Low Anastomosis Research Articles

"Virtual ileostomy" combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report.

Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A "virtual ileostomy" (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis. This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016. We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%. The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity.

How can we operate safely in the setting of immunosuppression? Sims et al.

While the effect of immunosuppressive therapy on postoperative outcomes have been thoroughly evaluated in patients with inflammatory bowel disease, there are less outcome data in immunosuppressed patients undergoing surgery for colorectal cancer. Sims et al. 1 utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine the effect of immunosuppression on 30-day postoperative morbidity and mortality following surgery for colon and rectal cancer. As one might expect, the authors found an increased rate of 30-day postoperative morbidity and mortality in the group receiving immunosuppression. While this is useful information and captures a large number of patients, there are important limitations to the ACS-NSQIP database. First, the definition of ‘immunosuppression’ includes corticosteroids, immunomodulators and biologics. While we can assume that most of these patients are on corticosteroids, the database does not separate the patients into cohorts based on immunosuppressive type. From the literature in inflammatory bowel disease, we know that various immunosuppressives are more consistently shown to be higher risk for postoperative complications – corticosteroids are associated with increased postoperative morbidity 2, 3, immunomodulators do not appear to increase risk of postoperative morbidity 4, and biologic therapy remains controversial 3, 5, 6. Second, the definition of ‘immunosuppression’ does not, after 2011, include chemotherapeutic regimens which may contribute to perioperative complications. Third, there are no long term data to better understand if infectious complications or anastomotic leaks impact long term oncologic outcomes or stoma reversal rates. Despite these limitations, the authors point out that immunosuppression does increase morbidity, namely in the infectious complications as septic complications and surgical site infectious were increased while pulmonary, cardiovascular, renal, and neurologic complications remained unchanged. Therefore, holding immunosuppression, lowering doses, and having a lower threshold to divert low anastomoses may be warranted in patients undergoing abdominal surgery for colon and rectal cancer.

Prevencinės ileostomos uždarymo artimieji rezultatai

[straipsnis ir santrauka lietuvių kalba; santrauka anglų kalba]
 Įvadas
 Prevencinės ileostomos (PI) dažniausiai formuojamos siekiant apsaugoti žemą tiesiosios žarnos jungtį nuo jos nepakankamumo. PI dažniausiai atliekamos operuojant apatinės tiesiosios žarnos dalies vėžį.
 Tikslas
 Apžvelgti PI uždarymo artimuosius rezultatus.
 Metodika
 Atlikta retrospektyvi 2015–2017 m. LSMU KK Chirurgijos skyriuje, Koloproktologijos sektoriuje operuotų pacientų, kuriems operacijos metu buvo uždaryta ileostoma, duomenų analizė. Analizuotas amžius, lovadienių skaičius, komplikacijos, nagrinėta, ar buvo taikytas neoadjuvantinis gydymas prieš operaciją, laikas iki iloestomos uždarymo, rezekcijos tipas, jungties rūšis,operacijos trukmė ir pooperacinis laikotarpis. Statistinė duomenų analizė atlikta naudojant Microsoft Excel programą.
 Rezultatai
 Išanalizuotos 64 pacientų – 34 vyrų (53,12 %) ir 30 moterų (46,88 %) – ligos istorijos. Pacientai operuoti dėl tiesiosios, klubinės, riestinės žarnos navikų ir dėl perforavusio divertikulito. Pacientų amžiaus vidurkis – 64±3,1 metų. Neoadjuvantinis gydymas prieš operaciją skirtas 16 pacientų (25 %). Prevencinė ileostoma buvo uždaryta vidutiniškai po 5,17±0,95 mėnesių.
 Pacientų hospitalizacijos trukmės vidurkis – 5,7±0,74 dienos. Operacijos trukmė vidutiniškai buvo 75,93±8,57 min. Operacijos metu žarnos segmento rezekcija atlikta 38 pacientams (59,37 %). Suformuotos jungtys: „galas su galu“ – 20 pacientų (52,63 %), „galas su šonu“ – 13 pacientų (34,21 %) ir „šonas su šonu“ – 5 pacientams (13,16 %). Po PI uždarymo ankstyvosios komplikacijos pasireiškė septyniems pacientams (10,94 %). Kraujavimas iš anastomozės vietos pasireiškė dviem pacientams (3,12 %). Vienam iš jų buvo atlikta jungtis „galas į šoną“, kitam – kraštinė rezekcija. Ritmo sutrikimas atsirado dviem pacientams (3,12 %). Žarnų nepraeinamumo simptomai pasireiškė taip pat dviem pacientams (3,12 %). Vienam iš jų buvo atlikta kraštinė rezekcija, kitam – segmento rezekcija ir suformuota jungtis „galas su galu“. Po kraštinės rezekcijos vienam pacientui (1,58 %) susiformavo pilvo sienos abscesas. Pakartotinės operacijos nereikėjo.
 Išvados
 1. Uždarant PI operacijos metu, segmento rezekcija atliekama 59,37 % pacientų. 2. Vidutinis laikas iki ileostomų uždarymo yra penki mėnesiai. 3. Atliekant segmento rezekciją, dažnesnė nesklandi pooperacinė eiga. 4. Palyginti su segmento rezekcijos pooperacine eiga, formuojant jungtį „galas su galu“, laikotarpis po operacijos yra sklandesnis.

