Anastomotic Leakage In Colorectal Surgery Research Articles

Mesenteric Artery Stenosis is a Risk Factor for Anastomotic Leakage in Colorectal Surgery

Mesenteric Artery Stenosis is a Risk Factor for Anastomotic Leakage in Colorectal Surgery

Anastomotic leaks in colorectal surgery

A leakage of acolorectal anastomosis represents asevere complication in visceral surgery. An anastomotic insufficiency (AI) is apotentially life-threatening complication for patients that carries ahigh risk of subsequent complications and long-term stoma care. Numerous factors influence the risk of AI. Knowing and being able to estimate these factors are essential for successful treatment in colorectal surgery as they help determine the surgical strategy. The recognition of an AI can be challenging for practitioners due to the variability in the clinical presentation. If the presence of AI is suspected appropriate diagnostic measures must therefore be taken. If an AI has occurred acolorectal specialist should definitely be involved in the treatment as this can significantly reduce further complications and the rate of permanent stomas.

Suture reinforcement using a modified cyanoacrylate glue to prevent anastomotic leak in colorectal surgery: a prospective multicentre randomized trial

BackgroundAnastomotic leakage (AL) is the most frequent life-threating complication following colorectal surgery. Several attempts have been made to prevent AL. This prospective, randomized, multicentre trial aimed to evaluate the safety and efficacy of nebulised modified cyanoacrylate in preventing AL after rectal surgery.MethodsPatients submitted to colorectal surgery for carcinoma of the high-medium rectum across five high-volume centres between June 2021 and January 2023 entered the study and were randomized into group A (anastomotic reinforcement with cyanoacrylate) and group B (no reinforcement) and followed up for 30 days. Anastomotic reinforcement was performed via nebulisation of 1 mL of a modified cyanoacrylate glue. Preoperative features and intraoperative and postoperative results were recorded and compared. The study was registered at ClinicalTrials.gov (ID number NCT03941938).ResultsOut of 152 patients, 133 (control group, n = 72; cyanoacrylate group, n = 61) completed the follow-up. ALs were detected in nine patients (12.5%) in the control group (four grade B and five grade C) and in four patients (6.6%), in the cyanoacrylate group (three grade B and one grade C); however, despite this trend, the differences were not statistically significant (p = 0.36). However, Clavien–Dindo complications grade > 2 were significantly higher in the control group (12.5% vs. 3.3%, p = 0.04). No adverse effects related to the glue application were reported.ConclusionThe role of modified cyanoacrylate application in AL prevention remains unclear. However its use to seal colorectal anastomoses is safe and could help to reduce severe postoperative complications.

Treatment of anastomotic leak in colorectal surgery by endoluminal vacuum therapy with the VACStent avoiding a stoma - a pilot study

PurposeAnastomotic leak (AL) represents the most relevant and devastating complication in colorectal surgery. Endoscopic vacuum therapy (EVT) using the VACStent is regarded as a significant improvement in the treatment of upper gastrointestinal wall defects. The innovative concept of the VACStent was transferred to the lower GI tract, gaining initial experience by investigating safety and efficacy in 12 patients undergoing colorectal resections.MethodsThe pilot study, as part of a German registry, began with 2 patients suffering from AL, who were treated with the VACStent after stoma placement. Subsequently, 6 patients with AL were treated with the VACStent omitting a stoma placement, with a focus on fecal passage and wound healing. Finally, the preemptive anastomotic coverage was investigated in 4 patients with high-risk anastomoses to avoid prophylactic stoma placement.ResultsIn total 26 VACStents were placed without problems. The conditioning and drainage function were maintained, and no clogging problems of the sponge cylinder were observed. No relevant clinical VACStent-associated complications were observed; however, in 2 patients, a dislodgement of a VACStent occurred. The 6 patients with AL but without stoma had a median treatment with 3 VACStents per case with a laytime of 17 days, leading to complete wound healing in all cases. The 4 prophylactic VACStent applications were without complications.ConclusionThe clinical application of the VACStent in the lower GI tract shows that successful treatment of anastomotic colonic leaks and avoidance of creation of an anus praeter is possible.Trial registration numberClinicaltrials.gov NCT04884334, date of registration 2021-05-04, retrospectively registered.

