Low Pelvic Anastomosis Research Articles

Overuse of Proximal Fecal Diversion in Colorectal Surgery.

Many surgeons tend to overuse proximal fecal diversion in the setting of colonic surgery. The decision to proximally divert an anastomosis should be made with careful consideration of the risks and benefits of proximal diversion. Proximal diversion does not decrease the rate of anastomotic leak, but it does decrease the severity of leaks. Anastomotic height for low pelvic anastomoses, hemodynamic instability, steroid use, male sex, obesity, malnutrition, smoking, and alcohol abuse increase the rate of anastomotic leak. Biologics, most immunosuppressive agents, unprepped colons, and radiation for rectal cancer do not contribute to increased rates of anastomotic leak. Proximal fecal diversion creates additional potential morbidity, higher rates of readmission, and need for a subsequent hospitalization and operation for reversal. Additionally, diverted patients have higher rates of anastomotic stricture and delayed recognition of chronic leaks. These downsides to diversion must be weighed with a patient's perceived ability to handle the physiologic stress and consequences of a severe leak if reoperation is required. When trying to determine which patients can handle a leak, the modified frailty index can help to objectively determine a patient's risk for increased rate of morbidity and failure to rescue in the event of a leak. While proximal diversion is still warranted in many cases, we find that certain clinical scenarios often lead to overuse of proximal diversion. The old surgical adage "If you are considering diverting, you should probably do it" should be tempered by an understanding of the risk and benefits of diversion.

The Pathology and Physiology of Ileostomy.

An ileostomy is a surgery that is commonly performed to protect low pelvic anastomoses or prevent high-risk anastomotic leakages. However, various postoperative complications remain of major concern. After an ileostomy, the distal intestinal segment is left open for an extended period and is in a non-functional state. Consequently, the intestinal mucosa, smooth muscle, and microbiota undergo significant changes that are closely related to postoperative recovery and complications. A systematic description of these changes is necessary to understand the relationship among them and take more effective measures for postoperative intervention.

A development study of drain fluid gastrografin as a biomarker of anastomotic leak.

PurposeAnastomotic leakage (AL) is the anathema of colorectal surgery. Its occurrence leads to increased morbidity and mortality and a prolonged hospital stay. Much work has gone into studying various biomarkers in drain fluid to facilitate early detection of AL. This stage 2a development study aims to assess the safety and feasibility of reliably detecting the iodine in Gastrografin (GG; Bayer Australia Ltd.) in drain fluid and stool samples by dual-energy computed tomography (DECT).MethodsThis is a prospective, observational, controlled, consecutive cohort study establishing the safety and feasibility of the detection of GG in surgical drain fluid and stool as a biomarker of AL when patients with a low pelvic colorectal anastomosis undergo luminal flushing of the rectal tube with GG.ResultsTen consecutive patients were allocated to the saline flush group and the following 10 to the GG flush group. Three patients in the saline flush group developed an AL. One patient in the GG flush group developed an AL. An elevation in the drain fluid GG was detected using DECT on the day of clinical deterioration. None of the patients in the control group were found to have a positive result on DECT.ConclusionThis study demonstrates the safety of a novel approach to the early detection of AL from extraperitoneal colorectal anastomoses. The technique requires validation in a larger cohort and a multicenter study is planned to investigate the efficacy of GG rectal tube flushes as an early biomarker of AL in low pelvic anastomoses.

Geographical Variation in the Use of Diverting Loop Ileostomy in Australia and New Zealand Colorectal Surgeons.

PurposeAnastomotic leak (AL) after a low pelvic anastomosis is a devastating complication, with short- and long-term morbidity and increased mortality. Surgeons may employ various adjuncts in an attempt to reduce AL rates or mitigate their impact. These include the use of temporary diverting ileostomy (TDI), transanal or rectal tubes and pelvic drains. This questionnaire evaluates the preferences and routine use of these adjuncts in Australasian colorectal surgeons.MethodsA cross-sectional survey was administered to Australian and New Zealand colorectal surgeons on September 20, 2018. The study survey consisted of 15 questions exploring basic demographics and the number of rectal resections and ileal pouches performed in 12 months, along with the surgeon’s preference for the use of diverting stomas, rectal tubes, and pelvic drains.ResultsThere were 90 respondents to the survey (31.6%). Surgeons in Western Australia (71.4%) were more likely to use a mandatory TDI in colorectal extraperitoneal anastomoses than surgeons in Queensland (14.3%). South Australian surgeons are more likely to employ a mandatory TDI (100%) for ileal pouches than Queensland surgeons (42.9%). Rectal tubes are not commonly utilized (40.0% never use them), and pelvic drains are (45.6% in all cases). Surgeons consider a median AL rate of 15% was felt to justify the use of a TDI in low pelvic anastomoses and a median AL rate of 10% for ileal pouchesConclusionThere is considerable geographical variation in colorectal surgical practice throughout Australia and New Zealand. While surgeons interrogate the same literature, there are presumably other factors that see translation into variations in clinical practice.

