Higher Anastomotic Leak Rate Research Articles

Anastomotic leak rate following the implementation of a powered circular stapler in elective colorectal surgeries: a retrospective cohort study.

The objective of this study was to compare the anastomotic leak rates between powered and manual circular staplers in elective left-sided colorectal resections. A retrospective cohort study of elective left-sided colorectal resections before and after implementation of a powered circular stapler at a tertiary care center was conducted. The manual stapler group consisted of consecutive resections performed between January 2016 to December 2016 and the powered stapler group, between September 2021 and December 2022. Primary outcome was 30-day anastomotic leak rate. A chi-squared analysis was performed to compare anastomotic leak rates. Factors associated with anastomotic leak were examined. Two-hundred forty-seven patients were included: 154 in the manual stapler group and 93 in the powered stapler group. Mean (SD) age was 60 (15) years old, 37.7% were female and 72.9% of resections were performed for malignancy. Both groups had similar patient characteristics and surgical technique. Overall leak rate was 2.0% in the manual stapler group and 10.8% in the powered stapler group. The powered staplers were found to have 6.06 times the odds of leak compared to manual staplers (95% CI, 1.62-22.65; p = 0.01). None of the other factors were found to be associated with anastomotic leak. Patients who had left-sided colorectal anastomosis had higher anastomotic leak rates with powered compared to manual circular staplers. This finding is contrary to previous retrospective studies that found lower leak rates with powered staplers.

Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer.

Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT. An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak. A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort. In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.

National trends and outcomes of total proctocolectomy and completion proctectomy ileal pouch-anal anastomosis procedures for ulcerative colitis.

The purpose of this study is to assess US operative trends and outcomes of ulcerative colitis (UC) patients undergoing total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) or completion proctectomy with IPAA (CP-IPAA). Adult UC patients who underwent TPC-IPAA or CP-IPAA were analysed retrospectively using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Factors associated with 30-day overall and serious morbidity were identified using multivariable logistic regression. A total of 1696 patients were identified, with 958 patients (56.5%) undergoing TPC-IPAA and 738 (43.5%) undergoing CP-IPAA. A greater proportion of TPC-IPAAs were performed each year (except in 2019) compared to CP-IPAAs over the study period (P trend <0.001). Unadjusted analysis showed comparable rates of overall (20.8% vs. 24.4%, P = 0.076) and serious morbidity (14.3% vs. 12.7%, P = 0.352) between TPC-IPAA and CP-IPAA patients. Robotic TPC-IPAA had no differences in complications compared to laparoscopic and open approaches. Robotic CP-IPAA had higher anastomotic leak rates and longer hospital length of stay compared to laparoscopic and open approaches. Obesity was associated with increased odds of overall and serious morbidity for patients who underwent TPC-IPAA. Steroid/immunosuppressive therapy was associated with increased odds of overall and serious morbidity for patients who underwent CP-IPAA. Obese patients should be informed of their increased morbidity risk and offered counselling on weight loss prior to surgery when feasible. Patients on steroid/immunosuppressive therapy within 30 days preoperatively should not undergo CP-IPAA or should delay surgery until they can be safely off those medications.

Clinical relevance of inflammation on rectal biopsy for Hirschsprung disease: An outcomes analysis.

Inflammation on diagnostic rectal biopsy for children with suspected Hirschsprung disease (HSCR) is reported on pathology, and its significance is unknown. We describe the management and outcomes of a cohort with inflammation on rectal biopsy compared to those without. Specifically, to address the hypothesis that inflammation on diagnostic biopsy is associated with increased complication rates irrespective of intervention type and timing. A single institution retrospective review of children with HSCR who underwent biopsy and endorectal pull-through (ERPT) from 2010 to 2020 was performed. The primary outcome was overall complications at 30-days following ERPT. Secondary outcomes included timing and type of operative intervention as well as postoperative enterocolitis diagnosed within 6-months of ERPT. Forty-nine children were identified; inflammation was present on diagnostic biopsy for 17 children. Those with inflammation were more likely to have clinical evidence of enterocolitis at the time of biopsy (p = 0.001) and were more likely to undergo leveling colostomy before ERPT (p = 0.01). Children with inflammation had a higher anastomotic leak rate (p = 0.04). Subgroup analysis of patients with inflammation undergoing primary ERPT versus leveling colostomy demonstrated no significant difference in outcomes following definitive ERPT. Our study suggests inflammation on diagnostic rectal biopsy for HSCR is associated with increased anastomotic leak rates. While additional prospective studies are indicated, attention to methods of mitigating inflammation and confirming its resolution before definitive pull-through may be of benefit for improving clinical outcomes in patients found with inflammation on diagnostic rectal biopsy.

