Consequences Of Anastomotic Leakage Research Articles

258. A VIDEO-UPDATE OF THE LEARNING CURVE OF THE INTRODUCTION OF MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE)

Abstract Background A radical esophagectomy is considered the cornerstone of a curative treatment strategy for esophageal cancer. However, transthoracic approaches are associated with high morbidity rates, even in expert centers. Pulmonary complications and anastomotic leakage are the most frequent and have the most impact. In the pursuit to improve clinical outcomes for patients with esophageal cancer, reducing post-operative complications is essential. Methods Minimally Invasive trans-Cervical Esophagectomy (MICE) is an innovative surgical technique, combining a single-port trans-cervical mediastinal dissection with a laparoscopic transhiatal esophagectomy. This approach facilitates a radical esophagectomy and a two- or three-field lymphadenectomy, while avoiding a thoracoscopy/thoracotomy. Therefore, MICE could reduce pulmonary complications and the consequences of anastomotic leakage, without compromising oncological radicality. Reducing post-operative complications will impact mortality, quality of life, long-term survival, and costs. Results The first MICE procedure in a Dutch esophageal cancer patient was performed at Radboudumc in January 2021, after an extensive pre-clinical trajectory. Subsequently a prospective pilot study was conducted in 20 consecutive patients undergoing MICE. The primary outcome, pulmonary complication rate, was 15% (3/20), which is substantially lower than after transthoracic minimally invasive esophagectomy (TMIE). Recurrent laryngeal nerve palsy (RLNP) occurred in seven (35%) cases, of which six recovered spontaneously, and this is in concordance with the results of Japanese series. Anastomotic leakage occurred in 15% of patients, which is in similar to our national benchmark of 18%. Conclusion We would like to share one of our latest surgical videos of MICE during our learning curve. Probably this will be around consecutive case number 70.

269. CURRENT STATUS OF THE INTRODUCTION PROCESS OF MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE), TYPICALLY IDEAL 2A STRUGGLES

Abstract Background The introduction of a novel complex surgical technique is a challenging process and can be associated with a long learning curve and learning-associated morbidity. In order to introduce Minimally Invasive transCervical Esophagectomy (MICE) in a safe way, the IDEAL framework was a used. Method MICE is an innovative surgical technique, combining a single-port transcervical mediastinal dissection with a laparoscopic transhiatal esophagectomy. MICE could reduce pulmonary complications and the consequences of anastomotic leakage, without compromising oncological radicality. Our five-step approach of the ‘pre-clinical stage 0’ made the IDEAL framework more applicable as a practical guideline and led to a safe ‘first-in-human procedure, IDEAL stage 1’. Currently we are prospectively collecting data of a single-center Radboudumc cohort, going through the learning curve and finetuning the surgical technique, which is typical for IDEAL stage 2A ‘Development’. Results In another abstract, the clinical outcomes of our single-center Radboudumc learning curve cohort will be presented. By the time of the 2023 ISDE conference, around 70 cases will be included. As a result of technical difficulties during the learning curve and succinct evaluation with peers and patients, several changes to the MICE procedure have been made, like: indications, cervical incision, continuous NIM, sequence of abdominal/cervical approach, camera system, extraction and reconstruction, conversion, surgical team. Conclusion The surgical technique of MICE evolved during the collection of a singe-centre Radboudumc learning curve cohort. These changes are typical for the ‘IDEAL development stage 2A’, thorough evaluation of these changes might help limiting learning associated morbidity.

Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer.

Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.

