Clinical Anastomotic Leakage Research Articles

Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma.

Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p<0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p=0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p<0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p<0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.

Esophagectomy Outcomes in the Endoscopic Mucosal Resection Era

Endoscopic mucosal resection (EMR) and esophagectomy are treatment options for cT1 esophageal adenocarcinoma. Our aim was to study outcomes for patients undergoing EMR then esophagectomy. We identified patients undergoing EMR and esophagectomy for cT1 esophageal adenocarcinoma over 10 years. EMR histology was used to predict nodal involvement with a risk-scoring tool. Patient demographics, surgical techniques, pathology, postoperative outcomes, and survival were recorded. Of 1,092 that esophagectomies were performed, 51 patients underwent EMR and esophagectomy for cT1 esophageal adenocarcinoma. The mean time between EMR and esophagectomy was 4 (SD,8.0) months. According to the risk-scoring tool based on EMR histology, 1 patient was low risk, 13 (25%) were at moderate risk, and 37 (73%) were at high risk for lymph node metastasis. The time between EMR and the surgical intervention was longer and more patients had multiple EMRs in the moderate-risk group (9vs 1.4 months, p= 0.03) compared with the high-risk group (38% vs 11% patients, p= 0.04). Operative mortality was 4% and morbidity was 43%. Pneumonia occurred in 3 of 51 patients (6%), atrial fibrillation in 4 (8%), and clinical anastomotic leak in 6 (12%). Of the 51 patients, 14 (27%) were upstaged after esophagectomy. Nodal involvement was present in 3 of 13 moderate-risk patients (23%) and in 7 of 37 high-risk patients (19%). The 5-year survival was reduced in moderate-risk compared with high-risk patients (54% vs 84%, p= 0.04). Studying outcomes for cT1 esophageal adenocarcinoma is important. These patients can be divided into those undergoing EMR for staging before esophagectomy and those in whom esophagectomy is a salvage procedure after therapeutic EMRs. Care should be taken to avoid upstaging of patients in the latter group, and we recommend frequent restaging and surveillance to prevent undetected progression of disease. A low threshold for esophagectomy when EMR fails to control disease should be considered.

Poster

Poster

Risk factors for clinical anastomotic leakage after right hemicolectomy.

Anastomotic leakage (AL) after right hemicolectomy is a devastating complication, and risk factors for AL in this setting are rarely investigated exclusively. Recent reports suggest that anastomotic type may influence the rate of AL in ileocolic anastomoses. We investigated risk factors and short-term outcomes in patients subjected to right hemicolectomy. Data from all patients undergoing right hemicolectomy at our institution between 2009 and 2013 were collected in a database. Risk factors for clinical AL, 30-day mortality, hospital and intensive care unit stay were investigated. Stepwise logistic regression was used to adjust for confounding. 22/445 (4.9%) patients had AL. Median time to AL was 6days (range 2-11days). A stapled anastomosis was associated with an increased AL rate compared with the handsewn approach (adjusted odds ratio (aOR) 2.84; 95% CI 1.14-7.07; P = 0.025). Other risk factors for AL were tobacco use (aOR 2.70; 95% CI 1.06-6.86; P = 0.037) and diabetes (aOR 5.95; 95% CI 2.23-15.90; P < 0.001). Anastomotic ischemia was present in 6/13 stapled and 1/9 handsewn leaking anastomoses, P = 0.081, while generalized peritonitis was observed after 4/13 stapled and 7/9 handsewn leaking anastomoses, P = 0.030. Thirty-day mortality was 2/22 (9.1%) in patients with AL and 23/423 (5.4%) in patients without AL, P = 0.468, and 13/160 (8.1%) and 12/285 (4.2%), P = 0.085, in stapled and handsewn anastomoses, respectively. Risk factors for AL after right hemicolectomy were diabetes, tobacco use and stapled compared with handsewn anastomoses.

Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients.

Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n=44), 45-54 (n=80), 55-64 (n=166), 65-74 (n=95) and ≥75years (n=61). Elderly patients presented significantly higher ASA score (p=0.004), higher Charlson comorbidity index (p<0.0001) and more frequent cardiovascular, pulmonary (p<0.0001) and neurological (p=0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43%, p=0.70). Medical morbidity slightly increased with age (14-9-14-19-26%, p=0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p=0.039), neoadjuvant radiotherapy/chemoradiotherapy (p=0.034) and operative time ≥240min (p=0.013). This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.