954 Oesophagectomy vs. Gastrectomy; a Type II Dilemma

Abstract Aim The optimal operation for Siewert type II cancers is unclear, with both oesophagectomy and total gastrectomy being undertaken. This study aimed to investigate the overall survival and associated operative outcomes of both approaches. Method A retrospective cohort study was performed of all Siewert type II Gastro-Oesophageal Junctional (GOJ) resections from a single oesophagogastric centralised service between 2010 and 2017. The primary outcome was 5-year overall survival (OS). Secondary outcomes were recurrence rate and operative morbidity. Results A total of 163 patients were included; 127 (77.9%) oesophagectomy vs. 36 (22.1%) gastrectomy. The 5-year OS for oesophagectomy vs. gastrectomy were 50.4% vs 41.7% with a median survival of 57 months vs. 31 months respectively (p = 0.062). No differences in the rate of recurrence (44.9% vs. 33.3%, p = 0.216) or overall rate of complications (63.8% vs. 63.9%, p = 0.990) were identified. Yet, significantly more major (Clavien-Dindo III+) complications occurred in the gastrectomy compared to the oesophagectomy cohort (38.9% vs. 20.5%, p = 0.012), driven partially by a higher anastomotic leak rate (19.4% vs 9.4%, p = 0.099). Cox regression revealed no significant difference in the 5-year OS between the two groups when accounting for confounders (HR 0.906, 95% CI 0.339-2.060, p = 0.814). Only age (HR 0.971, 95% CI 0.944-0.999, p = 0.046) and pT stage (HR 1.794, 95% CI 1.097-2.935, p = 0.020) were determinants of 5-year OS. Conclusions When accounting for confounders there were no significant differences in the overall survival based on the two approaches. Further multi-centre prospective studies would be advantageous to establish a consensus on the best approach.

Impact of Morbid Obesity on Post-esophagectomy Leak Rate: a NSQIP Analysis

BackgroundMorbid obesity is becoming more prevalent and is a known risk factor for esophageal cancer. Esophagectomy in this population is technically more challenging than the non-obese, thus increasing the risks of surgery. This study hypothesizes that higher body mass index (BMI) is associated with higher anastomotic leak rates after esophagectomy. MethodsThis study is a retrospective review of patients undergoing esophagectomy in the National Surgical Quality Improvement Program (NSQIP) Targeted Esophagectomy database from 2016 to 2019. Patients were stratified by BMI < 35 versus BMI > 35, with the primary outcome being leak post-esophagectomy. Univariate analyses were performed for demographics and post-operative outcomes, and multivariate analyses were performed specifically for the primary outcome of anastomotic leak (all diagnoses and malignancy/dysplasia subgroup). This study was approved by the Institutional Review Board. ResultsOf 4165 patients, 439 (10.5%) had a BMI > 35. Patients with BMI > 35 were often younger (mean age 60 vs 64 years, p < 0.001), White (p < 0.001), female (p < 0.001), non-smoker (p < 0.001), diabetic (p < 0.001), with hypertension (p < 0.001), and ASA ≥ 3 (p < 0.001). There were no differences between BMI groups with regard to indication for esophagectomy (malignancy/dysphasia vs other), conversion to open, mortality, or length of stay. The BMI > 35 cohort reported higher operative times (p < 0.001), open operative approach (p = 0.04), superficial surgical site infection (p < 0.001), return to operating room (p = 0.01), and leak (13.5% vs 10.1%, p = 0.01). BMI > 35 was not an independent predictor of leak for all diagnoses; however, the subgroup analysis of esophagectomy for malignancy/dysplasia demonstrated that BMI > 35 was predictive of leak (OR 1.42, 95% CI 1.05–1.91), as well as operative time and hypertension. ConclusionPatients with a BMI > 35 and who undergo esophagectomy have a higher rate of anastomotic leak. BMI > 35 was also an independent predictor of leak when esophagectomy was performed for malignancy/dysplasia, but not for all diagnoses. The risk of anastomotic leak should be considered in morbidly obese patients undergoing esophagectomy, particularly for malignancy.