Predictors of dehydration and acute renal failure in patients with diverting loop ileostomy creation after colorectal surgery.

BACKGROUNDDespite the potential benefits of fecal diversion after low pelvic anastomosis in colorectal surgery, diverting loop ileostomy construction is related to significant rates of complications.AIMTo determine potential predictors of high output related complications in patients with diverting loop ileostomy creation after colorectal surgery.METHODSPatients who underwent open and laparoscopic colorectal surgery requiring a diverting loop ileostomy from January 2010 to March 2018 were retrospectively analyzed. We included patients older than 18 years, who underwent colorectal surgery with primary low pelvic anastomosis, and with the creation of a diverting loop ileostomy, at elective or emergency settings for the treatment of benign or malignant conditions. Univariate and multivariate logistic regression analysis was used to determine the effect of the potential predictors on the rate of high output related complications. The high output related complications were dehydration and acute renal failure that required visits to the emergency department and hospitalizations.RESULTSOf the 102 patients included in the study, 23.5% (n = 24) suffered high output related complications. In this group of patients at least one visit to the emergency department (mean 1.6), and at least one readmission to the hospital was needed. The factors associated with high-output ileostomy, in the univariate analysis, were: urgent surgical intervention (OR = 2.6; P = 0.047), the development of postoperative complications (OR = 3; P = 0.024), have ulcerative colitis (OR = 4.8; P = 0.017), use of steroids (OR = 4.3; P = 0.010), mean output at discharge greater than 1000 mL/24 h (OR = 3.2; P = 0.016), and use of loperamide at discharge (OR = 2.8; P = 0.032). Multivariate logistic regression analysis identified two independent risk factors for high output related complications: ulcerative colitis [OR = 7.6 (95%CI: 1.81-31.95); P = 0.006], and ileostomy output at discharge ≥ 1000 mL/24 h [OR = 3.3 (1.18-9.37); P = 0.023].CONCLUSIONIn our study, patients with ulcerative colitis and those with an ileostomy output above 1000 mL/24 h at discharge, were at increased risk of high output related complications.

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database.

The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30days were compared between the groups. A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22). Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients

IntroductionHand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique. MethodsWe queried the 2012–2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach. ResultsThis query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p < 0.001), and total abdominal colectomy (OR 10.39, p < 0.001). Younger age, black race, ASA class ≥3, inflammatory bowel disease, and low pelvic anastomosis were predictive of OC (all p < 0.05). HALS demonstrated reduced overall complications (p < 0.001), wound complications (p < 0.001), anastomotic leak (p = 0.014), transfusion (p < 0.001), postoperative ileus (p < 0.001), length of stay (p < 0.001), and readmission (p < 0.001) without increased operative time. For segmental resection, HALS demonstrated reduced overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion, length of stay, and readmissions (all p < 0.05). ConclusionsCompared to OC, HALS demonstrates improved perioperative outcomes without increased operative time.

Reoperative surgery for the failed low pelvic anastomosis

The most serious complication of rectal cancer surgery is an anastomotic catastrophe that can lead to worse oncologic outcomes, decreased ability to maintain the anastomosis, and retain good functional outcome. Redo surgery for failed colorectal and coloanal anastomoses is a surgical challenge, with technical difficulties and high morbidity, but may be the only option to improve a patient׳s quality of life. The aim of this article is to summarize the approaches to salvage the anastomosis that is beset by late complications including leakage, stenosis, sinus tract, chronic presacral chronic sepsis, fistula, or disunion.