Efficacy of transanal tube placement after anterior resection for rectal cancer: a systematic review and meta-analysis.

BackgroundAnastomotic leakage is a serious complication that can occur after anterior resection of the rectum. There is a question regarding whether the placement of a transanal tube can decrease the rate of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the efficacy of transanal tube placement after anterior resection.MethodsWe searched three major databases (PubMed, Embase, and the Cochrane Library) up until January 2015 for studies evaluating the benefit of transanal tubes after anterior resection for rectal cancer. The primary outcome measure was the rate of clinical anastomotic leakage. Secondary outcome was the rate of reoperation. Pooled risk ratios (RR) with 95 % confidence intervals (CI) were obtained using random effects models.ResultsOne randomized controlled trial and three observational studies involving 909 patients met inclusion criteria. Clinical anastomotic leakage occurred in 3.49 % (14 of 401) of patients with transanal tubes and 12.01 % (61 of 508) of patients without transanal tubes. Meta-analysis of the studies showed a lower risk of anastomotic leakage (RR, 0.32; 95 % CI 0.18–0.58) and reoperation related to leakage (RR, 0.19; 95 % CI 0.08–0.46) when the transanal tube was placed.ConclusionsWhile studies are few and mostly observational, the data to date indicate that placement of a transanal tube decreases the rate of clinical anastomotic leakage and reoperation related to leakage. More studies are needed to confirm these findings.

Value of protective stoma in rectal cancer surgery

Anastomotic leakage is the most serious surgical complication in rectal surgery. The aim of this study was to find out whether a protective stoma was capable of lowering the rate of clinical anastomotic leakage and to evaluate the rate of anastomotic leakages requiring resurgery. A retrospective study included a sample of 149 consecutive patients with rectal cancer who had undergone elective rectal resection with primary anastomosis. After total mesorectal excision, the anastomosis was created using either the single stapling or double stapling anastomotic technique. Anastomotic integrity was verified by transanal air insufflations with the pelvis filled with saline. A protective covering colostomy was added in selected cases and according to the surgeon's preference. A protective stoma was created in 31% of patients. Clinical anastomotic leakage occurred in 6.7% of patients (10/149). Anastomotic leakage occurred in 8.5% of the patients with a protective stoma (4/47) and in 5.9% of those without a protective stoma (6/102), which was not statistically significant. Surgery lasted significantly longer when a stoma had to be created than in case when it was not needed (p=0.024). The overall rate of resurgery due to postoperative surgical complications was 5.3% and in three cases this happened because of anastomotic leakage. All patients with a protective stoma and clinical anastomotic leakage were treated conservatively, compared to 50% of patients without a protective stoma who suffered anastomotic leakage and had to be operated. A stoma cannot prevent but it can surely minimize surgical complications related to anastomotic leakage and it does reduce the rate of resurgery.

Single-Layer Continuous Versus Double-Layer Continuous Suture in Colonic Anastomoses—a Randomized Multicentre Trial (ANATECH Trial)