Robotic Esophagectomy Trends and Early Surgical Outcomes: The US Experience

BackgroundRecent esophagectomy trends were evaluated to describe the shift in surgical approach and outcomes using The Society of Thoracic Surgeons General Thoracic Surgery Database. MethodsAll patients who underwent an esophagectomy with gastric conduit from 2015 to 2019 were identified and analyzed according to original intended approach. After performing volume trend analysis of patients, operative outcomes were evaluated. ResultsAmong 10,607 patients, esophagectomy was open in 5763 (54.3%), minimally invasive (MIE) in 3524 (33.2%), and robotic (RAMIE) in 1320 (12.4%). Within 5 years, MIE and RAMIE combined rose to majority approach (open from 58% to 42% of annual volume). While MIE and RAMIE were associated with higher rates of anastomotic leak, loss of conduit, pulmonary embolus, and reoperation, R0 resection and harvested number of lymph nodes exceeded those in open approaches. Operative mortality did not differ by approach (3.21% open vs 2.72% MIE vs 2.50% RAMIE; P = .2329). On multivariable analysis, RAMIE was independently associated with higher rate of anastomotic leak compared to open (adjusted odds ratio 1.53, 95% CI 1.14-2.04), while both MIE and RAMIE had lower mean length of stay. Propensity matching of 1320 pairs found a higher risk of anastomotic leak requiring surgery for RAMIE compared with MIE (adjusted odds ratio 1.39, 95% CI 1.01-1.92). ConclusionsIn less than a decade, the dominant surgical approach in The Society of Thoracic Surgeons General Thoracic Surgery Database has become minimally invasive (RAMIE and MIE). While anastomotic leak and reoperation, more common in RAMIE, require a technical solution, these complications have not raised operative mortality. Further studies are needed to address long-term results and oncologic outcome.

SP10.1.6 Effect of hyaluronate-based bioresorbable membrane (Seprafilm) on outcomes of abdominal surgery: a meta-analysis and trial sequential analysis of randomised controlled trials

Abstract Background We aimed to evaluate comparative outcomes of abdominal surgery with and without hyaluronate-based bioresorbable membrane (Seprafilm). Methods We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Small bowel obstruction, anastomotic leak, surgical site infections, ileus, and severity of adhesions were the evaluated outcome measures. Results Thirteen randomised controlled trials reporting a total of 3,665 patients evaluating outcomes of abdominal surgeries with (n=1,800) or without (n=1,865) use of Seprafilm were identifed. Use of Seprafilm was associated with significantly lower risk of small bowel obstruction (RR:0.53, 95% CI 0.38–0.73, P=0.0001) but significantly higher rate of anastomotic leak (RR: 1.85, 95% CI 1.15–3.00 P=0.01). Moreover, while Seprafilm resulted in significantly more adhesions-free patients (RR:5.57, 95% CI 3.37–9.19, P&amp;lt;0.0001) compared to no Seprafilm, its use was associated with significantly lower grade 2 (RR:0.57, 95% CI 0.35–0.95, P=0.003) or 3 (RR:0.31, 95% CI 0.17–0.55, P&amp;lt;0.0001) adhesions. There was no significant difference in surgical site infection (RR:1.21, 95 CI 0.86–1.70, P=0.28), intra-abdominal abscess (RR: 1.46, 95 CI 0.92–2.32, P=0.11) or paralytic ileus (RR:0.97, 95 CI 0.68–1.38, P=0.87) between two groups. The trial sequential analysis demonstrated that the meta-analysis findings are conclusive. Conclusions Seprafilm reduces the risk of small bowel obstruction and severity of adhesions after abdominal surgery. However, it may increase the risk of anastomotic leak. We recommend use of Seprafilm in any abdominal surgery which does not involve an anastomosis.

