Occurrence Of Anastomotic Leakage Research Articles

Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study

BackgroundIt was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery.MethodsA total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch’s t tests, one-way ANOVA, chi-square tests and Fisher’s exact tests were applied.ResultsThere was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups.ConclusionsUsing mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.

Preoperative risk factors for anastomotic leak after esophagectomy with gastric reconstruction: A 6-year national surgical quality improvement (NSQIP) database analysis

BackgroundAnastomotic leak is a serious complication after esophagectomy that has been associated with worse outcomes. However, identifying patients at increased risk for anastomotic leak remains challenging. MethodsPatients were included from the 2016 to 2021 National Surgical Quality Improvement Project database who underwent elective esophagectomy with gastric reconstruction for cancer. A multivariable logistic regression model was used to identify risk factors associated with anastomotic leak. ResultsA total of 4,331 patients were included in the study, of whom 647 patients experienced anastomotic leak (14.9%). Multivariable logistic regression revealed higher odds of anastomotic leak with smoking (adjusted odds ratio 1.24, confidence interval 1.02–1.51, P = .031), modified frailty index-5 score of 1 (adjusted odds ratio 1.44, confidence interval 1.19–1.75, P = .002) or 2 (adjusted odds ratio 1.52, confidence interval 1.19-1.94, P = .000), and a McKeown esophagectomy (adjusted odds ratio 1.44, confidence interval 1.16–1.80, P = .001). Each 1,000/μL increase in white blood cell count was associated with a 7% increase in odds of anastomotic leak (adjusted odds ratio 1.07, confidence interval 1.03–1.10, P = .0005). Higher platelet counts were slightly protective, and each 10,000/ μL increase in platelet count was associated with 2% reduced odds of anastomotic leak (adjusted odds ratio 0.98, confidence interval 0.97–0.99, P = .001). ConclusionIn this study, smoking status, frailty index, white blood cell count, McKeown esophagectomy, and platelet counts were all associated with the occurrence of anastomotic leak. These results can help to inform surgeons and patients of the true risk of developing anastomotic leak and potentially improve outcomes by providing evidence to improve preoperative characteristics, such as frailty.

A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy.

The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.

Quantification of fluorescence angiography for visceral perfusion assessment: measuring agreement between two software algorithms

BackgroundIndocyanine green fluorescence angiography (ICG-FA) may reduce perfusion-related complications of gastrointestinal anastomosis. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for visceral perfusion assessment between two independently developed quantification software implementations.MethodsThis retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analyzed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland–Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations.ResultsSeventy pre-anastomosis ICG-FA recordings were included in the study. The Bland–Altman analysis indicated a mean relative difference of + 58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < 0.001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively).ConclusionThis is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.

Impact of Arteriosclerosis on Reconstruction-related Complications After Esophagectomy and Usefulness of Tailor-made Reconstruction Technique.

Anastomotic leakage is one of the most common and serious postoperative complications following esophagectomy. This study analyzed the effect of risk factors, such as the degree of arteriosclerosis, comorbidities, and patient characteristics on the incidence of reconstruction-related complications including anastomotic leakage. Furthermore, the usefulness of tailor-made reconstruction methods was clarified using wide gastric conduit. Patients who underwent esophagectomy with a gastric conduit for esophageal cancer between 2011 and 2018 were enrolled. In the initial group that underwent esophagectomy between August 2011 and February 2016, gastrointestinal reconstruction was performed using a narrow gastric conduit. In the latter group, reconstruction using subtotal gastric conduit was selected for high-risk patients between March 2016 and March 2018. Postoperative complications including reconstruction-related complications were assessed. The occurrence of anastomotic leakage was significantly associated with the patient's risk in the initial group. The rates of anastomotic leakage and reconstruction-related complications were significantly lower in the latter group than in the initial group (3.2% vs. 23.0%, p=0.001; 27.0% vs. 44.3%, p=0.044). The incidence of all complications was significantly lower in the latter group than in the initial group (28.6% vs. 59.0%, p=0.001). The change in bodyweight loss one year after the operation was significantly lower in the latter group than in the initial group (p=0.042). Tailor-made reconstruction using wide gastric conduit for high-risk cases of esophageal cancer could reduce the occurrence of anastomotic leakage and promote a better quality of life after surgery.