PurposeApart from stapling methods, single- or double-layer continuous hand sutures are established techniques for colonic anastomoses. It is unclear which hand suture technique has superior anastomotic safety. This randomized trial evaluated the incidence of postoperative complications depending on anastomosis technique. MethodsThis multicentre randomized trial enrolled adult elective patients between February 2004 and June 2012 in four German university hospitals. Primary endpoint was incidence of clinical anastomotic leakage until 3 months postoperatively. Estimated sample size was 768 randomized patients. Main secondary endpoints were duration of anastomotic suture, postoperative morbidity and stool patterns at 3-month follow-up. Patients and postoperative outcome assessors were blinded to the group assignment. This trial is registered (NCT00996554). ResultsDue to slow recruitment, the trial was stopped prematurely. Two hundred fifty-two patients (129 to single-layer suture anastomosis (SLA), 123 to double-layer suture anastomosis (DLA)) were randomized and analysed. Nine patients (3.6 %) were lost during follow-up. Exploratory primary endpoint analysis by intention-to-treat principle showed no significant difference for clinical anastomotic leakage between suturing techniques (SLA, 4 of 129 (3.1 %) vs. DLA, 6 of 123 (4.9 %), p = 0.532). Secondary endpoint analysis showed on average a 6-min shorter suture duration for SLA than DLA (18 min (4–49) vs. 24 min (8–50), p < 0.001). At 3-month follow-up, subjective well-being and stool patterns were not significantly different between groups. ConclusionsThe present study did not reach sufficient power and cannot confirm whether both techniques might be equally or if one technique might be superior. Exploratory analysis suggests that in elective colonic resections, the single-layer continuous hand suture technique may be equally effective as the double-layer technique regarding incidence of anastomotic leakage, length of hospital stay, overall postoperative complications, subjective short-term well-being and stool patterns. Lessons learned from this trial course are summarized. Trial RegistrationThis trial is registered (Trial registration: NCT00996554). Link: https://clinicaltrials.gov/ct2/show/NCT00996554.

Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis.

There is no clear consensus on how to assess low rectal anastomotic integrity and patency prior to reversal of de-functioning stoma. The aim of this systematic review was to assess the utility of contrast enema (CE) in this context and to clarify the natural history of radiological leaks. Keyword search of electronic databases (Embase, MEDLINE, Cochrane Library, Google Scholar) and bibliographic cross-referencing were performed to identify appropriate studies. Data extraction and synthesis was performed with the primary outcomes being the sensitivity and specificity of CE for detecting clinically significant abnormalities. Statistical analysis was performed using Open Meta-Analyst software. Narrative review of outcomes including those of clinical and radiological leaks was also undertaken. A total of 1,142 CE from 11 articles were included in the final meta-analysis. CE had high specificity (95.4; 95% confidence interval = 92.0-97.4) and negative predictive value (98.4; 97.4-99.1) and moderate sensitivity (79.9; 63.9-89.9) and positive predictive value (64.6; 55.5-72.9) for the detection of clinically significant anastomotic problems. There was a high degree of correlation between CE and clinical examination findings (96.7%). Occult radiological leaks were seen in 5.7% of CE, and all but one (97%) eventually underwent successful reversal. Only three quarters of patients with clinical leak underwent successful reversal. CE is effective at excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks. However, false positive results can be observed in asymptomatic patients, and it is unclear how much additional information CE provides over clinical assessment in the low uncomplicated anastomosis.

Laparoscopic Colorectal Cancer Resection in High-Volume Surgical Centers: Long-Term Outcomes from the LAPCOLON Group Trial.

Strong evidence has confirmed the benefit of laparoscopy in colorectal cancer resection but remains a challenging procedure. It is not clear that such promising results in selected patients translate into a favorable risk-benefit balance in real practice. We conducted a multicenter national observational registry to assess operative and oncologic long-term outcomes following laparoscopic colorectal cancer resection. All patients with laparoscopic colorectal cancer resection between 2001 and 2004 were included. Data were extracted from the prospective Italian national database of 10 high-volume centers (≥40 colorectal cancer laparoscopic resections per year). Surgical technique and follow-up were standardized. Survivals were analyzed by Kaplan-Meier method. We reported 1832 patients with colon (58.5%) and rectal cancer (41.5%). TNM stage was 0-I-II in 1044 patients (57%) and III-IV in 788 patients (43%). Surgery included a totally laparoscopic procedure in 1820 patients (99.3%). Conversion was 10.5%. Postoperative morbidity and 30-day mortality rates were 17 and 1.2%, respectively. Clinical anastomotic leakage rate was 8.3% (n=152). R0 resection was 95%. With a median follow-up of 54.2 months, cancer recurrence rate was 13.3%. At 5 years, cancer-free survival was 86.7%. Upon multivariate analysis, age (P=0.001) and TNM stage (P<0.001) were associated with cancer-free survival. Predictive factors of cancer recurrence were gender (P=0.029) and TNM stage (P<0.001). In high-volume centers and non-selective patients, laparoscopic colorectal resection for cancer achieves good operative results with satisfactory long-term oncologic results. Even in the laparoscopy era, age, gender, and TNM stage remain the most powerful predictor of oncologic outcomes.