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.

Does Tri-Staple™ technology reduce the risk of anastomotic leakage in colorectal surgery? A propensity score matching analysis.

This study evaluates the Tri-Staple™ technology in colorectal anastomosis. Patients who underwent rectosigmoidectomy between 2016 and 2022 were retrospectively evaluated and divided into two groups: EEA™ (EEA) or Tri-Staple™ (Tri-EEA). The groups were matched for age, sex, American Society of Anesthesiologists(ASA), and neoadjuvant radiotherapy using propensity score matching (PSM). Three hundred and thirty-six patients were included (228 EEA; 108 Tri-EEA). The groups were similar in sex, age, and neoadjuvant therapy. The Tri-EEA group had fewer patients with ASA III/IV scores (7% vs. 33%; p < 0.001). The Tri-EEA group had a lower incidence of leakage (4% vs. 11%; p = 0.023), reoperations (4% vs. 12%; p = 0.016), and severe complications (6% vs. 14%; p = 0.026). There was no difference in complications, mortality, readmission, and length of stay. After PSM, 108 patients in the EEA group were compared with 108 in the Tri-EEA group. The covariates sex, age, neoadjuvant radiotherapy, and ASA were balanced, and the risk of leakage (4%vs. 12%; p = 0.04), reoperation (4% vs. 14%; p = 0.014), and severe complications (6% vs. 15%; p = 0.041) remained lower in the Tri-EEA group. Tri-Staple™ reduces the risk of leakage in colorectal anastomosis. However, this study provides only insights, and further research is warranted to confirm these findings.

Prevention of Anastomotic Leak in Colorectal Surgery: Current Knowledge and Next Steps

Prevention of Anastomotic Leak in Colorectal Surgery: Current Knowledge and Next Steps

Is Peritoneal Drain pH an Indicator of Anastomotic Leakage in Colorectal Surgery?

Is Peritoneal Drain pH an Indicator of Anastomotic Leakage in Colorectal Surgery?

Indocyanine green fluorescence angiography in colorectal surgery: A retrospective case-control analysis in Mexico

Introduction and aimsAn anastomotic leak is one of the most dreaded complications in colorectal surgery because it increases postoperative morbidity and mortality. The aim of the present study was to identify whether indocyanine green fluorescence angiography (ICGFA) reduced the anastomotic dehiscence rate in colorectal surgery. Material and methodsA retrospective study on patients that underwent colorectal surgery with colonic resection or low anterior resection and primary anastomosis, within the time frame of January 2019 and September 2021, was conducted. The patients were divided into the case group, in which ICGFA was performed for the intraoperative evaluation of blood perfusion at the anastomosis site, and the control group, in which ICGFA was not utilized. ResultsA total of 168 medical records were reviewed, resulting in 83 cases and 85 controls. Inadequate perfusion that required changing the surgical site of the anastomosis was identified in 4.8% of the case group (n = 4). A trend toward reducing the leak rate with ICGFA was identified (6% [n = 5] in the cases vs 7.1% in the controls [n = 6] [p = 0.999]). The patients that underwent anastomosis site change due to inadequate perfusion had a 0% leak rate. ConclusionsICGFA as a method to evaluate intraoperative blood perfusion showed a trend toward reducing the incidence of anastomotic leak in colorectal surgery.