Tu1755 Impact of Omental Pedicle Flap Creation on Anastomotic Leak and Septic Complications After Low Pelvic Anastomosis: A Study From the NSQIP Database

Tu1755 Impact of Omental Pedicle Flap Creation on Anastomotic Leak and Septic Complications After Low Pelvic Anastomosis: A Study From the NSQIP Database

Body mass index predicts operative time in elective colorectal procedures

BackgroundObesity currently affects more than a third of the United States population and is associated with increased surgical complications. Compared to all other subspecialties, colorectal surgery is the most affected by the increasing trend in obese surgical patients. Operative time has been found to have the greatest impact on hospital costs and physician workload. This study was conducted to determine whether obesity has a direct impact on operative time in elective colorectal procedures using a high-powered, nationally representative patient sample. MethodsA retrospective analysis was conducted on 45,362 patients who underwent open and laparoscopic ileocolic resections, partial colectomies, and low pelvic anastomoses using American College of Surgeons National Surgical Quality Improvement Program data from 2005–2009. Operative time was the main outcome variable, whereas body mass index (BMI) was the main independent variable. BMI was divided into three classes as follows: normal (<25), overweight and/or obese (25–35), and morbidly obese (>35). A univariate linear model was used to analyze the relationship while controlling for confounding factors such as demographics and preoperative conditions. Statistical significance was established at P ≤ 0.05. ResultsMorbidly obese patients were found to have longer operative times than did normal patients across each individual colorectal procedure (P < 0.001), ranging from a mean difference of 17.8 min for open ileocolic resections to 56.6 min for laparoscopic low pelvic anastomoses with colostomies. ConclusionsBMI, as an objective measure of obesity, is a direct, statistically significant independent predictor of operative time across elective colorectal procedures.

Diverting ileostomy in colorectal surgery: when is it necessary?

The role of fecal diversion using a loop ileostomy in patients undergoing rectal resection and anastomosis is controversial. There has been conflicting evidence on the perceived benefit vs. the morbidity of a defunctioning stoma. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of constructing a diverting ileostomy in current colorectal surgical practice. Retrospective and prospective articles spanning the past 50 years were reviewed to identify the definition of an anastomotic leak (AL), evaluate risk factors for AL, and assess methods of evaluation of the anastomosis. We then pooled the evidence for and against fecal diversion, the incidence and consequences of stomal complications, and the evidence comparing loop ileostomy vs. loop colostomy as the optimal method of fecal diversion. Evidence shows that despite the fact that fecal diversion does not decrease postoperative mortality, it does significantly decrease the risk of anastomotic leak and the need for urgent reoperation when a leak does occur. Diverting stomas are a low-risk surgical procedure from a technical standpoint but carry substantial postoperative morbidity that can greatly hamper patients' quality of life and recovery. High-risk patients such as those with low colorectal anastomoses (<10 cm from anal verge), colo-anal anastomoses, technically difficult resections, malnutrition, and male patients seem to reap the greatest benefit from fecal diversion. Fecal diversion is recommended as a selective tool to protect or ameliorate an anastomotic leak after a colorectal anastomosis. It is most beneficial when used selectively in high-risk patients with low pelvic anastomoses that are at an increased risk for AL. New tools are needed to identify patients at high risk for anastomotic failure after anterior resection.

Reoperative Pelvic Surgery

Reoperative pelvic surgery is technically challenging and carries with it significant potential risk. Pelvic pathology that requires reoperative surgery typically involves recurrent malignancies, complications from ileal pouch-anal anastomoses (IPAA) for inflammatory bowel disease, complications from low pelvic anastomoses, and palliative situations. The goals of reoperative pelvic surgery are resection/repair of the primary indication and reconstruction whenever possible. This review describes pelvic anatomy and operative management for recurrent rectal cancer. Complications following IPAA, low anastomotic complications, and palliative reoperative pelvic surgery are also detailed. Tables outline prognostic factors negatively impacting outcomes following surgery for recurrent rectal cancer, absolute and relative contraindications for exenterative surgery, survival following exenteration for recurrent rectal cancer, intraoperative radiotherapy doses related to resection margin, indications for reoperative pouch surgery, and mobilization techniques for difficult reconstructions. Figures show anterior and posterior exenteration; the anatomy of presacral space after rectal mobilization; vascular exposure and dissection; unicortical transverse osteotomy; placement of Silastic mesh; division of the sacrospinous and sacrotuberous ligaments and piriformis muscle; posterior sacral osteotomy; transperineal delivery of pedicled myocutaneous rectus flap; vertical rectus abdominis myocutaneous flap; gracilis flap; total thigh fillet flap; sacropelvic resection classification; and increasing colon length with primary, secondary, and tertiary maneuvers. This review contains 18 figures, 6 tables, and 89 references.