Hand-sewn versus stapled anastomoses for esophagectomy: We will probably never know which is better

ObjectiveEsophagectomy remains the mainstay of treatment for nonmetastatic esophageal cancer. The optimal technique for anastomosis after esophagectomy remains unknown. The purpose of this systematic meta-analysis is to combine the available high-quality evidence to provide esophageal surgeons with an evidence base for their decision making. MethodsA systematic search of multiple databases was conducted to find randomized controlled trials of esophageal anastomotic techniques. A meta-analysis of the pooled data was conducted. ResultsA total of 19 studies with 2123 patients were included in the meta-analysis. The pooled analysis revealed a 102% higher incidence of anastomotic leak after hand-sewn anastomosis compared with stapled anastomosis (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.48-2.75). Anastomotic stricture rate was also 31% higher with hand-sewn anastomosis (OR, 1.31; 95% CI, 1.00-1.7). Thirty-day mortality did not show statistical difference favoring one anastomosis technique to another (OR, 0.68; 95% CI, 0.45-1.04). None of anastomotic leak rate, anastomotic stricture rate, or 30-day overall survival differed between anastomotic techniques in studies with only thoracic anastomoses. In cervical position hand-sewn anastomosis was associated with higher rate of anastomotic leak (OR, 2.02; 95% CI, 1.33-3.05) and stricture (OR, 1.77; 95% CI, 1.15-2.72), but no difference in 30-day mortality. ConclusionsThis meta-analysis showed a signal of higher rate of leak and stricture in hand-sewn anastomoses, but sensitivity analyses did not show a consistent outcome, so these results should be interpreted with caution.

Effect of hyaluronate-based bioresorbable membrane (Seprafilm) on outcomes of abdominal surgery: a meta-analysis and trial sequential analysis of randomised controlled trials.

We aimed to evaluate comparative outcomes of abdominal surgery with and without hyaluronate-based bioresorbable membrane (Seprafilm).We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Small bowel obstruction, anastomotic leak, surgical site infections, ileus, and severity of adhesions were the evaluated outcome measures. Thirteen randomised controlled trials reporting a total of 3665 patients evaluating outcomes of abdominal surgeries with (n = 1800) or without (n = 1865) use of Seprafilm were identified. Use of Seprafilm was associated with significantly lower risk of small bowel obstruction (RR 0.53, 95% CI 0.38-0.73, P = 0.0001) but significantly higher rate of anastomotic leak (RR 1.85, 95% CI 1.15-3.00 P = 0.01). Moreover, while Seprafilm resulted in significantly more adhesions-free patients (RR 5.57, 95% CI 3.37-9.19, P < 0.0001) compared to no Seprafilm, its use was associated with significantly lower grade 2 (RR 0.57, 95% CI 0.35-0.95, P = 0.003) or 3 (RR 0.31, 95% CI 0.17-0.55, P < 0.0001) adhesions. There was no significant difference in surgical site infection (RR: 1.21, 95 CI 0.86-1.70, P = 0.28), intra-abdominal abscess (RR 1.46, 95 CI 0.92-2.32, P = 0.11) or paralytic ileus (RR 0.97, 95 CI 0.68-1.38, P = 0.87) between two groups. The trial sequential analysis demonstrated that the meta-analysis findings are conclusive. Our meta-analysis demonstrated that Seprafilm reduces the risk of small bowel obstruction and severity of adhesions after abdominal surgery. However, it may increase the risk of anastomotic leak. We recommend use of Seprafilm in any abdominal surgery which does not involve an anastomosis.

Segmental versus extended colectomy for tumours of the transverse colon: a systematic review and meta-analysis.