Catheter-guided anvil insertion for circular stapler esophagojejunal anastomosis: a novel technique in laparoscopic total gastrectomy.

This study evaluates feasibility, safety, and short-term outcomes of employing the catheter-guided stapler anvil insertion technique for esophagojejunal anastomosis using a circular stapler during laparoscopic total gastrectomy (LTG). From September 2021 to April 2023, the catheter-guided stapler anvil insertion technique was employed in 80 patients undergoing laparoscopic total gastrectomy (LTG) for esophagojejunal anastomosis. A modified D2 dissection, according to the en bloc technique, was performed in the patients. Subsequently, a longitudinal incision, approximately 2cm in length, was made on the anterior wall of the esophagus, about 2cm above the tumor. The transection line was pre-marked with blue dye along the esophagus's minor axis, and the tail of the anvil was capped with a 10-cm length ofcatheter (F14 d4.7mm). The surgeon secures the head of anvil and carefully inserts it into the esophagus, ensuring that only a 5-cm segment of the catheter remains outside the esophagus. A linear cutter was employed to transect and seal the lower end of the esophagus. Subsequently, esophagojejunostomy was performed under laparoscopic guidance using a circular stapler. Among patients undergoing esophagojejunal anastomosis with the new technique, postoperative complications included pneumonia or pleural effusion in 14 patients (17.5%), anastomotic stenosis in 3 patients (3.75%), abdominal infection in 2 patients (2.5%), and intestinal obstruction in 1 patient (1.25%). No instances of anastomotic leakage, anastomotic bleeding, or deaths were recorded. All patients experiencing complications improved with conservative treatment, without the need for secondary surgery. The catheter-guided stapler anvil insertion technique is demonstrated to be a safe and effective method for esophagojejunostomy, potentially reducing the occurrence of anastomotic leakage.

Does transanal drainage tubes placement have an impact on the incidence of anastomotic leakage after rectal cancer surgery? a systematic review and meta-analysis

BackgroundWhether Transanal drainage tubes (TDTs) placement reduces the occurrence of anastomotic leakage (AL) after rectal cancer (RC) surgery remains controversial. Most existing meta-analyses rely on retrospective studies, while the prospective studies present an inadequate level of evidence.MethodsA systematic review and meta-analysis of prospective studies on TDTs placement in RC patients after surgery was conducted. The main analysis index was the incidence of AL, Grade B AL, and Grade C AL, while secondary analysis index was the incidence of anastomotic bleeding, incision infection, and anastomotic stenosis. A comprehensive literature search was performed utilizing the databases Cochrane Library, Embase, PubMed, and Web of Science. We recorded Risk ratios (RRs) and 95% confidence intervals (CI) for each included study, and a fixed-effect model or random-effect model was used to investigate the correlation between TDTs placement and four outcomes after RC surgery.ResultsSeven studies (1774 participants, TDT 890 vs non-TDT 884) were considered eligible for quantitative synthesis and meta-analysis. The meta-analysis revealed that the incidence of AL was 9.3% (83/890) in the TDT group and 10.2% (90/884) in the non-TDT group. These disparities were found to lack statistical significance (P = 0.58). A comprehensive meta-analysis, comprising four studies involving a cumulative sample size of 1259 participants, revealed no discernible disparity in the occurrence of Grade B AL or Grade C AL between the TDT group and the non-TDT group (Grade B AL: TDT 34/631 vs non-TDT 26/628, P = 0.30; Grade C AL: TDT 11/631 vs non-TDT 27/628, P = 0.30). Similarly, the incidences of anastomotic bleeding (4 studies, 876 participants), incision infection (3studies, 713 participants), and anastomotic stenosis (2studies, 561 participants) were 5.5% (24/440), 8.1% (29/360), and 2.9% (8/280), respectively, in the TDT group, and 3.0% (13/436), 6.5% (23/353), and 3.9% (11/281), respectively, in the non-TDT group. These differences were also determined to lack statistical significance (P = 0.08, P = 0.43, P = 0.48, respectively).ConclusionThe placement of TDTs does not significantly affect the occurrence of AL, Grade B AL, and Grade C AL following surgery for rectal cancer. Additionally, TDTs placement does not be associated with increased complications such as anastomotic bleeding, incision infection, or anastomotic stenosis.Trial registrationPROSPERO: CRD42023427914

Evaluation of the Usefulness of Contrast-Enhanced Computed Tomography for the Early Detection of Anastomotic Leakage After Esophagectomy.