Anastomotic Leakage after Gastrointestinal Surgery : Risk Factors , Presentation and Outcome

Background: Intestinal anastomosis is one of the most commonly performed surgical procedures, especially in the emergency setting and is also commonly performed in the elective setting when resections are carried out for benign or malignant lesions of the gastrointestinal tract. Anastomotic leak after gastrointestinal anastomosis is one of the important postoperative complication that leads to significant morbidity and adversely affects length of hospital stay. Objective: To define the risk factors, presentation and outcome of anastomotic leakage after gastrointestinal anastomosis. Methods: Prospective data collection from patients who underwent small or large bowel resection and anastomosis without fecal diversion in the surgical department in Al Zahraa University Hospital in the period between November 2010 and April 2014. Demographic details of the patients as well as preoperative, intraoperative and postoperative data were recorded. Leak found or not and on which postoperative day leak found. How it was identified (clinical or radiological) and how it was treated. Outcome of patients was recorded as mortality rate and postoperative hospital stay. Results: There were 70 (63.64%) males and 40 (36.36%) female patients. Mean age was (44.23 ± 15.78) years. Anastomotic leak was occurred in 17 (15.4%) patients group I, while there was no leak in 93 patients (84.6%) group II. The mean postoperative period for diagnosis of anastomotic leakage was 9 days range (5-16) days. Categorical variable found to be significantly affecting the outcome of anastomosis were age of the patients (P£0.001), smoker versus nonsmoker (P£0.0001), preoperative chemotherapy, radiation and anti T.B. (P£0.001), type of surgery elective versus emergency (P£0.05). Bowel preparation done in 73 versus not done in 37 (P£0.05), level of anastomosis small bowel and choledocojejunostomy versus gastrojejunstomy and large bowel (P£0.001), left versus right side colonic anastomosis (P£0.05). Intraoperative blood loss (P£0.0001). Blood transfusion >2 unit (P£0.0001). Mortality rate was (29.41%) 5/17 in group I, while it was (3.23%) 3/93 in group II. The postoperative hospital stay was (24.7 ± 5.92) days in group I, while for group II it was (12.83 ± 3.8) days. Conclusion: Postoperative gastrointestinal anastomotic leak is a very serious complication that has great clinical impact on patients, putting surgeons in dilemmas of detection and management. There is multiple risk and predictive factors associated with occurrence of leak were suspected in this study such as: older patients, preoperative anemia, hypoalbuminemia, immunosuppressive therapy, smoking, surgery performed in an emergency setting, without adequate bowel preparation, long operative time, intraoperative blood loss and blood transfusion and low pelvic anastomosis, but many factors remain unclear. The presentation of anastomotic leakage varying from severe peritonitis and leakage of bowel content through the wound or from the drain to asymptomatic (small pelvic abscess). Early detection and expediently treatment is very helpful to improve the patients outcome but death after leak is most often a substitute for a critically ill patients and was infrequently the actual cause of death and so every effort needs to be made to bring down the mortality rates and hospital stay associated with anastomotic leak.

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.

Turnbull–Cutait abdominoperineal pull-through: a safe approach for recurrent sacrococcygeal teratoma complicated by rectovaginal fistula