Angiografía por fluorescencia con verde de indocianina en cirugía colorrectal: análisis retrospectivo de casos y controles en México

Introduction and aimsAn anastomotic leak is one of the most dreaded complications in colorectal surgery because it increases postoperative morbidity and mortality. The aim of the present study was to identify whether indocyanine green fluorescence angiography (ICGFA) reduced the anastomotic dehiscence rate in colorectal surgery. Material and methodsA retrospective study on patients that underwent colorectal surgery with colonic resection or low anterior resection and primary anastomosis, within the time frame of January 2019 and September 2021, was conducted. The patients were divided into the case group, in which ICGFA was performed for the intraoperative evaluation of blood perfusion at the anastomosis site, and the control group, in which ICGFA was not utilized. ResultsA total of 168 medical records were reviewed, resulting in 83 cases and 85 controls. Inadequate perfusion that required changing the surgical site of the anastomosis was identified in 4.8% of the case group (n=4). A trend toward reducing the leak rate with ICGFA was identified (6% [n=5] in the cases vs 7.1% in the controls [n=6] [P=.999]). The patients that underwent anastomosis site change due to inadequate perfusion had a 0% leak rate. ConclusionsICGFA as a method to evaluate intraoperative blood perfusion showed a trend toward reducing the incidence of anastomotic leak in colorectal surgery.

A nationwide population-based study on the clinical and economic burden of anastomotic leakage in colorectal surgery

AimAnastomotic leakage (AL) is one of the most dreaded complications in colorectal surgery. In 2013, the International Classification of Diseases code K91.83 for AL was introduced in Germany, allowing nationwide analysis of AL rates and associated parameters. The aim of this population-based study was to investigate the current incidence, risk factors, mortality, clinical management, and associated costs of AL in colorectal surgery.MethodsA data query was performed based on diagnosis-related group data of all hospital cases of inpatients undergoing colon or sphincter-preserving rectal resections between 2013 and 2018 in Germany.ResultsA total number of 690,690 inpatient cases were included in this study. AL rates were 6.7% for colon resections and 9.2% for rectal resections in 2018. Regarding the treatment of AL, the application of endoluminal vacuum therapy increased during the studied period, while rates of relaparotomy, abdominal vacuum therapy, and terminal enterostomy remained stable. AL was associated with significantly increased in-house mortality (7.11% vs. 20.11% for colon resections and 3.52% vs. 11.33% for rectal resections in 2018) and higher socioeconomic costs (mean hospital reimbursement volume per case: 14,877€ (no AL) vs. 37,521€ (AL) for colon resections and 14,602€ (no AL) vs. 30,606€ (AL) for rectal resections in 2018).ConclusionsDuring the studied time period, AL rates did not decrease, and associated mortality remained at a high level. Our study provides updated population-based data on the clinical and economic burden of AL in Germany. Focused research in the field of AL is still urgently necessary to develop targeted strategies to prevent AL, improve patient care, and decrease socioeconomic costs.

Role of C-Reactive Protein (CRP) as a Predictive Marker of Anastomotic Leak in Colorectal Surgery: Is it Still Reliable?

Introduction: Anastomotic leaks after colorectal surgery is associated with serious morbidity and early diagnosis is critical. C-reactive protein (CRP) on postoperative day (POD) 3 to 5 has been described as a good predictor of anastomotic leak. Therefore, this study aims to review if CRP level of greater than 150mg/l is a reliable predictor of anastomotic leak. 1.2. Methodology: The study was conducted using a prospectively held database from Department of Colorectal Surgery, Singapore General Hospital. From 1 January 2011 to 31 October 2017, all patients who had anastomotic leaks after colorectal resection surgery were analysed retrospectively. Patients without postoperative CRP levels were excluded.