Anastomotic leakage is one of the most severe complications after esophagectomy. However, a diagnostic gold standard for anastomotic leakage has not been established yet. This retrospective cohort study aimed to evaluate the potential use of routine postoperative contrast-enhanced computed tomography findings as an early predictor of anastomotic leakage in patients who underwent esophagectomy for esophageal cancer. This study included 75 patients who underwent Mckeown esophagectomy, of whom 22 developed anastomotic leakage after surgery. The computed tomography findings for this patient cohort were categorized into 3 grades based on mural enhancement patterns observed at the anastomotic site. Both semiquantitative and quantitative analyses were performed, and the interobserver agreement between the 2 experienced radiologists was assessed. It was found that poor enhancement in both the early and portal venous phases (grade 2) had a robust association with the occurrence of anastomotic leakage. The computed tomography enhancement ratio that is used to estimate wall degeneration and ischemia was significantly higher in patients with anastomotic leakage. Routine postoperative contrast-enhanced computed tomography could be beneficial for the early detection of anastomotic leakage, even in asymptomatic patients, after esophagectomy.

Primena transanalnog drena nakon prednje resekcije rektuma - uticaj na prevenciju nastanka "Ahilove tetive" kolorektalne hirurgije

Aim: The aim of our study was to investigate the potential reduction in the likelihood of anastomotic leakage occurrence in patients undergoing open anterior resection of the rectum without a protective stoma for stage III adenocarcinoma, by employing a transanal tube after performing stapled colorectal anastomosis. Results: Considering the influence of all included risk factors, male gender (p=0.032; OR=2.873) and patients with type 2 diabetes mellitus (p=0.033; OR=2.873) demonstrated an increased likelihood of anastomotic leakage, while the presence of a transanal tube (p=0.043; OR=0.349; 95% CI: 0.126, 0.966) was associated with a statistically significant reduction in the likelihood of anastomotic leakage. T-test revealed that patients with anastomotic leakage without a placed tube had a statistically significantly longer mean postoperative hospitalization (20.94 days) compared to those with a transanal tube (19.43 days) (t=2.375; p=0.025). Kaplan-Meier analysis didn't show a statistically significant difference in the average estimated time to the occurrence of anastomotic leakage between patients without (3.86 days) and with a transanal tube (4.58 days) (p=0.057). Conclusion: Our study found that the placement of a transanal tube after colorectal anastomosis may be associated with a reduced likelihood of anastomotic leakage and shorter hospitalization in case leakage occurs. Additionally, although no statistically significant difference was found in the effect of the tube on the occurrence of anastomotic leakage depending on the presence of type 2 diabetes mellitus, the indication for its use in patients with type 2 diabetes mellitus may be of particular benefit.

Predictive factors of postoperative anastomotic leakage after bowel surgeries, retrospective chart review

Objective: This study aimed to identify host-related and operation-related risk factors and recognize factors that can help in predicting postoperative anastomotic leakage. Methods: It was a retrospective analytical study, conducted in King Fahad Specialist Hospital, Saudi Arabia. Data were collected from medical records. Results: The current study revealed male predominance (57.8%) with 35.9% aged over 60 years. Most participants had no Crohn\&amp;apos;s Disease (81.4%). Hemicolectomy was the common procedure (50.8%), with tumor resection as the primary cause (49.5%). Anastomotic leakage (36.9%) was prominent, and associated with lower albumin levels. Surgery site, reason, and Crohn\&amp;apos;s Disease did not significantly correlate. Bowel resection/anastomosis and emergent surgeries showed notable associations with anastomotic leakage. Conclusion: The study highlighted male predominance and a significant occurrence of anastomotic leakage, correlated with lower albumin levels. Surgery site, reason, and Crohn\&amp;apos;s Disease did not show significant associations, contrasting with bowel resection/anastomosis and emergent surgeries.

