Anastomotic Leakage In Colorectal Surgery Research Articles

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Utility of C-reactive protein in the early diagnosis of anastomotic leakage in colorectal surgery

Utility of C-reactive protein in the early diagnosis of anastomotic leakage in colorectal surgery

Intraoperative fluorescence angiography in colorectal surgery

Fluorescence angiography with indocyanine green (ICG-FA) is frequently used in colorectal surgery to assess the blood perfusion in the region of an anastomosis. Previous studies with ICG-FA in both open and laparoscopic surgery could show alow rate of anastomotic leakage, e.g. the PILLARII study with aleakage rate of 1.4%. This article presents own results, the current status of ICG-FA and the fields of application. The aim of the study was to analyze whether the results obtained so far with ICG-FA are sufficient to recommend an extended use of this relatively new method in colorectal surgery. From July 2009 to June 2019 a total of 378 colorectal resections (280 colon resections and 98 rectal resections) with intraoperative examination of the anastomosis using ICG-FA were performed. In 13patients (3.4%) there was reduced intraoperative perfusion, which led to achange in the operative procedure (resection of the anastomosis and new anastomosis, colostomy). The total anastomotic leakage rate was 3.7% with 8leaks in the colon (2.9%) and 6in the rectum (6.1%). Without the intraoperative change in 13patients the rate of leakages could have increased to 7.1% (27/378). The use of ICG-FA in the group of patients studied potentially led to a reduction of the leakage rate by 48%. Current publications show similar results with apotential decrease in the rate of anastomotic leaks in colorectal surgery. The results show avery low rate of anastomotic leakage when using ICG-FA. These results are promising in colorectal surgery but controlled randomized studies are lacking and should be carried out before final recommendations can be given.

Human Gut Microbiota and Connective Tissue Disorders: Incidence of Anastomotic Leak in Colorectal Surgery

Journal of the American College of Surgeons 229(4):p e93, October 2019. | DOI: 10.1016/j.jamcollsurg.2019.08.966

Drain fluid's pH predicts anastomotic leak in colorectal surgery: results of a prospective analysis of 173 patients.

The early risk assessment of anastomotic leak (AL) after colorectal surgery is crucial. Several markers have been proposed, including peritoneal fluid's pH. Aim of the present study is to evaluate the role of drain fluid pH as predictor of AL. All patients undergoing colorectal surgery from January 2015 to December 2017 were considered eligible. Hartmann procedures, procedures including temporary ileostomy and emergency surgery were excluded. Drain fluid was submitted for pH and chemical-physical assessment on postoperative day 1 (POD1) and postoperative day 3 (POD3). Out of 173 patients, those who developed AL showed a lower drain fluid's pH on POD1 and on POD3 compared to patients who did not (P<0.05). The plotted ROC curves identified 7.53 as pH cut-off on POD1 (AUC 0.80) and 7.21 on POD3 (AUC 0.86). With both the cut-offs, pH was an independent predictor of AL at multivariable analysis (P<0.001). pH<7.53 on POD1 and pH<7.21 on POD3 showed 93.75% sensitivity and 97% specificity respectively. Drain fluid's pH on POD1 is useful to select patients who will not develop AL while on POD3 it might identify those requiring a more careful management.

Reducing anastomotic leak in colorectal surgery: The old dogmas and the new challenges.

Anastomotic leak (AL) constitutes a significant issue in colorectal surgery, and its incidence has remained stable over the last years. The use of intra-abdominal drain or the use of mechanical bowel preparation alone have been proven to be useless in preventing AL and should be abandoned. The role or oral antibiotics preparation regimens should be clarified and compared to other routes of administration, such as the intravenous route or enema. In parallel, preoperative antibiotherapy should aim at targeting collagenase-inducing pathogens, as identified by the microbiome analysis. AL can be further reduced by fluorescence angiography, which leads to significant intraoperative changes in surgical strategies. Implementation of fluorescence angiography should be encouraged. Progress made in AL comprehension and prevention might probably allow reducing the rate of diverting stoma and conduct to a revision of its indications.