Predictive Factors for Anastomotic Leak in Colorectal Surgery: A Bi-National Database Study

IntroductionAnastomotic leak (AL) is a serious complication following colorectal surgery. This study aimed to identify factors associated with the development of AL and analyze its impact on survival.Materials and MethodsAll consecutive adult colorectal cancer resections with curative intent and anastomosis formation were included from a prospectively maintained bi-national database between 2007 and 2020. The primary outcome measure was the rate of AL. The secondary outcome measure was 5-year overall survival (OS).ResultsThere were 7566 eligible patients. The rate of AL was 2.3% and 4.4% in patients with colon and rectal cancer respectively. AL was a significant independent predictor of reduced 5-year OS in patients who underwent curative surgery for rectal cancer (Odds ratio 1.999, p = 0.017). Emergency surgery (p = 0.013), surgery at a public hospital (p &lt; 0.01), and an open surgical approach (p = 0.002) were all significantly associated with a higher risk of AL in patients with colon cancer, with higher rates of AL noted in left colectomies as compared to right hemicolectomies (6.8% vs 1.6%, p &lt; 0.05). In rectal cancer patients, ultra-low anterior resections had the highest risk of AL (4.6%), and associations were found with neoadjuvant chemotherapy (p = 0.011), surgery in a public hospital (p = 0.019), and an open approach (p = 0.035). Anastomosis formation technique (hand-sewn vs stapled) did not impact on rate of AL.DiscussionClinicians should be cognizant of the predictive factors for AL and consider early intervention for patients at risk of this.

Predictive models and prophylactic strategies for anastomotic leakage in colorectal surgery

Anastomotic leakage (AL) has always been a persistent issue for colorectal surgeons. It is still difficult to reduce the incidence of AL despite the advances in technology and equipment. With the development of evidence-based medicine, increasing high-risk factors for AL have been identified. How to efficiently and systematically combine and quantify these isolated risk factors to provide a scientific early warning of AL in clinical practices and help surgeons in choosing the optimal prophylactic strategies, is of great significance for reducing the incidence of AL. There are generally two types of AL prediction models in colorectal surgery, including prognostic models (for preoperative and intraoperative AL prediction) and diagnostic models (for early warning and improving the early diagnosis rate of AL). Prophylactic strategies for AL include stabilizing the underlying diseases, improving anemia and hypoalbuminemia, choosing an appropriate operative time window, and emphasizing and improving anastomotic techniques (including choosing an appropriate size of stapler). However, a prophylactic ostomy is still the most common method for surgeons. However, how to reduce the morbidity of complications following prophylactic ostomy and how to avoid the conversion of the prophylactic stoma to permanent stoma need further study.

Predictors That Identify Complications Such As Anastomotic Leak in Colorectal Surgery: A Systematic Review

Leakage of the anastomotic site is considered to be one of the most serious complications after colon and rectal surgery. It is associated with increased mortality, morbidity, and longer hospital stays. This systematic review examines the need for blood markers such as C-reactive protein (CRP), procalcitonin (PCT), albumin, and various other molecular markers that assist in their propensity to diagnose anastomotic leakage (AL) early after surgery.Utilizing PubMed and Google Scholar as resources and including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the articles, and studies over the last five years were included. A total of 12 studies have been discussed, and most articles suggest CRP as an excellent indicator. CRP compared to Dutch leakage scores (DLS) and PCT studies suggest that the three combinations improve the predictable outcome of AL. In addition, CRP and PCT have been shown to diagnose AL early in the postoperative period. Other studies include the role of markers of oxidative stress markers, Interleukin-6, Interleukin-10, and other molecular markers in the peritoneal drain which are predictive for identifying AL after three days postoperatively (POD-3).Overall, CRP has proven to be a reliable standard indicator of diagnosis. This is because the postoperative elevation of this protein indicates a problem of leakage with clinical symptoms. Other blood parameters are useful for diagnosis as well, but the limitations are the lack of appropriate studies and the number of randomized controlled trials in this area of ​​study.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery.

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient’s presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

Impact of near-infrared fluorescence imaging with indocyanine green on structural sequelae of anastomotic leakage after laparoscopic intersphincteric resection of malignant rectal tumors.