There is no consensus on the appropriate extent of oncological resection for tumours of the transverse colon. Concerns regarding tumour factors such as pattern of lymph node spread and technical factors such as anastomotic perfusion lead to a variety of procedures being performed. A comprehensive search for published studies examining outcomes following segmental versus extended colectomy for transverse colon tumours was performed adhering to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Random effects methods were used to combine data. Seven comparative series examining outcomes in 3395 patients were identified. Segmental colectomy results in shorter operating times (mean difference 15.80 min, 95% CI -20.98 to -10.62, P<0.001) and less ileus (OR 0.52, 95% CI 0.33-0.81, P=0.004). There was no difference in length of hospital stay (mean difference 1.53days, 95% CI -3.79 to 0.73, P=0.18). Extended colectomy results in a lower rate of anastomotic leak (OR 0.62, 95% CI 0.40-0.97, P=0.04). There are fewer nodes retrieved in segmental colectomy (mean difference 7.60 nodes, 95% CI -9.60 to -5.61, P<0.001) but no difference in disease recurrence (OR 0.88, 95% CI 0.59-1.34, P=0.56) or overall survival (OR 0.98, 95% CI 0.68-1.4, P=0.9). Available data are limited due to a lack of randomized controlled trials. However, based on current evidence, segmental resection for transverse colon tumours is associated with less ileus but lower lymph node yields and higher anastomotic leak rates. Length of stay is similar. Oncological outcomes are equivalent.

Impact of the number of stapler firings on anastomotic leakage in laparoscopic rectal surgery: a systematic review and meta-analysis.

Several univariate and multivariate studies have already identified the number of stapler firings for laparoscopic rectal transection for rectal cancer as an independent risk factor for anastomotic leakage. The aim of this study was to perform a systematic review and meta-analysis of the anastomotic leakage rate in laparoscopic rectal surgery according to the need of using one or two stapler firings for rectal transection. PubMed, Ovid, the Cochrane Library database and ClinicalTrials.gov were searched. All of the statistical analyses were performed using Revman software. Five studies were included (1267 patients). The overall anastomotic leakage rate was 5.5% [0.7-8.4%]. Anastomotic leak occurred in 3.5% (17/491) of the cases where 1 stapler firing was used versus 6.7% (50/786) of the cases in which 2 firings were needed (50/786). Two stapler firings were significantly associated with an increased risk of anastomotic leakage (OR 2.44, 95% CI 1.34-4.42, p = 0.003, I2 = 1%). Our systematic review and meta-analysis suggest that two firings imply a higher rate of anastomotic leak than a single firing after laparoscopic rectal surgery with a double stapling technique. Coloproctologists should strive to reduce the number of linear stapler firings and try to transect the rectum with a single firing.

Can we perform esophagectomy for esophageal cancer patients with concomitant liver cirrhosis? A comprehensive systematic review and meta-analysis.

Liver cirrhosis is sometimes encountered in esophageal cancer patients intended for surgery. However, the impact of liver cirrhosis on patients with surgically treated esophageal cancer remains unclear. Therefore, we conducted the first meta-analysis focusing on current topic. We comprehensively searched relevant studies in Pubmed, Embase, and Web of Science on September 3, 2018. Data for analysis included both short-term (including morbidity and mortality rates) and long-term (5-year survival rate) outcomes. Our meta-analysis was conducted by using the STATA 12.0 package. We finally included a total of six cohort studies involving a total of 1426 patients (161 cirrhotic patients and 1265 noncirrhotic patients). Meta-analysis showed that cirrhotic patients had a significantly higher morbidity rate (risk ratio (RR)=1.226; 95% Confidence interval (CI)=[1.043, 1.442]; P=0.014) than noncirrhotic patients. For specific complications, cirrhotic patients had a significantly higher rate of pulmonary complications (RR=2.354; 95%CI=[1.376, 4.026]; P=0.002) and pleural effusion (RR=2.414; 95%CI=[1.482, 3.613]; P<0.001) than noncirrhotic patients and there was a trend toward a higher rate of anastomotic leak (RR=1.759; 95%CI=[0.945, 3.274]; P=0.075) in cirrhotic patients. Moreover, cirrhotic patients also had a significantly higher mortality rate (RR=2.529; 95%CI=[1.480, 4.324]; P=0.001) than noncirrhotic patients. Cirrhotic patients tended to yield a lower 5-year survival rate than those noncirrhotic patients after surgical resection of esophageal cancer (RR=0.715; 95%CI=[0.492, 1.039]; P=0.079). In conclusion, liver cirrhosis was significantly correlated with high morbidity and mortality rates. However, there was no sufficient evidence of unfavorable survival in cirrhotic patients. Esophagectomy can be performed for certain esophageal cancer patients with concomitant liver cirrhosis with acceptable operative risks, providing that careful preoperative evaluation and patient selection have been achieved.

Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis.

The effectiveness of bariatric surgery has been well-studied. However, complications after bariatric surgery have been understudied. This review assesses <30-d major complications associated with bariatric procedures, including anastomotic leak, myocardial infarction and pulmonary embolism. This review included 71 studies conducted in the USA between 2003 and 2014 and 107,874 patients undergoing either gastric bypass, adjustable gastric banding or sleeve gastrectomy, with mean age of 44years and pre-surgery body mass index of 46.5kgm-2 . Less than 30-d anastomotic leak rate was 1.15%; myocardial infarction rate was 0.37%; pulmonary embolism rate was 1.17%. Among all patients, mortality rate following anastomotic leak, myocardial infarction and pulmonary embolism was 0.12%, 0.37% and 0.18%, respectively. Among surgical procedures, <30-d after surgery, sleeve gastrectomy (1.21% [95% confidence interval, 0.23-2.19%]) had higher anastomotic leak rate than gastric bypass (1.14% [95% confidence interval, 0.84-1.43%]); gastric bypass had higher rates of myocardial infarction and pulmonary embolism than adjustable gastric banding or sleeve gastrectomy. During the review, we found that the quality of complication reporting is lower than the reporting of other outcomes. In summary, <30-d rates of the three major complications after either one of the procedures range from 0% to 1.55%. Mortality following these complications ranges from 0% to 0.64%. Future studies reporting complications after bariatric surgery should improve their reporting quality.

Management of colorectal trauma: a review.

Traumatic colorectal injuries are common during times of military conflict, and major improvements in their care have arisen in such periods. Since World War II, many classification systems for colorectal trauma have been proposed, including (i) Flint Grading System; (ii) Penetrating Abdominal Trauma Index; (iii) Colonic/Rectal Injury Scale; and (iv) destructive/non-destructive colonic injuries. The primary goal of these classifications was to aid surgical management and, more particularly, to determine whether a primary repair or faecal diversion should be performed. Primary repair is now the preferred surgical option. Patients who have been identified as having destructive injuries have been found to have higher anastomotic leak rates after a primary repair. Damage control principles need to be adhered to in surgical decision-making. In this review, we discuss the mechanisms of injury, classifications, clinical presentation and current recommendations for the management of colorectal trauma.

Transthoracic anastomotic leak after esophagectomy: Still a catastrophe?