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann's Operation or Intersphincteric Abdomino-Perineal Excision?

In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann's procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired. A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann's procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival. There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann's procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann's procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann's procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien-Dindo 3-4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann's procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively. The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann's procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

PS01.093: REPEAT ESOPHAGEAL STRICTURE RESECTION: WHAT FACTORS ARE MOST INFLUENTIAL?

Abstract Background The objective of this study was to identify whether paralysis time following stricture resection and tension applied at the anastomosis influenced leak rate, need for repeat stricture resection (SR), or need for an interposition graft. Methods A retrospective chart review was performed of patients undergoing esophageal stricture resection and anastomosis from October 2007 to July 2017 (IRB# P00004344). Patients who required an interposition as their primary surgery were excluded. Leak rates following stricture resection and the need for further esophageal surgery was identified. Tension groups were also delineated into mild, moderate, and high anastomotic tension. Anastomotic tension and paralysis times were analyzed by multivariable logistic regression and area under the curve (AUC) to determine factors associated with development of leaks and an increased risk of repeat SR. Results Ninety-four patients were identified; 45 were males and mean gestational age was 35 weeks. Fifty-one patients were categorized with mild tension, 35 with moderate, and 8 with high tension. Four of the 51 patients (8%) with low tension and 15/43 (35%) with moderate or high tension developed leaks (P = 0.002). Seventeen patients overall required repeat SR (18%), including 3/51 with low tension (6%) versus 14/43 (33%) with moderate or high tension (P &lt; 0.001). Additionally, 12/17 (71%) patients requiring repeat operations initially had a Foker process for their esophageal atresia. Multivariable analysis indicated that moderate/high tension (P = 0.006) and longer paralysis time (p 0.04) were predictive of a leak after initial SR (AUC = 0.720). Paralysis time of 7 + days (P = 0.05), moderate/high tension (P = 0.05) and occurrence of a leak (P = 0.002) were independent risk factors for the need for repeat SR (AUC = 0.861, 95% CI: 0.772–0.949). Of the 17 patients with repeat SR, 10 (59%) underwent a jejunal interposition. Conclusion Tension, paralysis time, and presence of a leak are independent risk factors for repeat SR. Low tension anastomoses had a significantly small incidence of repeat surgery. Esophageal replacement shoudl be considered earlier among patients who originally undergo a Foker procedure for esophageal continuity and for those whose stricture repair is placed under moderate or high tension. Disclosure All authors have declared no conflicts of interest.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery.

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Late assessment of quality of life in patients with rectal carcinoma: comparison between sphincter preservation and definitive colostomy

PurposePatients with cancer of the lower and middle rectum who are candidates for curative surgery often have negative opinions on definitive colostomy. The purpose of this study is to compare the quality of life (QoL) of patients who undergo standard treatment for rectal cancer with sphincter preservation or definitive colostomy.MethodsA total of 125 patients with adenocarcinoma of the lower or middle rectum who underwent radical surgery with curative intent with a follow-up ≥ 1 year were recruited: 83 patients (group 1) were subjected to low anterior resection and low colorectal or coloanal anastomosis—thus preserving their sphincter—and 42 (group 2) were treated with abdominoperineal resection, followed by terminal definitive colostomy. QoL was assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires.ResultsHealth and global quality of life were similar between groups; however, patients who underwent definitive colostomy had higher scores on the emotional (p value = 0.016) and cognitive function scales (p value = 0.017). Patients with sphincter preservation presented with more symptoms that were related to stool frequency (p value < 0.001), intestinal constipation (p value = 0.005), fecal incontinence (p value = 0.001), buttock pain (p value = 0.023), and nausea and vomiting (p value = 0.036), whereas patients with permanent colostomy had higher scores for dysuria (p value = 0.033).ConclusionAlthough global QoL scores did not differ between groups, patients who underwent definitive colostomy had significantly better functional and symptom scale scores, reflecting greater function with fewer symptoms.