Should a Contrast Enema Be Performed Before Reversal of a Diverting Stoma in Lower Rectal Surgery?

See Article on Page 131-137 A defunctioning loop ileostomy is often used to reduce the consequences of anastomotic leakage, especially in a low rectal anastomosis. Hanna et al. [1] showed that fecal diversion could be recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. Tan et al. [2] also argued that the creation of diverting stomas could potentially minimize the fatal outcomes of anastomotic leakage, although it might not substantially decrease the incidence of anastomotic leakage in rectal cancer surgery. However, some authors reported that a diverting stoma did not have a significant relationship with symptomatic anastomotic leakage before and after their propensity score matching [3]. Another study also argued that a diverting stoma did not affect postoperative morbidity in a large cohort of patients undergoing low rectal anastomosis and that the routine use of a diverting stoma could rather delay postoperative recovery [4]. In the stage of stoma reversal, there are many different concepts and ideas about the effectiveness of a water-soluble contrast enema for the assessment of anastomotic integrity after low rectal surgery. Some investigators report that the contrast enema does not provide additional information when the results of rectoscopy and digital rectal examination (DRE) are normal [5]. However, in other studies, a contrast enema was effective in excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks [6]. Most surgeons perform the closure of the ileostomy after using a water-soluble contrast enema to check the anastomosis to confirm there is no sign of leakage. However, Palmisano et al. [7] performed the reversal of a protective stoma, despite a finding of persistent radiological and subclinical leakage, in selected patients. Seo et al. [8] evaluated the efficacy of a water-soluble contrast enema in predicting anastomotic healing after low rectal anastomosis and categorized the abnormal radiologic features into four types of their design based on the morphologic patterns: namely, dendritic, horny, saccular, and serpentine. They found that certain types of leakage forming cavitary lesions had better clinical outcomes after leakage had been arrested and the stoma had been restored. This issue should be discussed and evaluated through a larger-scale study for more definitive clinical implications. A water-soluble contrast enema study is helpful in detecting radiologic leakage before reversal of a diverting stoma, but these examinations are sometimes difficult to interpret, especially in the presence of a pouch or a dog-ear from a colo-anal anastomosis constructed by using the double-stapling technique. Therefore, for patients with a diverting stoma, surgeons should always be mindful to select the best way and the appropriate time to perform the stoma restoration, or they should decide to delay the stoma restoration, based on the radiologic finding, as well as clinical information, such as the results of a digital rectal examination.

Fibrin-based Biological Adhesives Prevent Anastomotic Leakage in Rectal Anastomoses: Prospective Multicentre Randomised Clinical Trial

Background: Fibrin-based biological adhesives are used for tissue adhesion improving the outcome of gastrointestinal sutures. The objective was to assess the effectiveness of fibrin-based biological adhesives for prevention of anastomotic leakage in high-risk gastrointestinal anastomoses. Methods: A randomized clinical trial was designed to recruit patients underwent a rectal resection surgery. A subgroup of patients with rectal anastomosis were recruited from 2 different hospital centres. Patients in which a biological fibrin-based biological adhesive was applied to the suture line (study group) were compared versus a control group under standard practice. The main outcome measures was presence or absence of leakage and need for reoperation. Results: Thirty seven patients underwent a rectal resection and anastomosis. In 21 standard practice was applied and a fibrin-based adhesive was used in 16. Fourteen patients (37.8%) had a clinical or subclinical anastomotic leak, 11 belonging to control group versus 3 patients in the study group (p-value of 0.04). Statistically significant difference (p-value of 0.048) in the need for reoperation. We found no association between the use of drains and anastomotic leakage. There were only 3 leaks in the group in which a drain was placed, as compared to 11 leaks in the group in which no drain was placed, but these findings were probably due to chance (p = 0.54). Conclusions: The use of these adhesives could not only reduce serious postoperative complications related to dehiscence but also improve the prognosis and oncological outcome of rectal and sigmoid cancer treatment.

Stoma Creation After Surgery for Rectal Cancer: Temporary or Permanent?