126 Background: Leaks from intrathoracic esophagogastric anastomosis are thought to be associated with higher rates of morbidity and mortality than leaks from cervical anastomosis. We challenge this assumption, and hypothesize that there is no significant difference in mortality based on the position of the esophagogastric anastomosis. Methods: A systematic literature search was conducted using PubMed and Embase databases on all studies published between January 2000 and June 2015 comparing transthoracic (TTE) and transhiatal (THE) esophagectomies. Studies that used alternate reconstruction approaches were excluded. Outcomes analyzed were leak rate, leak-associated mortality, overall 30-day mortality, and overall morbidity. Meta-analyses were performed using Mantel Haenszel statistical analyses on studies that reported on leak rates of both approaches. Nominal data are presented as frequency and interquartile range (IQR); measures of the association between treatments and outcomes are presented as odds ratio (OR) with 95% confidence interval (CI). Results: Twenty-one studies (including 3 randomized controlled trials) were included comprising of 7167 patients (54% TTE). THE approach yields a higher anastomotic leak rate (12%; IQR: 11.6% - 22.1%) than TTE (9.8%; IQR: 6.0% - 12.2%) (OR: 1.83 [0.34-06.92]), without any difference in leak-associated mortality (7.1% TTE vs. 4.6% THE; OR: 1.83, [0.39-8.52]). There was no difference in overall 30-day mortality (3.9% TTE vs. 4.3% THE; OR: 0.86, [0.66-1.13]) and morbidity (59.0% TTE vs. 66.6% THE; OR: 0.76, [0.37-1.59]). Conclusions: Transthoracic esophagectomy is associated with a lower leak rate and does not result in higher morbidity or mortality than transhiatal esophagectomy. The previously assumed higher rate of transthoracic leak-associated mortality is overstated, thus allowing surgeon discretion and other factors to influence the choice of intrathoracic versus cervical esophagogastric anastomosis.

Influence of preoperative peripheral parenteral nutrition with micronutrients after colorectal cancer patients.

Background. The inflammatory reactions are stronger after surgery of malnourished preoperative patients. Many studies have shown vitamin and trace element deficiencies appear to affect the functioning of immune cells. Enteral nutrition is often inadequate for malnourished patients. Therefore, total parenteral nutrition (TPN) is considered an effective method for providing preoperative nutritional support. TPN needs a central vein catheter, and there are more risks associated with TPN. However, peripheral parenteral nutrition (PPN) often does not provide enough energy or nutrients. Purpose. This study investigated the inflammatory response and prognosis for patients receiving a modified form of PPN with added fat emulsion infusion, multiple vitamins (MTV), and trace elements (TE) to assess the feasibility of preoperative nutritional support. Methods. A cross-sectional design was used to compare the influence of PPN with or without adding MTV and TE on malnourished abdominal surgery patients. Results. Both preoperative groups received equal calories and protein, but due to the lack of micronutrients, patients in preoperative Group B exhibited higher inflammation, lower serum albumin levels, and higher anastomotic leak rates and also required prolonged hospital stays. Conclusion. Malnourished patients who receive micronutrient supplementation preoperatively have lower postoperative inflammatory responses and better prognoses. PPN with added fat emulsion, MTV, and TE provides valid and effective preoperative nutritional support.

Factors Influencing Oncologic Outcomes after Tumor-specific Mesorectal Excision for Rectal Cancer