Revising Our Concepts about Stoma Covering a Low Rectal Anastomosis

Abstract Introduction There has been conclusive evidence that defunctioning stoma with either transverse colostomy or ileostomy mitigates the serious consequences of anastomotic leakage. However, whether transverse colostomy or ileostomy is preferred for defunctioning a rectal anastomosis remains controversial. The present study was designed to identify the best defunctioning stoma for colorectal anastomosis. Objective To improve the quality of life in patients with rectal resection and anastomosis and reduce the morbidity before and after closure of the stoma. Patients and Methods The present study included 48 patients with elective colorectal resection who were randomly arranged into 2 equal groups, with 24 patients each. Group I consisted of patients who underwent ileostomy, and group II consisted of patients who underwent colostomy as a defunctioning stoma for a low rectal anastomosis. All surviving patients were readmitted to have their stoma closed and were followed-up for 6 months after closure of their stomas. All data regarding local and general complications of construction and closure of the stoma of the two groups were recorded and blotted against each other to clarify the most safe and tolerable procedure. Results We found that all nutritional deficiencies, dehydration, electrolytes imbalance, peristomal dermatitis, and frequent change of appliances are statistically more common in the ileostomy group, while stomal retraction and wound infection after closure of the stoma were statistically more common in the colostomy group. There were no statistically significant differences regarding the total hospital stay and mortality between the two groups. Conclusion and Recommendation Ileostomy has much higher morbidities than colostomy and it also has a potential risk of mortality; therefore, we recommend colostomy as the ideal method for defunctioning a distal colorectal anastomosis.

Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer

Identifying predictors of anastomotic leakage can contribute to prevention of this common complication after esophagectomy. This study identified predictors for anastomotic leakage and assessed the influence of anastomotic leakage on short-term outcomes and long-term survival. A retrospective cohort study was conducted of consecutive patients who underwent esophagectomy in the Amsterdam University Medical Centers, location Amsterdam Medical Center, between 1993 and 2019. Multilevel logistic and Cox regression models were used to assess predictors for anastomotic leakage and survival, and an operation year-level random effects was considered for the unmeasured characteristics at year of operation. Included were 1539 patients, and anastomotic leakage developed in 288 (19%). Predictors for developing anastomotic leakage after a transthoracic esophagectomy were a higher body mass index and a cervical anastomosis. Diabetes mellitus type 2 and chronic obstructive pulmonary disease were predictors for anastomotic leakage after a transhiatal esophagectomy. Median intensive care unit and hospital stay was longer for patients with anastomotic leakage than for patients without anastomotic leakage (both P < .001 for transthoracic esophagectomy, P= .010 and P < .001, respectively, for transhiatal esophagectomy). A higher percentage of patients with anastomotic leakage died within 30 days (3.8% vs 1.9%, P= .050). However, anastomotic leakage did not significantly influence long-term survival (hazard ratio, 0.994; 95% CI, 0.849-1.176; P= .994). Higher body mass index, cervical anastomosis, diabetes mellitus, and chronic obstructive pulmonary disease are predictors for anastomotic leakage after esophagectomy. Anastomotic leakage is associated with worse short-term outcomes, but long-term survival was not influenced. Future studies should focus on patient optimization, accurate patient selection, and development of tools in risk assessment.

Safety of anastomotic techniques and consequences of anastomotic leakage in patients with colorectal cancer: a single surgeon experience.

IntroductionColorectal cancer is a common type of malignant disease of the digestive tract. Anastomotic leakage (AL) still represents a serious complication in gastrointestinal surgery, associated with high morbidity and mortality.MethodsWe conducted a retrospective case-control study and analyzed a single surgeon’s data about 359 patients treated for colorectal cancer. Patients were divided as follows: Study Group (patients with AL - 37 patients) and Control Group (patients without AL - 322 patients). Surgical and anastomotic technique-related information was processed.ResultsSurgical procedures for right sided colon tumors resulted in a significantly lower rate of anastomotic leakage (P=0.0231). For left sided colectomies end to end handsewn double layer anastomosis presented decreased odds (OR=0.176). For sigmoid segmental resection end to end anastomotic techniques developed low rate of fistula formation (handsewn - OR=0.593, stapled - OR=0.685). Performing Dixon type surgical interventions, anastomotic techniques seemed without influence on anastomotic leak appearance (handsewn and stapled), although distal anastomoses were identified as significant risk factors for fistula formation (P=0.0017). In order to perform subtotal colectomy, side to side sutures (handsewn and stapled) seemed safe choices for anastomotic procedure (P=0.0073). Patient with anastomotic leakage suffered a significantly longer hospital stay (P=0.0079), presented higher rate of surgical reintervention (P=0.0001), increased mortality (P=0.0001) and elevated hospitalization costs (P=0.0079).ConclusionPostoperative complications like anastomosis leakage significantly increase hospitalization period, necessity of surgical reintervention, mortality and financial costs. In order to avoid these unpleasant events, bowel anastomoses require standardization during surgery.

Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer

IntroductionThe need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer. Materials and methodsPatients having TME with primary anastomosis and HSD for low or mid rectal cancer between December 2014 and March 2017 were compared with a historical control group with RD in the preceding period since January 2011. HSD was introduced in conjunction with uptake of transanal TME. ResultsIn the RD group, 45/50 patients (90%) had a primary diverting stoma, and 3/40 patients (8%) in the HSD group. Anastomotic leakage occurred in 10 (20%) and three (8%) cases after a median follow-up of 36 and 19 months after RD and HSD, respectively. There was no postoperative mortality. An unintentional stoma beyond 1 year postoperative was present in six and two patients, respectively. One-year stoma-related readmission and reoperation rate (including reversal) after RD were 84% and 86%, respectively. Corresponding percentages were significantly lower after HSD (17% and 17%; P < 0.001). Total hospital stay within one year was median 11 days (IQR 8–19) versus 5 days (IQR 4–11), respectively (P < 0.001). ConclusionThis single institutional comparative cohort study shows that highly selective defunctioning of a low anastomosis in rectal cancer patients did not adversely affect incidence or consequences of anastomotic leakage with a substantial decrease in 1-year readmission and reintervention rate, leading to an overall significantly reduced hospital stay.

INFLUENCE OF DEFUNCTIONING COLOSTOMY AFTER LOW ANTERIOR RESECTION FOR RECTAL CANCER ON EARLY POSTOPERATIVE PERIOD

The AIM of this study was to evaluate the influence of defunctioning colostomy after low anterior resection for cancer on early postoperative period and effectiveness of Fast Track protocol. MATERIALS. Retrospective analysis of medical records of 186 patients with rectal cancer who underwent anterior resection of the rectum in our department was done. All patients were allocated into 2 groups - conventional (had conventional perioperative care) and optimized (perioperative treatment according to Fast Track protocol). Both groups were subdivided into 3 subgroups (unprotected anastomosis, defunctioning colostomy and Hartmann procedure). The following data were analysed: average time of operation, operative bloodloss, volume of infusion and urination, time of mobilization removement of dranages and catheters, postoperative complications. RESULTS. Age, sex, comorbidities had no effect on decision about a preventive colostomy. The main reason for preventive colostomy was a middle-rectum location of a tumor. Preventive colostomy didn’t affect the course of early postoperative period in groups. Defunctioning colostomy effectively prevent catastrophic consequences of anastomotic leakage and didn’t compromise Fast Track protocol. CONCLUSION. Defunctioning colostomy did not reduce postoperative anastomotic leak rate, but mitigate consequences of an anastomotic leakage. Defunctioning colostomy did not affect the course of early postoperative period and Fast Track protocol.

Ileostomy Reversal in Rectal Cancer: Outcomes After Neoadjuvant Radiation Therapy