E-Posters

Introduction: Serum C-reactive protein concentration (CRP) is a useful tool to detect an anastomotic leak after colorectal surgery. There was a continuous debate about the cut-off of CRP and the clinical applications of such cut-offs. Methods Patients who underwent an abdominal operation which involved an intestine anastomosis between December 2016 and October 2018 were included in the study. Post-operative dates (POD) were verified with the receipt times of the corresponding histopathology specimens on the electronic pathology system. Result 327 patients were recruited during the study period. 29 were excluded from the study and the reasons were illustrated in figure 1. There were 122 left-sided colonic resections, 117 ileocolic anastomoses, and 59 small intestine anastomoses. Indications of the procedures were illustrated in the following table. Among left-sided colonic anastomoses, the Receiver operating characteristic (ROC) curve was drawn with the anastomotic leakage as the state variable, and the CRP level as the detection variable. The area under the curve (AUC) was 0.52, 0.67, 0.79, 0.83 and 0.87, respectively. The calculated CRP ratio cut-offs of all the rest of PODs (2, 3, 4 and 5) were highly significant in the laparoscopic group and the overall group (p<0.001). Conclusion: Our cohort confirmed the incidence of anastomotic leaks in colorectal surgery. POD 3 CRP below 234mg/L, or CPR ratio (POD2/POD1) below 1.9 had a negative predictive value of 1 in open surgery (p=0.001 and <0.0001 respectively). CRP ratio enabled the early exclusion of an anastomotic leak and spared additional CRP.

Tu1686 – Does Laparoscopic Versus Open Approach Affect Predictive Ability of C-Reactive Protein to Detect Anastomotic Leaks in Colorectal Surgery? a Systematic Review and Metaanalysis

Tu1686 – Does Laparoscopic Versus Open Approach Affect Predictive Ability of C-Reactive Protein to Detect Anastomotic Leaks in Colorectal Surgery? a Systematic Review and Metaanalysis

Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial.

Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. Intraoperative indocyanine-green (ICG) angiography has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections, and thus possibly reducing the leak rate. Aim of this study was to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG. The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (p = n.s.). Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm. ClinicalTrials.gov NCT02662946.

Role of Indocyanine Green Fluorescence Imaging in Preventing Anastomotic Leak in Colorectal Surgery: What Lies Ahead?

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida Funding/Support: None reported. Financial Disclosure: Dr Wexner receives consulting fees and royalties from Karl Storz Endoscopy and from Intuitive Surgical. Correspondence: Steven D. Wexner, M.D., Ph.D. (Hon.), 2950 Cleveland Clinic Blvd, Weston, FL 33331. E-mail: [email protected]

Evaluation of Factors Associated with Anastomotic Leakage in Colorectal Surgery

Evaluation of Factors Associated with Anastomotic Leakage in Colorectal Surgery

Financial Impact of Anastomotic Leakage in Colorectal Surgery

BackgroundAnastomotic leakage after colorectal surgery is a complication that requires additional treatments strongly affecting the economic outcomes. We evaluated the use of resources and the economic burden associated with anastomotic leaks following colorectal surgery. MethodsBetween January 2015 and December 2016, we retrospectively evaluated patients who underwent colorectal surgery with primary anastomosis. We compared the medical resource utilization and the DRG-based reimbursement of cases with uncomplicated surgery and cases complicated by anastomotic leakage. ResultsOf the 95 patients included in the study, 87 (92%) presented an uneventful postoperative course and 8 patients (8%) developed an anastomotic leakage requiring surgery. The statistical analysis showed no significant differences in terms of demographics, risks factor, and operative results, except the length of hospital stay (9.7 vs. 29.1 days, p < 0.01). The cost for 87 uncomplicated cases was 1,535,297 EUR (average cost of 17,647 EUR), whereas the cost of the 8 patients with anastomotic leakage was 575,822 EUR (average cost of 71,978 EUR) (p < 0.01). For each patient, the hospital had 542 EUR profit in the uncomplicated group and a 12,181 EUR loss in the anastomotic leakage group (p < 0.01). The multiple R-squared line regression analysis showed that factors independently related to costs were age (p = 0.05) and length of hospital stay (p = 0.01). ConclusionsIn terms of economic impact, the occurrence of an anastomotic leakage has a large negative influence on medical resource utilization, so that, despite the complication-related increase of DRG-reimbursement, every complicated case represents a financial burden for the hospital.