Influential Factors Affecting Intestinal Anastomotic Leakage and Their Predictive Significance

Background: The occurrence of anastomotic leakage following intestinal surgery stands as a significant contributor to postoperative complications and fatalities. This prospective study was conducted with the aim of assessing different factors associated with the risk of anastomotic leakage. Methods: This study was carried out within the Department of Surgery over the course of one year. It encompassed patients who underwent intestinal anastomosis, whether in emergency situations or as part of routine surgical procedures. The study encompassed a total of 150 patients. Results: Anastomotic leakage was identified in 18.02% of cases, with a higher incidence among males and individuals from a lower socioeconomic background. However, age, gender, and socioeconomic status were not found to be significant risk factors for anastomotic leakage. The incidence of leaks was elevated in patients with chronic illnesses such as malignancy, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and those on chronic corticosteroid therapy. Additionally, malnourished patients and those with sepsis, as indicated by their blood investigation reports, had a notably higher leak rate. After conducting logistic regression analysis, several independent predictors for anastomotic leaks were identified, including peritonitis (\(p&lt; 0.05;\) odds ratio \(2.156\)), bowel obstructions (\(p&lt; 0.05\); odds ratio \(2.864\)), receiving more than 2 units of blood transfusion (\(p&lt; 0.05\); odds ratio \(2.334\)), serum albumin levels \(&lt; 3.0\) gm/dL (\(p&lt; 0.001\); odds ratio \(8.873\)), corticosteroid therapy (\(p&lt; 0.001\); odds ratio \(4.877\)), serum creatinine levels \(&gt;1.2\) mg/dL (\(p&lt; 0.001\); odds ratio 11.785), surgery duration exceeding 4 hours (\(p&lt; 0.01\); odds ratio 3.0251), and ASA Grading (III &amp; IV) (\(p&lt; 0.01\); odds ratio 3.707). Conclusion: This study has successfully identified key risk factors that influence the occurrence of anastomotic leakage. The findings from this research are expected to be valuable in efforts to mitigate the incidence of anastomotic leakage following surgery.

Nomogram prediction model of cervical anastomotic leakage after esophageal cancer surgery

Objective: To retrospectively analyze the risk factors of anastomotic leakage in the neck after esophageal cancer and establish a nomogram prediction model that can accurately predict the occurrence of anastomotic leakage in the neck of the patient. Methods: The study retrospectively analyzed 702 patients who underwent radical esophageal cancer surgery between January 2010 and May 2015 at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. A multivariate logistic regression model was used to determine the risk factors for neck anastomotic leak, and a nomogram model was constructed, internal validation methods were used to evaluate and verify the predictive effectiveness of the nomogram. Results: There were 702 patients in the whole group, 492 in the training group and 210 in the validation group. The incidence of postoperative cervical anastomotic leak was 16.1% (79/492) in 492 patients with esophageal cancer in the training group. Multifactorial analysis revealed calcification of the descending aorta (OR=2.12, 95% CI: 1.14, 3.94, P=0.018), calcification of the celiac artery (OR=2.29, 95% CI: 1.13, 4.64, P=0.022), peripheral vascular disease (OR=5.50, 95% CI: 1.64, 18.40, P=0.006), postoperative ventilator-assisted breathing (OR=5.33, 95% CI: 1.83, 15.56, P=0.002), pleural effusion or septic chest (OR=3.08, 95% CI: 1.11, 8.55, P=0.031), incisional fat liquefaction and infection (OR=3.49, 95% CI: 1.68, 7.27, P=0.001) were independent risk factors for the development of cervical anastomotic leak after esophageal cancer surgery. The results of the nomogram prediction model showed that the consistency indices of the training and external validation groups were 0.73 and 0.74, respectively (P<0.001), suggesting that the prediction model has good predictive efficacy. Conclusion: The nomogram prediction model can intuitively predict the incidence of postoperative cervical anastomotic leakage in patients with high prediction accuracy, which can help provide a clinical basis for preventing cervical anastomotic leak and individualized treatment of patients.

