Failure Of Colorectal Anastomosis Research Articles

Pathology gradual assessment of colorectal anastomosis

Aim: to analyze the state of the colorectal anastomosis after laparoscopic and open resection of the sigmoid and rectum in patients with colorectal cancer and to develop a unified grading of pathological changes in the anastomosis during its laparoscopic and videorectoscopic assessment. Materials and methods. Results of the treatment of 79 patients who underwent resection of the rectum and sigmoid colon due to adenocarcinoma were analyzed. Patients were divided into two groups. The first group consisted of 34 (43.04 %) patients, whose treatment method was laparoscopic resection of the sigmoid and rectum (main group). The second group consisted of 45 (56.96 %) patients who underwent laparotomic resection. A stapler colorectal anastomosis was formed in both groups. The patients had II–III stages of the oncological disease without prior chemotherapy or radiotherapy in the anamnesis. During the operation visual assessment of the applied anastomosis was performed taking into account both external and internal characteristics. For external examination visual assessment of the anastomosed ends from the side of the serous membrane and a pneumohydrotest were used, for internal – an ordinary 10 mm laparoscope was inserted into the anus with CO2 insufflation at the level of 6 mm Hg and a visual assessment was carried out from the side of the mucosa. According to the received data, an original gradation of pathological changes in the colorectal anastomosis and recommendations for the prevention of its failure were developed. Results. The developed technique for assessing and gradation of pathological changes in colorectal anastomosis made it possible to identify and eliminate suturing defects in 19 (24.05 %) patients, to eliminate stitching defects, control bleeding, identify ischemic zones of the anastomotic ends and improve total results of the treatment. One patient had anastomotic failure on the third day after operation. This case required reoperation with removal of the anastomosis and formation of the terminal colostomy. There were no lethal cases in both groups. Usage of additional methods for assessing the anastomosis is time-consuming and important in detecting pathological changes in the colorectal anastomosis. Conclusions. The gradation of pathologic changes in the colorectal anastomosis should be comprehensive with an assessment of not only its external characteristics but also internal ones using videorectoscopy and allows to reduce the risks of colorectal anastomosis failure. The average number of points in the combination of laparoscopic and videorectoscopic evaluation is higher than in the laparoscopic one alone, but there is no statistical significance (U = 884.5; P = 0.071). This makes it possible to use the proposed grading system both in laparoscopy and in open surgery with the same results. There is no statistically significant difference in the number of detected anastomotic complications between open and laparoscopic resection of the sigmoid colon or the rectum (P = 0.137).

Features to Prevent Failed Hardware Colorectal Anastomoses in Laparoscopic Rectal Resections

The aim of research was to study proper results of laparoscopic anterior rectal resection using intraoperative measures to prevent failure of hardware colorectal anastomoses in patients with rectal tumor.Material and methods. Out of 68 patients included in the study, colorectal anastomotic leakage occurred clinically only in 2 cases (2.9%, class A and B) and required no further surgical interventions. When evaluating the risk of colorectal anastomosis failure in each specific case, it is necessary to consider pre- and intraoperative risk factors. Formation of colorectal anastomosis with one angular end of the rectal stump followed by immersion; additional strengthening of the anastomosis zone with interrupted serous-muscular sutures; adequate drainage of the pelvic cavity (the most effective - transperineal presacral) are intraoperative methods that reduce the risk of failed hardware colorectal anastomoses.Results. Out of 68 operated patients, colorectal anastomosis failure occurred clinically only in 2 cases (2.9%, class A and B) and did not require repeated surgical intervention. When assessing the risk of colorectal anastomosis failure in each specific case, it is necessary to take into account pre-and intraoperative risk factors. Formation of a colorectal anastomosis with one angular end of the rectal stump, followed by its immersion; additional strengthening of the anastomosis zone with nodular serous-muscular sutures; adequate drainage of the pelvic cavity (most effectively - trans-interventional presacral) - intraoperative methods that reduce the risk of failure of hardware colorectal anastomoses.Conclusion. Reasonable doubts in the intraoperative evaluation of the blood supply to the end section of the descending colon, viability of the colorectal anastomosis, presence of 3 or more risk factors, low position of anastomosis (less than 10 cm from the outer end of the anal canal) indicate the necessity to form preventive transversostomy.