See Article on Page 98-102 In rectal cancer surgery, creation of diverting stomas can potentially minimize the fatal outcomes of anastomotic leakage, although it may not substantially decrease its incidence [1,2]. Several studies showing that a defunctioning stoma seems to be useful in preventing clinical anastomotic leakage and urgent reoperations in patients receiving a low anterior resection have been reported [1,3]; however, whether a diverting stoma itself can prevent anastomotic leakage independently is still a controversial issue. Rather, stoma creation in patients undergoing a low anterior resection after neoadjuvant chemoradiotherapy may be helpful for a patient's well-being because the predictable poor bowel function in the immediate postoperative period may be avoided. Up to a quarter of patients who undergo sphincter-saving surgery with a temporary stoma may consequently remain in the permanent stoma status, including nonreversal conditions or re-creation of another stoma after stoma-closure surgery [4,5,6,7]. A review of the factors associated with a permanent stoma after a low anterior resection showed old age, anastomotic complications including leakage, radiation therapy, incurable local pelvic recurrence, systemic disease, and irreversible poor anal sphincter function after surgery to be significant [4,5,6,7]. The benefits of a stoma in mitigating the potential complications due to anastomotic problems/pelvic sepsis in low rectal cancer must be balanced against the potential disadvantages of ostomy-related complications and of its subsequent closure procedure. Although making a decision on whether or not to create a stoma based on these factors only is hardly possible, this issue should be discussed preoperatively so that permanent-stoma-creating surgery may be selected according to patient's condition, especially in more elderly patients who are receiving radiotherapy and who have a poor anal sphincter function preoperatively.

Impaired blood supply in the colonic anastomosis in mice compromises healing.

Colon anastomotic leakage has a multifactorial etiology and ischemia is considered one of the most important single factors. However, no existing animal models have established a direct link between ischemia and anastomotic leakage. The aim of this study was to establish a model of colon anastomotic leakage as a result of tissue ischemia. In colon anastomoses of 53 C57BL/6 mice, varying degrees of ischemia were induced. Supplying vessels were divided with bipolar coagulation in order to reduce anastomotic breaking strength and create clinical anastomotic leakage. Breaking strength of all the ischemic anastomoses were significantly lower compared with controls. Increasing ischemia resulted in higher rates of large bowel obstruction without creating anastomotic leakage. Healing was compromised as a result of impaired blood supply. However, clinical leakage was absent. Pure ischemia in otherwise healthy experimental animals may be too simple of an approach to create clinical leakage.

The safety of primary repair or anastomosis in high-risk trauma patients.

There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries. In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded. Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation. Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.

What Is the Risk of Clinical Anastomotic Leak in the Diverted Colorectal Anastomosis?

ObjectiveThe objective of this study was to identify clinical leak in diverted colorectal anastomoses. DesignCohort analysis. SettingThe study was conducted in a subspecialty practice at a tertiary care facility. PatientsConsecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012. InterventionsNo intervention was applied. Main Outcome MeasuresClinical anastomotic leak. ResultsTwo hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing. ConclusionsIn diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.

Role of fecal diversion in colorectal anastomotic failure: Where are we now?

The value of a diverting ostomy after low colorectal anastomosis continues to be a controversial subject in the literature. Sphincter salvage surgery has increased in recent years, and the role of prophylactic diversion continues to evolve. The authors sought to provide an evidence-based review of current recommendations for use of a diverting stoma in the setting of a low pelvic anastomosis. A search of MEDLINE, PubMed, and the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles. A total of 100 articles were identified, of which 54 were included for complete analysis, including 2 meta-analyses. A diverting ostomy lowers clinical anastomotic leak rate and need for re-operation as a consequence of a leak by 30–70%. Small non-randomized studies have suggested that a diverting ostomy can be selectively omitted in some low-risk patients with good results. The morbidity associated with diverting ostomies is not inconsequential and includes risk for readmission and increased odds of renal failure. This risk must be balanced against that of anastomotic leak. The current data suggests that a diverting ostomy does not prevent anastomotic leak but can significantly limit the clinical sequelae and need for re-operation. The creation of a diverting stoma is not without morbidity and as such should be selectively performed in high-risk colorectal anastomosis that meets specific criteria.