The consequences of anastomotic leakage following colorectal resection are severe. A recent Cochrane review supports the use of a covering stoma to reduce the consequence of distal anastomotic failure, particularly following neoadjuvant radiation therapy. It has been reported in recent publications that as much as 20-25% of temporary stomas are never reversed after radiation therapy due to operative complications. Our present study aims to review our institutional experience of temporary ileostomy reversal after preoperative radiation therapy. Data were collected retrospectively on consecutive patients undergoing definitive total mesorectal excision (TME) for rectal cancer. Patients were treated with preoperative radiation between January 2009 and June 2015. The radiation therapy was either given as standard 3D conformal radiation therapy with 5-FU based chemotherapy (CTRT, 50.4 Gy in 28 fractions) or high dose rate brachytherapy alone (HDRBT, 26 Gy in 4 fractions). Data were collected on reversal of ileostomy rates, time to reversal, reasons for delayed reversal (defined as > 6 months) and complications following reversal. A total of 386 patients were treated with preoperative radiation therapy at our center. These included 244 lower anterior resections (LAR, 63%) and 142 abdominoperineal resections (APR, 37%). Among the patients who were planned for LAR, there were 4 Hartmann procedures and 5 who had immediate anastomosis: these patients were excluded from the present analysis. Furthermore, there are 26 patients who had indications for adjuvant chemotherapy and have not yet been scheduled for reversal. As a consequence, 209 patients were retained for analysis. The median age at time of TME is 64 years; 92 patients were female (44%) and 117 were male (56%). The median time to ileostomy reversal was 7 months (range 1-29). The ileostomy closure rate was 89% (187/209), with no statistically significant difference between patients undergoing CTRT or HDRBT. The causes of ileostomy non-closure were: patient death from non-cancer cause (7/209, 3.3%), patient refusal (1/209, 0.5%), local recurrence (5/209, 2.4%), metastatic disease (4/209, 1.9%) and local complications (5/209, 2.4%). In our experience, the use of preoperative radiation does not have a negative impact on the ileostomy reversal rate, with a contribution to local complication rate of 2.4%. Our results compare favorably to the rate of 20-25% reported in the literature.

Colorectal anastomotic leakage can be predicted by abdominal aortic calcification on preoperative CT scans: A pilot study

There have been no solid data regarding whether patients with aortic calcification (AC) who have undergone colorectal surgery are at increased risk for anastomotic leakage. Our study aim to investigate the impact of AC on anastomotic leakage (AL) and postoperative morbidity after colorectal resection. This was a cohort study of 60patients who were prospectively registered in a database. We evaluated the relationship between an aortic calcification score (ACS), measured on preoperative computed tomography (CT) imaging, and surgical complications in patients undergoing colorectal surgery. ACS was strongly correlated with mortality rate. All three of the deceased patients were in the ACS-2 group (5%; P=0.021). The rate of AL was positively correlated with ACS; no leakage was found cases of ACS-0, with a rate of 18% in cases of ACS-1 and 44% in cases of ACS-2 (P=0.022). The consequences of AL were more serious according to the grade of ACS. This study suggested that aortic calcification score is correlated with surgical outcomes, particularly anastomosis leakage, after colorectal surgery. These findings could provide useful tools for adapting surgical strategies by delaying colorectal anastomosis in high-risk patients.

Risk factors and consequences of anastomotic leakage after Ivor Lewis oesophagectomy†.

Oesophageal carcinoma (EC) remains an aggressive disease. Despite extensive changes in therapeutic modalities, surgical resection remains the first choice therapy for curable oesophageal cancer patients. Anastomotic sites are prone to serious complications such as leakage, fistula, bleeding and stricture. Leakage of the anastomosis (AL) remains one of the main causes of postoperative morbidity and mortality. The purpose of this study was to identify predictors associated with postoperative leakage after Ivor Lewis oesophagectomy and its consequences in a single centre. We performed a retrospective analysis of 412 Ivor Lewis oesophageal resections in a single institute between 2005 and 2014. Univariable and multivariable logistic regression have been used to identify predictors of AL and its impact on postoperative outcome and overall survival. Kaplan-Meier curve was used to analyse overall survival and log-rank analysis to determine odds ratio. A total of 412 patients were evaluated. Mean age was 62 ± 11 years (77% male). Overall leak rate was 2.9%. In-hospital or 30-day mortality was 4.4%. Mean intensive care unit (ICU) stay was 1 day and mean hospital stay was 19 days. A history of renal failure, diabetes, higher American Society of Anaesthesiologists score and current cigarette and corticosteroid use were identified as predictors of AL on univariable analysis. Multivariable analysis identified active smoking [P = 0.05, odds ratio (OR) 4.34, 95% confidence interval (CI): 0.98-19.28] and active corticosteroid use (P < 0.001, OR 15.8, 95% CI: 3.25-76.7) as independent significant predictors. A history of diabetes tended to be associated with a higher leakage rate but failed to reach statistical significance. AL was associated with a longer ICU and hospital stay and a significantly higher mortality (42% in the AL group vs 3% in the control group, P < 0.0001). Anastomotic leakage after oesophagectomy is a major cause of postoperative morbidity and mortality. Identifying risk factors preoperatively can contribute to the prevention of postoperative complications.