Sacrococcygeal teratomas are rarely seen and are classified as type I germ cell tumors. While surgery is the main treatment option, poor postoperative urological and anal functional outcomes and recurrence are major concerns [1]. An extensive resection with proctectomy is one of theoptions offering a curative treatment for recurrent sacrococcygeal teratomas. Maintenance of intestinal continuity is another component of a comprehensive therapeutic approach and should be considered for the sake of the patient’s quality of life after surgery. We hereby present the Turnbull–Cutait abdominoperineal pull-through anastomosis (T–C) technique in a patient with recurrent sacrococcygeal teratoma complicated by a rectovaginal fistula. A 41-year-old female had undergone surgery for a benign sacrococcygeal teratoma 24 years ago and had no complaints until last year. After she sought help for tailbone pain at an outside hospital, a recurrent presacral mass was discovered with a computer tomography scan. Fine-needle biopsy performed at an outside hospital confirmed the diagnosis of a recurrent sacrococcygeal teratoma. The initial operation which was performed to excise the recurrent lesion failed, and a rectovaginal fistula developed on postoperative day 20. A diverting ileostomy was then created to control pelvic sepsis, and the patient was eventually referred to our institution. At presentation, a baseline pelvic magnetic resonance imaging scan was requested, which revealed the recurrent sacrococcygeal teratoma with operative changes related to prior surgery (Fig. 1a). A stricture at 7 cm from the anal verge was found where pus drainage was observed in rectal examination which was performed under general anesthesia. The patient had type 1 diabetes, a body mass index of 21.9 kg/m and an American Society of Anesthesiologists (ASA) score of 3. Her surgical history included cholecystectomy and total abdominal hysterectomy in addition to prior surgical intervention for sacrococcygeal teratoma. It was determined that a total mesorectal excision was necessary in order to achieve total removal of the neoplastic lesion. The patient was consented preoperatively for colovaginal fistula takedown and colorectal anastomosis plus possible abdominoperineal resection. During the operation, after resection of the rectum, stapled anastomosis was deemed inappropriate due to poor tissue quality and the decision was made to proceed with our traditional two-staged T–C technique [2]. The operation was completed uneventfully. The perineal colonic segment was resected on postoperative day 5, and hand-sewn coloanal anastomosis was performed (Fig. 1b). Postoperatively, the patient had persistent pelvic pain and developed a pelvic abscess which was diagnosed on postoperative day 12 and was drained percutaneously. Intravenous antibiotic therapy was started, and the patient was discharged on postoperative day 20 after pain control was achieved. A T–C pull-through with delayed coloanal anastomosis, T–C, was first described by Turnbull and Cutait for the treatment of rectal cancer, Hirschsprung’s disease and megacolon in Chagas disease [3, 4]. Basic steps of the Turnbull–Cutait abdominoperineal pull-through anastomosis were shown in the Fig. 1c–f. T–C is not typically preferred for low pelvic anastomoses, since advanced stapler technology is now used effectively. However, we believe that T–C has its place in low coloanal anastomoses, The study was supported by the Ed and Joey Story Endowed Chair in Colorectal Surgery.

The role of faecal diversion in low rectal cancer: a review of 1791 patients having rectal resection with anastomosis for cancer, with and without a proximal stoma

The morbidity of anastomotic dehiscence may be mitigated by a defunctioning stoma, but it is unclear if it is required for most low rectal anastomoses. Preoperative risk factors leading to anastomotic complications and the indications for faecal diversion have yet to be clearly defined. Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-use file, patients were identified who underwent low anterior resection with anastomosis for cancer at the 211 participating hospitals in 2005-08. A total of 1791 patients underwent low anterior resection. Patients were subdivided into two groups based on the level of the anastomosis. Of these 1266 patients had a low pelvic anastomosis (LPA) and 525 a coloanal anastomosis (CAA). In the LPA group, 606 patients had a stoma and 660 had no stoma. There were no differences in wound complications, sepsis or septic shock. Patients who had a stoma were more likely to have postoperative acute renal failure (1.7 vs 0.5%, P = 0.0485, OR 3.674). In the CAA group, 352 had a stoma and 173 had no stoma. In patients without faecal diversion, there was a significantly greater incidence of sepsis (8.7 vs 3.7%, P = 0.022, OR 2.47), septic shock (3.5 vs 0.57%, P = 0.018, OR 6.29) and need for reoperation (11 vs 1.7%, P = 0.0001, OR 7.11). Hospital length of stay was significantly longer with CAA and no stoma. On multivariate analysis, not having a stoma with a CAA was a risk factor for serious postoperative morbidity. While a defunctioning stoma with a coloanal anastomosis seems to protect from postoperative sepsis, septic shock and need for reoperation, it is likely that it is overused in rectal cancer surgery.

Transversus abdominis plane blocks and enhanced recovery pathways: making the 23-h hospital stay a realistic goal after laparoscopic colorectal surgery