Applications of indocyanine greenenhanced fluorescence in the laparoscopic treatment of colonic stricture after necrotizing enterocolitis

BackgroundThe status of anastomotic blood perfusion is associated with the occurrence of anastomotic leakage after intestinal anastomosis. Fluorescence angiography (FA) with indocyanine green (ICG) can objectively assess intestinal blood perfusion. This study aims to investigate whether anastomotic perfusion assessment with ICG influences surgical decision-making during laparoscopic intestinal resection and primary anastomosis for colonic stricture after necrotizing enterocolitis.MethodsPatients who underwent laparoscopic intestinal resection and primary anastomosis between January 2022 and December 2022 were retrospectively analyzed. Before intestinal anastomosis, the ICG fluorescence technology was used to evaluate the blood perfusion of intestinal tubes on both sides of the anastomosis. After the completion of primary anastomosis, the anastomotic blood perfusion was assessed again.ResultsOf the 13 cases, laparoscopy was used to determine the extent of the diseased bowel to be excised, and the normal bowel was preserved for anastomosis. The anastomosis was established under the guidance of ICG fluorescence technology, and FA was performed after anastomosis to confirm good blood flow in the proximal bowel. The anastomotic intestinal tube was changed in one case because FA showed a difference between the normal range of intestinal blood flow and the macroscopic prediction. There was no evidence of ICG allergy, anastomotic leakage, anastomotic stricture, or other complications. The median follow-up was 6 months, and all patients recovered well.ConclusionsThe ICG fluorescence technology is helpful in precisely and efficiently determining the anastomotic intestinal blood flow during stricture resection and in avoiding anastomotic leakage caused by poor anastomotic intestinal blood flow to some extent, with satisfactory short-term efficacy.

Anastomotic leak risk factors following colon cancer resection: a systematic review and meta-analysis.

Despite improved surgical techniques, anastomotic leakage is still a serious complication that can occur after colon cancer resection, resulting in increased morbidity and mortality. The aim of this study was to evaluate the risk factors for anastomotic leakage after colon cancer surgery, provide a theoretical basis for reducing its occurrence, and guide the practice of clinicians. A systematic review of PubMed, Ovid, Web of Science and Cochrane Central Register of Controlled Trials databases was conducted by using a combination of subject terms and free words for online searches. The databases were searched from their inception to 31 March 2022, and all cross-sectional, cohort or case‒control studies examining the risk factors for the development of anastomotic fistula after surgery for colon cancer were identified. A total of 2133 articles were searched for this study, and 16 publications were ultimately included, all of which were cohort studies. A total of 115,462 subjects were included, and a total of 3959 cases of anastomotic leakage occurred postoperatively, with an incidence of 3.4%. The odds ratio (OR) and 95% confidence interval (CI) were used for evaluation. Male sex (OR = 1.37, 95% CI: 1.29-1.46, P < 0.00001), BMI (OR = 1.04, 95% CI: 1.00-1.08, P = 0.03), diabetes (OR = 2.80, 95% CI: 1.81-4.33, P < 0.00001), combined lung disease (OR = 1.28, 95% CI: 1.15-1.42, P < 0.00001), anaesthesia ASA score (OR = 1.35, 95% CI: 1.24-1.46, P < 0.00001), ASA class ≥ III (OR = 1.34, 95% CI: 1.22-1.47, P < 0.00001), emergency surgery (OR = 1.31, 95% CI: 1.11-1.55, P = 0.001), open surgery (OR = 1.94, 95% CI: 1.69-2.24, P < 0.00001) and type of surgical resection (OR = 1.34, 95% CI: 1.12-1.61, P = 0.002) are risk factors for anastomotic leakage after colon cancer surgery. There is still a lack of strong evidence on whether age (OR = 1.00, 95% CI: 0.99-1.01, P = 0.36) and cardiovascular disease (OR = 1.18, 95% CI: 0.94-1.47, P = 0.16) are factors influencing the occurrence of anastomotic leakage after colon cancer surgery. Male sex, BMI, obesity, coexisting pulmonary disease, anaesthesia ASA score, emergency surgery, open surgery and type of resection were risk factors for anastomotic leakage after colon cancer surgery. The effect of age and cardiovascular disease on postoperative anastomotic leakage in patients with colon cancer needs further study.