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.

Anastomotic leakage after side-to-end anastomosis for rectal cancer: does leakage location matter?

To assess outcome according to location of anastomotic leakage (AL) after side-to-end stapler or manual low colorectal or coloanal anastomosis following laparoscopic total mesorectal excision (TME) for rectal cancer. All patients presenting with symptomatic or asymptomatic AL after TME and side-to-end low anastomosis for rectal cancer performed from 2005 to 2014 were identified from our prospective database. CT-scans with contrast enema were reviewed to assess location of AL origin. Among 279 patients who underwent TME with side-to-end anastomosis from 2005 to 2014, 70 patients presented with AL and were included: 43 (61%) patients with AL on the circular anastomosis (CAL) were compared to 27 (39%) with AL on the transverse stapling line of the colonic stump (TAL). CAL and TAL were associated with similar rates of symptomatic AL (63% versus 48%, respectively; p=0.339), severe postoperative morbidity rate (33% versus 18%; p=0.313), and long-term outcomes, including definitive stoma rate (10 versus 11%; p=0.622), and major low anterior resection syndrome rate (56% vs 57%; p=0.961). Our study showed that whatever the location of AL on a side-to-end low colorectal or coloanal anastomosis after TME for cancer, both short and long-term outcomes are similar. This article is protected by copyright. All rights reserved.

Usefulness of self-made gasbag double-cannula stool drainage device for prevention of anastomotic leakage following anterior resection

To evaluate the efficacy of self-made gasbag double-cannula stool drainage device for prevention of anastomotic leakage following anterior resection. Clinical data of 169 rectal cancer patients in the 8th Affiliated Hospital of Sun Yat-sen University between October 2010 and October 2016 were retrospectively analyzed. Among them, a self-made gasbag double-cannula stool drainage device was placed in 71 patients(stool drainage group), and the remaining 98 patients were taken as control. After an anastomosis, the drainage device was transanally placed by the assistant and the distal tube of drainage device was stretched more than 15 cm from anastomosis. The gasbag was inflated to fully expand the intestine. The main tube was fixed on perianal skin with 7-0 suture, kept more than 3-5 cm outside the anus, and connected to the drainage bag. The incidence of anastomotic leakage was compared between the two groups. The baseline data were similar between the two groups (all P>0.05). The differences in operative time, intraoperative blood loss, and time to bowel function recovery were not statistically significant (all P>0.05), however, time to oral intake and postoperative stay were shorter in stool drainage group as compared to the control group (both P<0.05). There was no perioperative death in both groups. In stool drainage group, there were 6 cases whose drainage device was pulled out within 48 hours due to intolerance. The ruptured gasbag was replaced 5 times and the tube was clogged by fecal material 21 times. After flushing, the tube did not recanalized and was pulled out in 3 cases. The incidence of anastomotic leakage in stool drainage group was significantly lower than that in the control group (2.8% vs. 11.2%, P=0.043). As for the low anastomosis (the distance to anal verge less than 5 cm), the incidence of anastomotic leakage in stool drainage group was also significantly lower than that in the control group (2.3% vs. 15.4%, P=0.028), while as for the high anastomosis, the difference was not statistically significant (3.6% vs. 3.0%, P=0.906). Logistic regression analysis revealed that the presence of a stool drainage device was an independent protective factor for anastomotic leakage (OR=0.316, 95%CI:0.114 ~ 0.769, P=0.003). The self-made gasbag double-cannula stool drainage device effectively prevents anastomotic leakage after anterior resection of rectal cancer. However it is not suitable for those patients with high anastomosis.

Transanal Hartmann's colostomy reversal assisted by laparoscopy: outcomes of the first 10 patients.