Effectiveness of mechanical bowel preparation versus no preparation on anastomotic leakage in colorectal surgery: a systematic review and meta-analysis.

It has been a standard practice to perform mechanical bowel preparation (MBP) prior to colorectal surgery to reduce the risk of colorectal anastomotic leakages (CAL). The latest Cochrane systematic review suggests there is no benefit for MBP in terms of decreasing CAL, but new studies have been published. The aim of this systematic review and meta-analysis is to update current evidence for the effectiveness of preoperative MBP on CAL in patients undergoing colorectal surgery. Consequently, PubMed, MEDLINE, Embase, CENTRAL and CINAHL were searched from 2010 to March 2017 for randomised controlled trials (RCT) that compared the effects of MBP in colorectal surgery on anastomotic leakages. The outcome CAL was expressed in odds ratios and analysed with a fixed-effects analysis in a meta-analysis. Quality assessment was performed by the cochrane risk of bias tool and grades of recommendation, assessment, development and evaluation (GRADE) methodology. Eight studies (1065 patients) were included. The pooled odds ratio showed no significant difference of MBP in colorectal surgery on CAL (odds ratio (OR) = 1.15, 95% CI = 0.68-1.94). According to GRADE methodology, the quality of the evidence was low. To conclude, MBP for colorectal surgery does not lower the risk of CAL. These results should, however, be interpreted with caution due to the small sample sizes and poor quality. Moreover, the usefulness of MBP in rectal surgery is not clear due to the lack of stratification in many studies. Future research should focus on high-quality, adequately powered RCTs in elective rectal surgery to determine the possible effects of MBP.

Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis.

Indocyanine green (ICG) fluorescence imaging has been proven to be an effective tool to assess anastomotic perfusion. The aim of this systematic review and meta-analysis was to evaluate its efficacy in reducing the anastomotic leakage (AL) rate after colorectal surgery. PubMed, Scopus, WOS, Google Scholar and Cochrane Library were searched up to January 2017 for studies comparing fluorescence imaging with standard care. ClinicalTrials.gov register was searched for ongoing trials. The primary outcome measure was AL rate with at least 1month of follow-up. ROBINS-I tool was used for quality assessment. A meta-analysis with random-effects model was performed to calculate odds ratios (ORs) from the original data. One thousand three hundred and two patients from 5 non-randomized studies were included. Fluorescence imaging significantly reduced the AL rate in patients undergoing surgery for colorectal cancer (OR 0.34; CI 0.16-0.74; p=0.006). Low AL rates were shown in rectal cancer surgery (ICG 1.1% vs non-ICG 6.1%; p=0.02). There was no significant decrease in the AL rate when colorectal procedures for benign and malignant disease were combined. To date, there are no published randomized control trials (RCTs) on this subject, though 3 ongoing RCTs were identified. ICG fluorescence imaging seems to reduce AL rates following colorectal surgery for cancer. However, the inherent bias of the non-randomized studies included, and their differences in AL definition and diagnosis could have influenced results. Large well-designed RCTs are needed to provide evidence for its routine use in colorectal surgery.