Risk Factors and Outcomes of Occurrence of Anastomotic Leakage and Reoperations for its Management after Colorectal Surgery

Abstract Background Anastomotic leakage (AL) is still the most annoying postsurgery complication after colorectal resection due to its serious complications up to death. Limited data were available regarding differences in AL incidence, management, and consequences for different types of colorectal resection.The aim of the present work was to evaluate differences in incidence of AL, incidence of postoperative complications, and length of hospital stay in a large number of patients who underwent elective colorectal resection for management of colorectal lesions. In addition to detect when and what type of reoperation for management of AL occur after colorectal resection. Patients All 250 included patients underwent elective surgeries for colorectal resection with performance of primary anastomosis for management of colorectal neoplastic and non-neoplastic diseases in the period between May 2016 and July 31, 2021.We followed the patients for 90 days; we registered the follow-up findings. Results the rates of AL occurrence were variable after the different procedures. The lowest rate of AL occurrence was found in patients who underwent right hemicolectomy, then in patients who underwent sigmoidectomy, left hemicolectomy, transversectomy and anterior resection (p = 0.004). A stoma was frequently performed during reoperation (79.5%) which was significantly different between different procedures: 65.5% in right hemicolectomy, 75.0% in transversectomy, 85.7% in left hemicolectomy, and 93.0% in sigmoid resection (p &lt; 0.001). Conclusion Rates, types, time of occurrence and severity of AL vary according to the type of colectomy performed and selective construction of stoma during AL reoperation is currently safely applied with comparable mortality rates for patients who did and who did not have a stoma after reoperation.

Impact of sarcopenia and visceral fat on postoperative morbidity and survival after rectal cancer surgery in patients treated with neoadjuvant chemoradiotherapy

BackgroundThe aim of this study was to assess the impact of sarcopenia, increased visceral fat and skeletal muscle loss on short-term outcomes and survival in patients undergoing neoadjuvant treatment followed by surgery for locally advanced rectal cancer. MethodsBetween 2008 and 2019, 100 patients with available baseline CT scan data at our institution were retrospectively analyzed. Body composition parameters were measured, including skeletal mass index (SMI), baseline sarcopenia, visceral fat area, subcutaneous fat area, visceral-to-subcutaneous ratio, visceral obesity, waist circumference and abdominal obesity. When CT scan after neoadjuvant therapy was available, evolution of skeletal muscle mass was calculated. ResultsThe prevalence of sarcopenia was 43% at baseline, and 53% after neoadjuvant treatment. During neoadjuvant treatment, 41% of patients lost ≥ 5% of skeletal muscle mass. No body composition parameter was associated with increased 30-day postoperative morbidity or occurrence of anastomotic leakage. Baseline sarcopenia and abdominal obesity significantly increased length of hospital stay and 90-day postoperative morbidity. Patients with baseline sarcopenia had a significantly lower 3-year disease-free survival (59% vs. 75%, p=0.041). In multivariate analysis, two variables adversely affected disease free survival: presence of baseline sarcopenia (HR=3.02; 95%CI: 1.23-7.43; p=0.016) and ypN+ stage (HR=2.95; 95%CI: 1.14-7.63; p=0.026). Loss of skeletal muscle mass during neoadjuvant treatment had no influence on short-term outcomes and survival. ConclusionsBaseline sarcopenia is associated with longer length of hospital stay, increased medium-term postoperative morbidity and worse survival in patients with locally advanced rectal cancer treated with neoadjuvant treatment. This parameter should be actively researched and corrected in order to improve management of these patients.

Indocyanine Green-enhanced Fluorescence to Assess Bowel Perfusion During Robotic-assisted Rectal Surgery

ABSTRACT Introduction Anastomotic leakage following rectal surgery is a major complication, which may occur due to insufficient vascular supply. We aimed to evaluate the efficacy of using indocyanine green fluorescence angiography for intraoperative assessment of vascular anastomotic perfusion in robotic low anterior resection. Methods This was a retrospective cohort study that included consecutive patients undergoing robotic low anterior resection for rectal cancer between March 2017 and February 2019. Intraoperative use of indocyanine green fluorescence for assessment of bowel perfusion was performed in patients operated after April 2018. Those who underwent the surgery before that comprised the control group. The primary outcome was the occurrence of anastomotic leakage between the two groups. Results Each group included 48 patients. There were no significant differences between the two groups in terms of demographic data or tumor characteristics. The planned anastomotic site was revised in 1 of 48 patients who received indocyanine green fluorescence based on the surgeon's subjective finding of a hypo-perfused distal segment. Postoperative anastomotic leakage was confirmed clinically and radiologically in one patient (2.8%) in the indocyanine green group compared with two patients (4.16%) in the control group. Conclusion Indocyanine green fluorescence may be considered a useful intraoperative tool for assessment of vascular perfusion of bowel during robotic rectal surgery. Change in the site of resection and/or anastomosis may be indicated, possibly affecting the incidence of anastomotic leakage.