See Article on Page 100-107 Total mesorectal excision (TME) was proposed by Heald et al. [1] more than 20 years ago and it is defined as the complete excision of the visceral mesorectal tissue to the level of the levators. The local recurrence rate after rectal cancer surgery has decreased dramatically to below 10% thanks to this TME technique. Currently TME is the gold standard for treatment of rectal cancer. However, if the tumor is located in upper rectum, partial mesorectal excision (PME) down to 5 cm below tumor can be performed. In 1998, Lopez-Kostner et al. [2] from Cleveland clinic insisted that TME is not necessary in case of the upper rectal cancer. And in the same year, Zaheer et al. [3] from Mayo clinic stated that appropriate mesorectal excision during anterior resection when tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. The term tumor-specific mesorectal excision (TSME) was noted first in this article. In the Europe, Maurer et al. [4] from Germany concluded that the rectal cancers of upper third are appropriately treated by PME to 5 cm below the tumor. TSME is defined as the precise perpendicular and circumferential excision of the mesorectum to the level of an appropriate distal resection margin by American Society of Colon and Rectal Surgeons. Law and Chu et al. [5] from Queen Mary's Hospital in Hong Kong compared the patients with TME for mid and lower rectal cancer and PME for upper rectal cancer, where the rectum was transected 4 to 5 cm below the tumor. Due to longer operative times, higher anastomotic leak rates, a more technically demanding surgery and a higher incidence of stoma formation, the authors called for a more selective use of TME. The authors argue that oncologic outcome is not compromised with this approach based on similar cancer-specific survival patterns between TME and PME in this study. This conclusion was confirmed by meta-analysis. Mirnezami et al. [6] examined the long-term oncological impact of anastomotic leakage after rectal cancer surgery using meta-analysis methods. They found that anastomotic leakage has a negative impact on local recurrence after the rectal cancer surgery. A significant association between anastomotic leakage and reduced long-term cancer specific survival was also noted. Junginger and Hermanek [7] reviewed the literature concerning oncologic outcomes after the rectal surgery. The authors recommended PME, if the rectal cancer is located 12 to 16 cm from anal verge. Oncologic outcomes after the rectal cancer surgery can be divided into the long-term survival and the local recurrence rate. Regarding rectal cancer, local recurrence rate is especially important compared to colon cancer. TSME itself and its quality is one of the most important factors to predict the local recurrence and even the long-term survival after rectal cancer surgery. Survival is mainly determined by the occurrence of distant metastasis, but TME seems to improve survival in patients without systemic disease. Therefore, the effort to improve the quality of TME is so crucial to improve oncologic outcomes after rectal cancer surgery. Preoperative concurrent chemoradiotherapy is another important factor to reduce the local failure. Pathologic results, such as distal margin, circumferential radial margin, T and N stage, lymphatic and vascular invasion, neural invasion, are also important factors to influence the oncologic results after TSME. In conclusion, surgeon is one of the most important factors to predicting oncologic outcomes after TME. Individual surgeon should make an effort to improve surgical skill and pathologist can help him with the specimen audit. Nationwide audit program is needed to improve the oncologic results after TME in rectal cancer in South Korea. The other important factor is the preoperative radiotherapy. Preoperative radiotherapy with high quality TME can almost abolish the possibility of local recurrence.

Minimally invasive approaches to oesophago-gastric cancer resection result in higher anastomotic leak rates than open surgery

Background: The use of minimally invasive techniques in oesophageal cancer surgery is becoming more common but safety concerns remain. The aim of this study was to examine some early outcomes of fully minimally invasive, hybrid procedures and open Ivor-Lewis oesophagectomy in a national audit.

Quality of Life, Functional Outcome, and Complications of Coloplasty Pouch After Low Anterior Resection

The colonic J-pouch has been used to improve bowel function in patients undergoing low colorectal or coloanal anastomosis. However, a narrow pelvis, difficulties in reach, a long anal canal with prominent sphincters, or a fatty mesentery may turn this technique into a technically challenging procedure in certain patients. In these circumstances, "coloplasty" offers an alternative to a straight anastomosis. The purpose of this study was to compare the quality of life, functional outcome, and complications between patients undergoing coloplasty, colonic J-pouch, or straight anastomosis. Altogether, 162 patients who underwent coloanal or low colorectal anastomosis between 1998 and 2001 were studied. Data collected included demographics, length of follow-up, technique and type of anastomosis, complications, quality of life, and functional outcome. Results were analyzed according to use of a coloplasty (n = 69), colonic J-pouch (n = 43), or straight anastomosis (n = 50). The choice of the technique was based on the surgeon's preference. Usually coloplasty or straight anastomosis was favored in male patients with a narrow pelvis or when a handsewn anastomosis was used. Quality of life assessment with the short form-36 questionnaire revealed better scores in coloplasty and colonic J-pouch groups. The coloplasty (1.0 +/- 1.7) and colonic J-pouch (1.0 +/- 1.2) groups had fewer night bowel movements than the straight anastomosis group (1.5 +/- 2.0) (P < 0.05). The coloplasty group also had fewer bowel movements per day than the straight anastomosis group (3.8 +/- 2.9 vs. 4.8 +/- 3.6; P < 0.05); also, less clustering and less antidiarrheal medication use were observed than in the straight anastomosis group. Colonic J-pouch patients with handsewn anastomosis had a higher anastomotic leak rate (44 percent) than the patients in the coloplasty with handsewn anastomosis group (3.6 percent). Coloplasty seems to be a safe, effective technique for improving the outcome of low colorectal or coloanal anastomosis. It is especially applicable when a colonic J-pouch anastomosis is technically difficult.