Necroziting fasciitis in right leg secondary to a presacral abscess related to colorectal anastomosis failure

Necroziting fasciitis in right leg secondary to a presacral abscess related to colorectal anastomosis failure

Preventive Loop Colostomy in Colorectal Cancer Surgery

Introduction. The problem of colonic anastomosis failure remains unsettled in colorectal surgery, since the use of various techniques of anastomotic protection does not preclude the development of complications.The aim of the study was to highlight surgical treatment outcomes of colorectal cancer using preventive stomas.Material and methods. The study included clinical outcomes of 248 patients with colorectal cancer. Group 1 included 85 patients who had a preventive colostomy after rectum resection and restoration of intestinal continuity. Group 2 (control) included 163 patients who had rectum resection without unloading stomas. The following parameters were evaluated in the study: gender, age, presence or absence of the preventive intestinal stoma, duration of stay in the surgical department, anastomotic failure.Results. In patients of group 1, colorectal anastomosis failure was manifested in 1 case (1.2%), in patients of group 2 - in 14 cases (8.6%). The average number of inpatient day in group 1 was 18, the average number of inpatient days in group 2 was 21.Conclusion. The application of a preventive intestinal stoma can reduce the incidence of failure, duration of hospital stay and improve long-term treatment outcomes

The Effect of TISSEEL® on Colorectal Anastomosis Healing Process in a Diabetic Animal Experimental Model.

Diabetes mellitus is an established risk factor of colorectal anastomosis failure. The purpose of the present study was to evaluate the effect of TISSEEL® in anastomotic healing. Forty male, Sprague-Dawley rats were used. Diabetes was induced in half of them by intraperitoneal injection of Streptozotocin, 60 mg/kg. One week after the injection, animals were operated and a 1 cm segment was removed and an end-to-end hand sewn anastomosis was performed. TISSEEL® was applied in each group (diabetic, non-diabetic) following randomization. The pathology analysis revealed improved tissue remodeling in the TISSEEL® group, both for the normoglycemic and the diabetic group. Specifically, the extent of inflammation was decreased (p<0.001), whereas fibroblast and collagen formation were improved (p=0.040 and p=0.008). Neovascularization was also improved (p=0.047). Application of TISSEEL® on colorectal anastomoses improves healing in rats that suffer from severe hyperglycemia.

Failure of Colorectal Anastomosis: Risk Factors, Prevention, Diagnosis, Therapeutic Tactics

Aim. To analyse and generalize available literature data on the problem of colorectal anastomotic leakage after rectal resection. Key findings. Over the last decade, there has been an increasing trend towards sphincter-preserving operations in modern colorectal surgery. The widespread use of suturing devices of various diameters allows the formation of ultra-low anastomoses (at the level of the pelvic floor). One of the menacing complications after rectal resection is anastomotic leakage, which frequency can reach 21%. The mortality from anastomotic leakage can reach 40%. The analysed literature sources discuss a variety of risk factors, both preoperative and intraoperative, affecting the healing of the inter-intestinal anastomosis. In almost all studies, the height of the tumour and the anastomosis from the anus, preoperative radiotherapy and male sex are independent risk factors for the development of colorectal anastomotic leakage. Concerning other factors, there are conflicting opinions. The timely use of preventive measures and early diagnosis of colorectal anastomotic leakage can reduce the number and severity of postoperative complications.Conclusion. Individual consideration of risk factors and their adequate assessment in terms of possible complications are decisive in the choice of the extent of surgical intervention, which will undoubtedly improve the immediate and long-term results of the surgical treatment of colorectal cancer.

FAILURE OF COLORECTAL ANASTOMOSIS. CLINICAL ANALYSIS

Failure of colorectal anastomosis was found in 1 case after 30 stapler operations and in 6 cases after 60 manual anastomoses. All the anastomoses were formed by two rows of sutures and were subperitoneal. The diagnosis of failure was mad on the basis of clinical data. One patient died. The errors in diagnosis of colorectal anastomosis failure are discussed. Visualization of a failure area by means of contrast enema and CT is essential. From 2013 to 2017 in Chernivtsi Oncological Center 90 operations were performed for rectal cancer with colorectal anastomoses. The first row of sutures was applied from the inner part of mucosa. In 25 cases invagination technique was applied. Anastomoses were made by 5 surgeons with a high level of professional work. One failure occurred on 11 day after formation of stepler anastomosis, by means of manual anastomoses failure appeared on 5-9 days. Conservative therapy was given to 2 patients. Transversostomy was performed in 4 patients, and lparotomy with resection of anastomosis – in 1 patient. In all cases surgeons were not informed about the size of dehiscence and level of drainage of subperitoneal abscess. In such situation transversostomy may be dangerous and subperitoneal abscess leads to peritonitis.