Restoration of intestinal continuity after Hartmann's procedure is a technically difficult surgery associated with significant morbidity and mortality. This study presents the short-term results of a new approach: a transanal Hartmann's colostomy reversal assisted by laparoscopy. This is a retrospective analysis of data collected in one tertiary hospital, from October 2013 to November 2015. During the study period, there were ten cases of transanal Hartmann's reversal. Reasons for Hartmann's procedure were: complicated diverticulitis (4), anastomotic leak (3), and recto-sigmoid cancer (3). Rectal stump length was 10.4 ± 4.5cm. Reconstruction was achieved in all patients. One low colorectal anastomosis was hand-sewn, the other 9 were stapled. Mean operative time was 204 ± 65min. Diverting loop ileostomies were created in five patients and all were closed during the following year. One case required hand-assistance but there was no conversion to open surgery. Iatrogenic laparoscopic enterotomies occurred in four patients and all were repaired primarily without consequences. Three patients had a total of four post-operative complications: ileus (2), abdominal abscess and wound infection (1). None required reoperation. Mean length of stay was 7.2 ± 4.3 days. One required readmission. A transanal Hartmann's reversal assisted by laparoscopy is a new approach for a difficult surgery. It has the potential to be an additional tool in the case of hostile pelvises or with a rectal stump difficult to identify. The surgery remains challenging and indications need to be clarified.

Anorectal functional outcome following laparoscopic low anterior resection for rectal cancer.

Low anterior resection (LAR) with total mesorectal excision has been considered a standard treatment for patients with rectal cancer. However, the functional outcome and life quality of laparoscopic LAR (LLAR) in Chinese patients remain unclear. A cohort of 51 Chinese patients (22 men and 29 women) who had undergone LLAR was included in this study. Anorectal manometry combined with the Wexner scores questionnaire were applied to assess functional outcome preoperatively (1 week) and postoperatively (at 3, 6 and 9 months). The validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires were also used to assess the patients' quality of life at the indicated time points. The results demonstrated that the manometric parameters exhibited a temporary decrease at 3 months postoperatively, but a gradual increase at 6 and 9 months, while the Wexner scores exhibited an opposite trend. Furthermore, patients with high anastomoses had significantly higher manometric parameters, a lower frequency of incontinence and lower Wexner scores compared with those with low anastomoses at 9 months (all P<0.05). For the entire cohort, quality of life at 3 months postoperatively was worse compared with the preoperative level, but returned to normal by 9 months. Patients with high anastomoses exhibited significantly better role, emotional and social function, had a better body image and sexual function, fewer problems with defecation and lower frequency of diarrhea, as well as fewer chemotherapy-related side effects at 6 months postoperatively when compared with the low anastomosis group (all P<0.05). In conclusion, LLAR is generally acceptable for Chinese patients with rectal cancer, particularly for those with middle or high rectal cancer, in terms of functional outcome and quality of life.

Fistulas after Low Anterior Resection with TME

Despite advances in modern anastomotic techniques for colorectal surgery, anastomotic fistulas are still considered a dreaded complication, with a reported rate varying from 2 to 25%. Although fistulas can appear after any bowel anastomosis, it seems that low colorectal anastomosis are the most prone to such complications. Herein we aim to provide a review on our own experience with postoperative anastomotic fistulas after low colorectal anastomosis. Between 1998 and 2016, 62 patients had a LAR procedure with TME and low colorectal anastomosis. The mean age was 62.29 years. Triple stapled side to end colorectal anastomosis was the preferred technique with protective ileostomy. We report a fistula rate of 9.67% (6 cases) after Low Anterior Resection including blind fistula seen on first month follow-up endoscopic evaluation. While blind fistulas generated little morbidity, clinically manifested fistulas posed significant management challenge. Nevertheless we report no mortality related to fistula. Indubitably, more research is needed to establish a proper prevention guideline for anastomotic leaks, a “golden-standard” anastomotic technique and ideal management criteria for fistulas.

THE TRANSANAL REINFORCEMENT OF LOW COLORECTAL ANASTOMOSIS: FIRST EXPERIENCE AND PERSPECTIVES

AIM. It was to evaluation the effect of using of transanal reinforcement of low colorectal anastomosis to the frequency of anastomotic leakage. MATERIALS AND METHODS. The study included six patients who underwent a low anterior resection for rectal cancer and the transanal reinforcement anastomosis. Preventive stomas not formed. RESULTS. The study contains an analysis of the immediate results of patients treatment. The leakage of the anastomosis was developed in 3 of 6 patents. This required break down of the anastomosis in one and the formation of diverting stoma in two patients. CONCLUSION. The first experience of the transanal reinforcement for low colorectal anastomosis is unsuccessful because of leakage appeared in every second patient. More careful selection of patients for this method is required.

Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly.

Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.

Colorectal anastomosis using a compression device

Abstract Background The most severe complication following an intestinal anastomosis is the dehiscence with the consequent development of sepsis, fistulas, stenosis, and death. For this reason the compression anastomosis (NiTi) system was developed, with the aim of reducing these complications. Material and methods A retrospective study was conducted, from 1 June 2012 to 30 August 2014, on total of 14 patients operated on the Humanitas Hospital Medical Group Coyoacan, the ASMED, and Clinica Medica Sur. The subjects were predominantly male 65%, a mean age of 58 years, with range 30–79 years. Results A total of 14 patients were included. The indication for surgery was complicated diverticular disease Hinchey II–III (36%), and the procedures performed were: 6 (43%) left hemicolectomy with primary end to end compression anastomosis, 2 (14%) major complications (dehiscence wall and anastomosis), 1 (7%) minor complication (infection of the soft tissues). There was a mean 98 ml (range 20–300 ml) of intraoperative bleeding, with start of oral feeding on the second day, a mean hospital stay of 4 days (range 2–10), one patient with ileo-rectal anastomosis dehiscence presented on the 4th post-operative day, and performing anastomosis with stapling device and loop ileostomy. Stenosis developed in 7% during follow-up and was resolved with a new anastomosis stapler. Conclusions The NiTi device is an additional alternative for colorectal anastomosis, mainly in low anastomosis, obtaining good results in this study without major complications.

Early endoscopic closure of colocutaneous fistula adjacent to unmatured low colorectal anastomosis with the Over-The-Scope Clip (OTSC)

We herein describe the case of an 82-year-old man with colocutaneous fistula adjacent to an unmatured but intact low colorectal anastomosis after low anterior resection for rectal adenocarcinoma. Early in the course, an OTSC (Over-The-Scope Clip) was successfully placed onto the fistula’s internal orifice, with concomitant reduction in our patient’s morbidity.

Prevention and management of anastomotic bleeding after laparoscopic anterior resection of rectal cancer

In recent years, the laparoscopic anterior rectal cancer resection is increasingly applied in clinical practice, however, laparoscopic operations and stapling techniques can bring a series of related complications. The anastomotic bleeding is one of the early complications in laparoscopic anterior rectal cancer resections. If the continuous anastomotic bleeding is not diagnosed or managed in time, it could lead to serious consequences, such as secondary surgery and shock. Therefore, the diagnosis and treatment of anastomotic bleeding is meaningful. This paper investigates the reasons of anastomotic bleeding after laparoscopic anterior resection of rectal cancer, and introduces related preventions and treatments. Conservative treatment can be used first for small or delayed bleeding. As for acute bleeding from low anastomosis, transanal suture hemostasis can be considered. When the bleeding comes from high anastomosis and is massive and active, laparoscopic or open surgery must be performed immediately.

Prevention and control of postoperative anastomotic leak after colorectal anastomosis

Anastomotic leak is a major complication after colorectal resection. Risk factors for anastomotic leak include patient and disease related factors, preoperative factors(e.g. use of neoadjuvant chemoradiation and mechanical bowel preparation), intraoperative factors(e.g. anastomotic techniques, performing of water injection test, preventive colostomy, and surgical procedures, etc; postoperative factors, such as postoperative medication use, etc. Early diagnosis of anastomotic fistula is crucial, which can be made by combining laboratory examination with imaging examination or take the prediction and diagnosis model as reference. Once diagnosed, anastomotic leak should be managed immediately according to individual status and severity of disease. As for intraperitoneal anastomosis, no matter whether the bowel lack of blood supply or not, original anastomosis should be removed and terminal loop ileumstomy should be created. As for extraperitoneal anastomosis(mainly low rectal anastomosis), adequate drainage and terminal loop ileumstomy can be considered when anastomosis is slightly cracked or invisible due to adhesion. When anastomosis is severely cracked or blood supply is too limited, however, we must disconnect the original anastomotic and create a proximal colostomy.

Complications of Loop Ileostomy upon the Creation of Low Colorectal Anastomosis

Complications of Loop Ileostomy upon the Creation of Low Colorectal Anastomosis