STAPLED VERSUS HANDSEWN INTESTINAL ANASTOMOSIS IN EMERGENCY SURGERY

Introduction The major problem following bowel anastomoses is the anastomotic failure leading to leakage peritonitis, fistula, abscess, sepsis, necrosis, stricture etc. adding to the morbidity and mortality. (e.g., 22% mortality in patients with a leak vs. 7.2% mortality in those without leak).The present study compares the complication rates of sutured and stapled anastomotic techniques in an emergency setting of a tertiary care institute in Kerala. Methodology The study evaluates the complications (leak /intra-abdominal abscess) of both stapled and hand-sewn techniques of intestinal anastomosis in emergency setting. The study is conducted in a tertiary care centre in Kerala and the data is collected from the medical records and emergency register. A total of 112 cases that meet the inclusion and exclusion criteria are included during the period from 2017 to 2021 Results Among the 61 patients who had undergone hand sewn anastomosis 7 (11.5%) had anastomotic leak and 54 (88.5%) patients had no leak. Among the 51 patients underwent stapled anastomosis, 6 (11.8%) had anastomotic leak and 45 (88.2%) patients developed no leak. This data is statistically analyzed using Chi Squared test and found that there is no significant difference between the occurrence of anastomotic leak between the two study groups irrespective of whether the anastomosis is hand sewn or stapled. The average time taken for surgery in the hand sewn group is about 192.1 minutes and in stapled group is 162.5 minutes. This difference in the average duration of surgery is analyzed statistically and it showed that the difference in of the duration of surgery is statistically significant. Conclusion There is no significant difference between the complication rates of both type of anastomosis is identified in the emergency setting. But there is a clear advantage of less operating time for stapled anastomosis.

The histopathological features and their prognostic impact in the postoperative follow-up of colorectal cancer patients.

The validation of histological prognostic markers in colorectal cancer not only for survival parameters but also for early postoperative outcomes is of paramount importance. The aim of our study was to search for the tumor histopathological (HP) characteristics that may influence the postoperative morbidity, especially the occurrence of anastomotic leakage. Our results indicated that peritumoral inflammatory cell infiltrate appeared to correlate with both anastomotic fistula and overall postoperative complications. Likewise, high-grade and undifferentiated colorectal tumors seemed to be correlated with a higher incidence of postoperative leakage and complications. No relation could be established between the other HP features and the postoperative untoward outcomes.

A novel nomogram for anastomotic leakage after surgery for rectal cancer: a retrospective study.

Anastomotic leakage remains one of the most common serious complications after rectal cancer surgery. How to predict its occurrence and prevent it remains largely elusive. This study aimed to identify the risk factors of anastomotic leakage and construct a nomogram for predicting postoperative anastomotic leakage in patients with rectal cancer. The data of 406 patients with rectal cancer after gastrointestinal surgery in the Third Affiliated Hospital of Sun Yat-sen University from January 2011 to May 2020 were collected (243 in the training set and 163 in the testing set). Logistic regression was applied to determine the risk factors of postoperative anastomotic leakage of rectal cancer, and a nomogram prediction model was thus established. Predictive performance of the nomogram was evaluated by C-index and area under the receiver-operating characteristic (ROC) curve. Logistic regression analysis showed that preoperative bowel obstruction (odds ratio [OR] = 12.846, 95% confidence interval CI [1.441-114.54], p=0.022) and early first defecation after surgery (OR = 0.501, 95% CI [0.31-0.812], p=0.005) were independent risk factors, which could be used to develop a nomogram to predict the occurrence of anastomotic leakage accurately. The evaluation of the prediction model shows that the C-index value of the model was 0.955, the area under the ROC curve (AUC) of the training set was 0.820, and the testing set was 0.747, whereas the optimal cut-off point based on the nomogram score was 174.6. This nomogram had a good prediction ability for postoperative anastomotic leakage in patients with rectal cancer. It can provide a reference for perioperative treatment and the selection of surgical methods to promote individualized and accurate treatment.