A single surgeon's series of transthoracic oesophageal resections.

Significant controversy persists over the optimum surgical management of oesophageal carcinoma. The authors report on a consecutive personal series of open transthoracic oesophageal resections. Data relating to resections performed between mid-1993 and the end of 2010 were analysed. Patient and tumour assessment evolved over this period. Preoperative chemotherapy in appropriate cases was introduced in 2002. A laparotomy and right lateral thoracotomy approach (Ivor-Lewis) was used. In all cases the pylorus was not interfered with, no attempt was made to perform a radical lymphadenectomy but surgical strategy was focused on producing an R0 resection and a hand sewn anastomosis was fashioned. A total of 165 resections were performed; 130 patients (80%) were male. The median age was 66 years (range: 31-82 years). Eighty per cent had an adenocarcinoma. Sixty-four per cent of the tumours were T3/T4 and sixty-two per cent node positive. Forty patients (24%) had an involved circumferential resection margin (CRM). Five patients (3.0%) had no resection and a quarter (26%) developed morbidity of some form. There was one clinical anastomotic leak (0.6%) and three benign strictures requiring dilation (1.8%). In-hospital mortality was 3.0% (5 patients). Disease specific survival at one, two and five years was 77%, 42% and 36% respectively. Neither CRM involvement nor preoperative chemotherapy influenced survival significantly. No patient required intervention to disrupt the pylorus. Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.

Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study

Background: Preoperative mechanical bowel preparation (MBP) for elective colorectal surgery has been criticized, but is still in use because of fear of fecal load and peritoneal contamination. Experience with an indigenous low cost technique for on-table colonic lavage (OTCL) in obstructive left-sided colonic pathology has been described. OTCL would be a step towards discouraging MBP before colorectal surgery. Patients and Methods: Fourteen patients for elective colorectal surgery without preoperative bowel preparation were evaluated and found with impacted fecal matter and loaded colon intraoperatively. Instead of two-stage procedure, we did OTCL by our own devised method followed by a single-stage curative resection. Results: All patients had successful resection and primary anastomosis of their lesions. Mean time for lavage was 21 min. There was no peritoneal contamination. No postoperative anesthesia or procedure-related complication was encountered. No clinical anastomotic leak or mortality was encountered. In one patient, surgical site wound infection occurred. Conclusion: In cases where bowel preparation is not done preoperatively and single-stage procedure discredited only because of impacted fecal matter, OTCL should be taken into account. Our technique of OTCL should be employed as it is simple, safe, and cheap and would prove to be a step towards discouraging preoperative MBP for elective colorectal surgery, especially in resource limited setting.

Creation of an effective colorectal anastomotic leak early detection tool using an artificial neural network

Anastomotic leaks greatly increase both morbidity and mortality amongst colorectal patients. Earlier detection of leaks leads to improved patient outcomes; however, diagnosis often proves difficult due to heterogeneous presentation and varied differential diagnosis. The purpose of the study was to create an artificial neural network (ANN) capable of accurately identifying patients at risk of developing a post-operative colorectal anastomotic leak. A genetic ANN was trained and validated on a retrospective patient cohort. Two comparative groups were identified: those with anastomotic leaks confirmed at re-operation with a control group of patients with a post-operative delayed recovery, but in whom leak was excluded and no re-operation required. Seventy-six patients were identified: 20 confirmed leaks and 56 controls. No significant difference in the baseline features between leak and control groups in terms of age (leaks 65.9 years [SD 9.29] controls 58.3 years [SD 17.0)], P = 0.054). Utilising backwards variable selection, ANN maintained 19 input variables. Internal validation of the ANN produced a sensitivity of 85.0 %, specificity of 82.1 %, and AUC of 0.89 for correct identification of clinical anastomotic leaks. Of the 20 confirmed leaks, the model correctly identified 17 and misclassified 10 control patients in the clinical leak category. External validation on 12 consecutive pilot prospective patients produced a specificity of 83.3 %. ANNs can be created to accurately detect clinical anastomotic leaks in the early post-operative period using routinely available clinical data. Further prospective ANN testing is required to confirm generalisability. ANNs may provide useful real-world tools for improving patient safety and outcomes.