Risk factors and consequences of anastomotic leak after colectomy: a national analysis.

Previous research has identified a number of patient and operative factors associated with anastomotic leak after colectomy; however, a study that examines these factors on a national level with direct coding for anastomotic leak is lacking. The purpose of this work was to identify risk factors associated with anastomotic leak on a national level and quantify the additional morbidity and mortality experienced by these patients. We performed a retrospective analysis of patients who underwent segmental colectomy with anastomosis from the 2012 American College of Surgeons National Surgical Quality Improvement Program colectomy procedure-targeted database. Anastomotic leak was defined as minor leak requiring percutaneous intervention or major leak requiring laparotomy. Multivariate logistic regression was used to determine predictors of anastomotic leak and its impact on postoperative outcomes. This study was conducted at a tertiary university department. This study includes 13,684 patients who underwent segmental colectomy with anastomosis at American College of Surgeons National Surgical Quality Improvement Program-affiliated hospitals in 2012. The primary outcome studied was anastomotic leak. The overall leak rate was 3.8%. Male sex, steroid use, smoking, open approach, operative time, and preoperative chemotherapy were associated with increased anastomotic leaks and diverting ileostomy with decreased incidence of leaks on multivariate analysis. Increased length of stay (13 vs 5 days; p < 0.001) and increased 30-day mortality (6.8% vs 1.6%; p < 0.001) were also seen in patients who experienced leaks. These patients also experienced increased readmission rates (43.5% vs 8.3%; p < 0.001) and were 37 times more likely to require reoperation as a complication of their primary procedure (p < 0.001). The main limitations of this study include its retrospective nature and the limited 30-day outcomes recorded in the American College of Surgeons National Surgical Quality Improvement Program database. This study identified patient and operative risk factors for anastomotic leak on a national scale. It also demonstrates that these patients have increased morbidity and 30-day mortality rates, experience multiple readmissions to the hospital, and have a higher likelihood of requiring further operative intervention.

The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases

Loop ileostomies are used currently in surgical practice to reduce the consequences of distal anastomotic failure following colorectal resection. It is often assumed that reversal of a loop ileostomy is a simple and safe procedure. However, many studies have demonstrated high morbidity rates following loop ileostomy closure. The aims of this systematic review were to examine all the existing evidence in the literature on morbidity and mortality following closure of loop ileostomy. A literature search of Ovid, Embase, the Cochrane database, Google Scholar and Medline using Pubmed as the search engine was used to identify studies reporting on the morbidity of loop ileostomy closure (latest at June 15th 2008), was performed. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital-related outcomes, post-operative bowel-related complications, and other surgical and medical complications. Forty-eight studies from 18 countries satisfied the inclusion criteria. Outcomes of a total of 6,107 patients were analysed. Overall morbidity following closure of loop ileostomy was found to be 17.3% with a mortality rate of 0.4%. 3.7% of patients required a laparotomy at the time of ileostomy closure. The most common post-operative complications included small bowel obstruction (7.2%) and wound sepsis (5.0%). The consequences of anastomotic leakage following colorectal resection are severe. However, the consequences of stoma reversal are often underestimated. Surgeons should adopt a selective strategy regarding the use of defunctioning ileostomy, and counsel patients further prior to the original surgery. In this way, patients at low risk may be spared the morbidity of stoma reversal.