Recent studies have indicated the potential benefit of intraoperative near-infrared fluorescence imaging (NIR-FI) with indocyanine green in reducing early anastomotic leakage in colorectal surgery. Nonetheless, whether NIR-FI is effective in reducing structural sequelae of anastomotic leakage (SSAL) remains unclear. The aim of the present study was to investigate the impact of NIR-FI on SSAL after laparoscopic intersphincteric resection (ISR) of malignant rectal tumors. This study was a retrospective single-center cohort study. A total of 293 consecutive patients who underwent elective laparoscopic ISR from May 2010 to August 2017 were included. Patients were divided into 2 groups; those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors using NIR-F (NIR-FI group) and those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors without using NIR-FI (control group). Thirty were excluded from the analyses (13 died, 7 had pelvic recurrence, and 10 were lost to follow-up). The primary endpoint was the rate of SSAL within 2years after the primary resection, whereas the secondary endpoint was the rate of natural defecation via the anus at 2years after the primary resection. Using various statistical analyses, such as propensity score matching, the rate of SSAL was compared between groups. A total of 263 patients were analyzed [177 males and 86 females, median age 61 (27-84) years]. Prior to propensity score matching (n = 263), NIR-FI was performed in 70 patients (26.6%) The rates of SSAL were 1.4% (1/70) in the NIR-FI group and 10.4% (20/193) in the control group (p = 0.02). After propensity score matching (n = 163), the rates of SSAL were 1.5% (1/66) in the NIR-FI group and 11.7% (12/103) in the control group (p = 0.02). Propensity score analyses, as well as simple regression analyses, revealed that NIR-FI was associated with a significantly lower risk of SSAL (OR 0.10-0.13; p = 0.03-0.05). NIR-FI is useful in reducing the rate of SSAL after laparoscopic ISR.

Fluorescence angiography likely protects against anastomotic leak in colorectal surgery: a systematic review and meta-analysis of randomised controlled trials

ObjectiveObservational studies have shown that fluorescence angiography (FA) decreases the incidence of anastomotic leak (AL) in colorectal surgery, but high-quality pooled evidence was lacking. Therefore, we aimed at confirming this preliminary finding using a systematic review and meta-analysis of randomised controlled trials (RCTs) in the field.MethodsMEDLINE, Embase and CENTRAL were searched for RCTs assessing the effect of intra-operative FA versus standard assessment of bowel perfusion on the incidence of AL of colorectal anastomosis. The systematic review complied with the PRISMA 2020 and AMSTAR2 recommendations and was registered in PROSPERO. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Heterogeneity was assessed using the Q-test and quantified using the I2 value. Certainty of evidence was assessed using the GRADE Pro tool.ResultsOne hundred and eleven articles were screened, 108 were excluded and three were kept for inclusion. The three included RCTs compared assessment of the perfusion of the bowel during creation of a colorectal anastomosis using FA versus standard practice. In meta-analysis, FA was significantly protective against AL (3 RCTs, 964 patients, RR: 0.67, 95% CI: 0.46 to 0.99, I2: 0%, p = 0.04). The RD of AL was non-significantly decreased by 4 percentage points (95%CI: − 0.08 to 0, I2: 8%, p = 0.06) when using FA. Certainty of evidence was considered as moderate.ConclusionThe effect of FA on prevention of AL in colorectal surgery exists but is potentially of small magnitude. Considering the potential magnitude of effect of FA, we advise that future RCTs have an adequate sample size, include a cost-benefit analysis of the technique and better define the subpopulation who could benefit from FA.Graphical abstract

Defunctioning Ileostomy to Prevent the Anastomotic Leakage in Colorectal Surgery. The State of the Art of the Different Available Types.

Defunctioning Ileostomy to Prevent the Anastomotic Leakage in Colorectal Surgery. The State of the Art of the Different Available Types.

AVOID; a phase III, randomised controlled trial using indocyanine green for the prevention of anastomotic leakage in colorectal surgery

IntroductionAnastomotic leakage (AL) is one of the major complications after colorectal surgery. Compromised tissue perfusion at the anastomosis site increases the risk of AL. Several cohort studies have shown that...