Meta-analysis of management of colorectal anastomotic leakage

To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.

PREDICTION OF COLORECTAL ANASTOMOSIS FAILURE

Aim. To study the possibilities of using chemiluminescent blood analysis and determining blood plasma lactate content for prediction of colorectal anastomosis failure. Materials and methods. Chemoluminescent blood analysis was carried out and blood plasma lactate content was determined within the days 1, 4 and 8 after the surgery in 78 patients with colorectal cancer, who had undergone the radical surgical intervention. Blood of 10 donors was used as a control. All patients were divided into 2 groups. Group I included 5 patients with interintestinal anastomosis failure developed, group II included the rest 73 persons. Results. Before the treatment started, a reliable elevation of chemiluminescence intensity was revealed in patients with colorectal cancer. Within the days 1 and 4 after the surgery, chemiluminescence indices were significantly higher in the group of patients with anastomosis failure than in patients of the second group. By the postoperative day 8, patients of group II experienced normalization of chemiluminescence indices, whereas in patients with anastomosis failure these indices remained reliably increased. Within the postoperative days 1 and 4, blood plasma lactate content significantly raised in patients of group I. No changes in lactate level among patients with uncomplicated postoperative course were noted. Conclusions. Chemiluminescent erythrocyte analysis and determination of blood plasma lactate content within the postoperative day 1 can be used to predict colorectal anastomosis failure in patients with malignant neoplasms of the colon.

COLORECRAL ANASTOMOSIS FAILURE (LITERATURE REVIEW)

Colorectal anastomosis failure is one of the serious complications following abdominoperineal resection of the rectum, accounting for approximately 40 % of cases. Mortality rate in patients with colorectal anastomosis was reported to be 39 % and above 90 % in cases with anastomosis located in the abdomen. The literature analysis showed the importance of the problem of colorectal anastomosis failure, thus dictating the necessity of searching for the new methods of prevention and treatment for this serious complication. The aim of the study was to analyze the literature on the risk factors for colorectal anastomosis. The main factor influencing anastomotic leakage is the height of the anastomosis above the anal verge. The authors’ data were often contradictory.

Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis.

Turnbull-Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull-Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis. We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality. Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred. Salvage Turnbull-Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon's armamentarium as an alternative to the creation of a permanent stoma.

Intraoperative blood pressure changes as a risk factor for anastomotic leakage in colorectal surgery

PurposeAnastomotic leakage is a serious complication after colorectal surgery. Pre- and intraoperative factors may contribute to failure of colorectal anastomosis. In this study we have tried to determine risk factors for anastomotic leakage, with special emphasis on intraoperative blood pressure changes.MethodsDuring a 24-month period, patients receiving a colorectal anastomosis were prospectively evaluated. For each patient preoperative characteristics, intraoperative adverse events and surgical outcome data were collected. Blood pressure changes were calculated as a relative decrease (>25% and >40%) from preoperative baseline values.ResultsDuring the study period, 285 patients underwent colorectal surgery with an anastomosis. Fifteen patients developed an anastomotic leakage (5.3%). All patients who developed a leakage had a left-sided procedure (P < 0.001). When blood loss was more than 250 mL (P = 0.003) or an intraoperative adverse event occurred (P = 0.050), the risk for developing an anastomotic leakage was significantly increased. A preoperative high diastolic blood pressure of ≥90 mmHg (P = 0.008) and severe intraoperative hypotension [>40% decrease in diastolic blood pressure (P = 0.049)] were identified as univariate risk factors for anastomotic leakage.ConclusionsThe development of an anastomotic leakage after colorectal surgery is related to surgical, patient and anaesthetic risk factors. A high preoperative diastolic blood pressure and profound intraoperative hypotension combined with complex surgery, marked by a blood loss of ≥250 mL and the occurrence of intraoperative adverse events, is associated with an increased risk of developing anastomotic leakage.