C Reactive Protein as a Predictor of Anastomotic Leakage in Colorectal Surgery. Comparison Between Open and Laparoscopic Surgery

IntroductionAnastomotic leak (AL) is a serious complication in colorectal surgery due to its increase in morbidity and mortality. The aim of this prospective non-randomised study is to determine whether C-reactive Protein (CRP) is useful as a predictor of AL in patients undergoing open versus laparoscopic surgery. MethodsA total of 168 patients undergoing elective colorectal surgery were included. CRP was measured daily during the first 5 postoperative days. Complications, specially AL, were analyzed. ResultsFollowing an open approach 32 patients (45.7%) presented complications, 15 (18.7%) in the laparoscopic group and 12 (29.4%) in the converted group (P=0.153). Following open surgery 9 patients experienced AL, 5 were detected in the laparoscopic group and none in those converted (P=0.153). There were significant differences in CRP values between the 3 groups (P=0.03). ROC Curves showed AUC for the open and laparoscopic approach of 0.731 and 0.760 respectively. On day 4 the AUC was 0.867 for the open group and 0.914 for the laparoscopic group.Cut-off points on day 4 were: Open: 159.2mg/L; sensitivity 75%, specificity 89% and NPP 96% (P<0.001). Following laparoscopic surgery the cut-off point was 67.3%; sensitivity 100%, specificity 89.5% and NPP 100% (P=0.016). ConclusionCRP on day 4 is useful to diagnose AL. Different cut-off values should be taken into account depending on the approach used.

Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery

PurposeThe aim of this study was to explore the choice of modality for diagnosis, treatments, and consequences of anastomotic leakage.MethodsThis is a retrospective study of consecutive patients who underwent surgery that included a colorectal anastomosis due to colorectal cancer, diverticulitis, inflammatory bowel disease (IBD), or benign polyps.ResultsA total of 600 patients were included during 2010–2012, and 60 (10%) had an anastomotic leakage. It took in mean 8.8 days (range 2–42) until the anastomotic leakage was diagnosed. A total of 44/60 of the patients with a leakage had a CT scan of the abdomen; 11 (25%) were initially negative for anastomotic leakage. Among all leakages, the anastomosis was taken down in 45 patients (76.3%). All patients with a grade B leakage (n = 6) were treated with antibiotics, and two also received transanal drainage. The overall complication rate was also significantly higher in those with leakage (93.3 vs. 28.5%, p < 0.001), and it was more common with more than three complications (70 vs. 1.5%, p < 0.001). There was a higher mortality in the leakage group.ConclusionThis study demonstrated that one fourth of the CT scans that were executed were initially negative for leakage. Most patients with a grade C leakage will not have an intact anastomosis. An anastomotic leakage leads to significantly more severe postoperative complications, higher rate of reoperations, and higher mortality. An earlier relaparotomy instead of a CT scan and improved postoperative surveillance could possibly reduce the consequences of the anastomotic leakage.

Serum Procalcitonin Predicts Anastomotic Leaks in Colorectal Surgery

Background:Anastomotic leaks in colorectal surgery results in a high morbidity and mortality rate. Serum procalcitonin levels is known as a sensitive and specific marker of sepsis and could be use as a marker for early detection of a leak allowing early intervention. It may help a clinician decide to perform a CT scan even earlier especially when the diagnosis of a leak is uncertain. The aim of this study is to determine whether serum procalcitonin is a good predictor of anastomotic leak in colorectal surgery.Methodology:Between July 2014 until October 2015, 70 patients undergoing colorectal surgery were prospectively analyzed in a single-center tertiary teaching hospital. Demographic and surgical data were obtained. Serum procalcitonin was taken before surgery and at day 3 (72 hours) postoperatively. During the postoperative period, the patients were observed in the ward for features of anastomotic leak and if present, it was managed accordingly. The primary outcome was to prospectively determine an association between serum procalcitonin levels and an anastomotic leak in patients who underwent colorectal surgery with a primary anastomosis.Result:The rate of anastomotic leak was 4.5% (3 patients) with a mortality rate of 4.3% (3 patients). A rise in serum procalcitonin was statistically significant among patients with anastomotic leak. The optimal procalcitonin cut-off level at postoperative day 3 was 5.27 ng/mL, resulting in 100% sensitivity, 85% specificity, 23% positive predictive value and 100% negative predictive value. Nevertheless, none of the variables showed statistical significance with an anastomotic leak.Conclusion:Procalcitonin is a reliable biochemical marker to help diagnose anastomotic leak in colorectal surgery. Our study has shown that a level of 5 times beyond normal is statistically significant and a value of more than 5.27 ng/mL is confirmatory of a leak.