Although enhanced recovery pathways (ERPs) may permit early recovery and discharge after laparoscopic colorectal surgery (LC), most publications report that the mean hospital stay is 4 and 6 days. This study evaluates the addition of a transversus abdominis plane (TAP) block to the standard ERP. In this study, 35 consecutive elective patients received a TAP block at the end of LC. The patients were matched by operation, diagnosis, age, gender, and body mass index (BMI) with 35 recent cases and followed in a prospective institutional review board (IRB)-approved database. All the patients were managed with a standardized ERP. The surgeon placed TAP blocks under laparoscopic guidance that infiltrated 15 ml of 0.5 % Marcaine on both sides of the abdomen. The cases included 8 low pelvic anastomoses, 4 proctectomies with or without an ileal pouch anal anastomosis, 5 sigmoid/left colectomies, 13 ileocolic/right colectomies, 1 total colectomy, and 5 others. The mean age was 59 years for the TAP group and 64.1 years for the control group (p = 0.21). The mean hospital stay was 2 days for the TAP patients and 3 days for the control patients (p = 0.000013). Of the 35 TAP patients, 13 went home on postoperative day (POD) 1 (37 %), 12 on POD 2 (34 %), 8 on POD 3 (23 %), and the remainder on POD 4. Of the 35 control patients, 1 went home on POD 1 (3 %), 10 on POD 2 (29 %), 10 on POD 3 (29 %), 11 on POD 4 (31 %), and the remainder on POD 5 to 8. The TAP patients required fewer narcotics postoperatively than the control patients (respective mean morphine equivalents, 31.08 vs. 85.41; p = 0.01). A bilateral TAP block significantly improved the results of an established ERP for patients undergoing LC. Surgeon-administered TAP blocks may be an economical and efficient method for improving the results of LC.

An initial experience using transanal vacuum therapy in pelvic anastomotic leakage

Treatment of the presacral cavity that forms after contained anastomotic leakage of a low pelvic anastomosis is challenging and often results in a permanent stoma. Endosponge™ therapy is a minimally invasive method of treating the presacral cavity which potentially avoids a permanent stoma. We report our initial experience of using Endosponge™ therapy. All patients who underwent Endosponge™ treatment for low pelvic anastomotic leakage in our hospital over a 45-month period were identified and data collected from clinical, operative and endoscopic notes. Eight patients (seven males, one female) underwent Endosponge™ therapy for extraperitoneal pelvic anastomotic leak during the study period; all had had defunctioning ileostomies placed at their original surgery. Six out of eight patients had complete closure or a reduction in the size of the abscess cavity. Five patients have had their ileostomies reversed with good or reasonable bowel function after a median follow-up of 41 months and four of these patients had Endosponge™ therapy instituted within 6 weeks of initial surgery. One patient had Endosponge™ therapy abandoned and conversion to a permanent end colostomy after accidental intraperitoneal placement of the sponge. Early use of Endosponge™ therapy appears to offer a minimally invasive and effective way of closing the presacral cavity after a pelvic anastomotic leak, reducing the risk of permanent stoma and resulting in acceptable bowel function. Endosponge™-specific complications can occur.

Delayed transanal repair of persistent coloanal anastomotic leak in diverted patients after resection for rectal cancer

Anastomotic leakage is a feared complication of colorectal surgery and can be devastating in low pelvic anastomosis. With the advent of nonoperative treatments for leakage, the question of management of persistent low colorectal and coloanal anastomosis arises. A review of patients who have undergone transanal repair of anastomotic leakage is presented. A review of all anastomoses performed in the Division of Colorectal surgery at two institutions, from January 2000 to June 2008, was performed. Anastomotic leakage was defined as the finding at reoperation of a dehiscence, or radiographic findings of extravasation from the anastomosis, or the identification of intra-abdominal abscess formation at the site of the anastomosis, enterocutaneous fistula or rectovaginal fistula. Patients who underwent transanal repair of the leakage were identified. There were 663 low anterior resections performed during the study period. Of these, 36 experienced leakage of a low colorectal or coloanal anastomosis. Of these 36 patients, five underwent transanal repair of the anastomotic leak. All had had a low anterior resection for rectal cancer (coloanal=4; low colorectal anastomosis=1). Four had had prior chemoradiation and ileostomy defunctioning at the initial operation. The fifth had an ileostomy created to treat a leak. Six transanal repairs were performed, including endorectal advancement flap (n=3), dermal flap (n=1), direct suture repair (n=1) and debridement of an infected cavity (n=1). At the time of the present assessment, four patients had undergone reversal of ileostomy after radiographic evidence of complete healing and the fifth patient has a persistent leak. Transanal repair of a persistent low colorectal or coloanal anastomotic leakage is feasible in selected cases, even when chemoradiation has been performed.

Risk Factors for Anastomotic Leakage After Colectomy

Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication. The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis. The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed. This study was performed at academic and community medical centers in the state of Michigan. Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010. Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage. Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003. The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review. Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.