ureters, or peritoneal metastases. Evaluation of perfusion with FA in augmented reality mode has an impact on reducing the ALR (anastomotic leakage rate) in rectal resections. Data analysis of patients after minimally invasive surgery (MIS) for middle and lower rectal adenocarcinoma with total mesorectal excision (TME) using fluorescent angiography (FA) with indocyanine green (ICG) (100 patients, 20152019) were subsequently compared with a historical control group (100 patients) operated on for the same diagnosis before the introduction of the FA-ICG method (20122015) using minimally invasive approach (MIS). The patients were operated on consequently at one workplace. In fifteen patients (15%), the resection line was shifted due to insufficient perfusion detected by FA-ICG. The incidence of AL was lower in the group with FA compared to the group without FA (9% vs. 19%, p=0.042, &#967; test). A retrospective analysis of the group revealed a significant risk factor (RF) for the anastomotic leak, namely diabetes (p=0.036) and, among others, a protective factor, application of the transanal drain (NoCoil) (p=0.032). The introduction of new procedures and the use of new technologies, such as the use of the FA method in the AR mode in resections of the rectum with TME for cancer can lead to a reduction in the incidence of anastomotic leakage.

Clinical Efficacy of an Indwelling Transanal Tube for the Prevention of Anastomotic Leakage After Hirschsprung's Disease: A Single Center Experience with Chinese Patients.

Background: The aim of this study was to investigate the clinical effectiveness of an indwelling transanal tube for the prevention of anastomotic leakage (AL) after a radical operation for Hirschsprung's disease (HD). Methods: We retrospectively analyzed the clinical data from 158 patients who had undergone laparoscopic-assisted Soave procedures for HD at our hospital from May 2015 to May 2019. Patients were divided into two groups depending upon whether the anal drainage tube was retained or not retained: an indwelling group (group A, n = 86) and a no-indwelling group (group B, n = 72). Results: All 158 children had a successful operation by a laparoscopic technique. There was no significant difference in the duration of the operation, the length of the incision, the amount of bleeding, or the postoperative hospitalization time between the two groups. Compared with the no-indwelling group, maintaining the transanal tube had significant advantages for preventing incidences of AL (P < .05). The 4-year follow-up showed that the incidence of postoperative enterocolitis with the indwelling transanal tube was significantly lower than in the group without the drainage tube (P < .05). Conclusions: The laparoscopic-assisted Soave procedure with an indwelling transanal tube is a safe and feasible method for the treatment of HD in children. This method can not only drain intestinal contents but also reduce the occurrence of AL.

Active cycle of breathing technique may reduce pulmonary complications after esophagectomy: A randomized clinical trial.

BackgroundThe purpose of the study was to determine whether the active cycle of breathing technique (ACBT) has an impact on postoperative pulmonary complication (PPC) after esophagectomy.MethodsIn this prospective randomized trial, patients who were candidates for esophagectomy were randomized into groups, wherein they received either ACBT (n = 146) or conventional chest physiotherapy (control group, n = 145) on postoperative days (POD) 1–3. The primary outcome was PPC. The secondary outcomes included the incidence of anastomotic leakage (AL), efficacy of airway clearance, and postoperative hospital length of stay (LOS).ResultsAfter esophagectomy, the PPC rate was significantly lower in the ACBT group (15.2%) than in the control group (31.0%) (p = 0.001). The incidences of AL were 5.5% and 12.4% in the ACBT and control groups, respectively (p = 0.042). Mean hospital LOS was 12.3 days for the ACBT group and 16.8 days for the control group (p = 0.008). ACBT significantly increased the mean sputum wet weight (g) on POD 1–3 when compared with conventional therapy (POD 1 9.08 vs. 6.47, POD 2 16.86 vs. 10.92, POD 3 24.65 vs. 13.52, all p < 0.001). Multivariable analysis revealed that ACBT decreased the rates of PPC (odds ratio [OR] 0.403, p = 0.003), AL (OR 0.379，p = 0.038)，arrhythmia (OR 0.397, p = 0.028), and bronchoscopy aspiration (OR 0.362, p = 0.016).ConclusionACBT is an effective airway clearance technique that significantly reduces the incidence of PPC after esophagectomy. ACBT could also significantly reduce both AL and LOS.