PRM7 - The Burden Associated with Intra-Operative Anastomotic Leaks in Colorectal Surgery

PRM7 - The Burden Associated with Intra-Operative Anastomotic Leaks in Colorectal Surgery

Assessing surgeon behavior change after anastomotic leak in colorectal surgery

BackgroundRecency effect suggests that people disproportionately value events from the immediate past when making decisions, but the extent of this impact on surgeons' decisions is unknown. This study evaluates for recency effect in surgeons by examining use of preventative leak testing before and after colorectal operations with anastomotic leaks. Materials and methodsProspective cohort of adult patients (≥18 y) undergoing elective colorectal operations at Washington State hospitals participating in the Surgical Care and Outcomes Assessment Program (2006-2013). The main outcome measure was surgeons' change in leak testing from 6 mo before to 6 mo after an anastomotic leak occurred. ResultsAcross 4854 elective colorectal operations performed by 282 surgeons at 44 hospitals, there was a leak rate of 2.6% (n = 124). The 40 leaks (32%) in which the anastomosis was not tested occurred across 25 surgeons. While the ability to detect an overall difference in use of leak testing was limited by small sample size, nine (36%) of 25 surgeons increased their leak testing by 5% points or more after leaks in cases where the anastomosis was not tested. Surgeons who increased their leak testing more frequently performed operations for diverticulitis (45% versus 33%), more frequently began their cases laparoscopically (65% versus 37%), and had longer mean operative times (195 ± 99 versus 148 ± 87 min), all P < 0.001. ConclusionsRecency effect was demonstrated by only one-third of eligible surgeons. Understanding the extent to which clinical decisions may be influenced by recency effect may be important in crafting quality improvement initiatives that require clinician behavior change.

The effect of isotonic drinks on electrolyte abnormalities of ileostomy patients: Preliminary results

Introduction: Ileostomy formation can reduce complications related to an anastomotic leakage in colorectal surgery but due to colonic exclusion ileostomy patients lose large amounts of sodium and fluid through their stoma effluent. Fluid and electrolyte abnormalities appear to be a common problem in this group of patients. Aim: The aim of the study was to assess the efficacy of an oral rehydration solution (isotonic drink) on electrolyte profile of patients with a temporary ileostomy. Materials and methods: Patients meeting inclusion criteria were both male and female patients who had undergone a rectosigmoidectomy procedure resulting or not in an ileostomy formation. A total of 48 rectosigmoidectomy patients were recruited for this prospective randomized controlled study, 31 of which had an ileostomy being constructed. The arms of the study were divided as follows: 1st arm included group A (ileostomy patients who received an intervention solution) and group B (ileostomy patients who did not receive a rehydration solution). The 2nd arm of the study comprised of patients who had undergone colorectal resection surgery without an ileostomy creation and were used as a control group. Serum electrolyte levels as well as renal function markers were assessed preoperatively and at 20 and 40 days postoperatively. Results: According to the statistical analysis mean blood sodium, urea and creatinine levels were significantly different between groups A and B (p= .046, p= .021 and p= .018 respectively). Moreover statistically significant differences were also noted between group B (no intervention solution) and the control group (p< .05). Conclusion: Administration of an isotonic oral rehydration solution seems to improve biochemical markers indicative of dehydration and renal impairment in this category of patients. The study will continue to recruit participants in order improve sample size and reach more valid and concise conclusions.