Risk Factors For Anastomotic Leakage Research Articles

Gastric conduit reconstruction after esophagectomy.

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations.

270. ANALYSIS OF THE RELATIONSHIP BETWEEN CARDIAC DIAMETER AND ANASTOMOTIC TROUBLE IN TRANS HIATAL ESOPHAGOGASTRIC JUNCTION CANCER SURGERY

Abstract Background The number of esophagogastric junction (EGJ) cancers has been increasing in recent years, and the trans hiatal lower esophagectomy is widely used for cases with shorter esophageal invasion. However, the mediastinal surgical view through the hiatus is sometimes poor due to cardiac compression, and resection and reconstruction are often difficult in these cases. We therefore retrospectively examined the influence of cardiac diameter on short-term postoperative outcomes. Methods From June 2004 to December 2022, 97 patients underwent radical surgery for EGJ cancer at our hospital, of those 67 patients underwent trans-hiatal approach. We retrospectively analyzed the relationship between cardiothoracic ratio (CTR) on preoperative chest radiographs and left ventricular diastolic diameter (LVDd) on echocardiography and postoperative complications in patients underwent trans hiatal approach. Results Patients with preoperative CTR >50% had a significantly higher rate of anastomotic leakage (33% v.s. 7%, p<0.05), and similarly for LVDd, when divided into two groups using 43 mm as cut-off, patients with larger heart diameter had significantly more anastomotic leakage (69% v.s. 24%, p<0.05). We performed a multivariate analysis using CTR, ASA-PS, blood loss, operative time, BMI, and tumor diameter, and defined CTR as an independent risk factor for anastomotic leakage (OR: 7.76, 95%CI: 1.45-41.4, p<0.05). Conclusion Trans-hiatal approach can be used for resection of EGJ cancer. However, special attention should be paid to the prevention of anastomotic leakage in patients with cardiac comorbidities or a large preoperative CTR or LVDd.

Risk Factors for Anastomotic Leakage after Rectal Surgery in Locally Advanced Rectal Cancer

Risk Factors for Anastomotic Leakage after Rectal Surgery in Locally Advanced Rectal Cancer

Anastomotic tension "Bridging": a risk factor for anastomotic leakage following low anterior resection.

Excessive tension at the anastomosis contributes to anastomotic leakage (AL) in low anterior resection (LAR). However, the specific tension has not been measured. We assessed whether "Bridging," characterized by the proximal colon resembling a suspension bridge above the pelvic floor, is a significant risk factor for AL following LAR for rectal cancer. This retrospective study reviewed the medical records and laparoscopic videos of 102 patients who underwent laparoscopic LAR using the double stapling technique at Yachiyo Hospital between January 2014 and December 2023. Patients were classified based on whether they had Bridging (tight or sagging) or were in a Resting state of the proximal colon, and the association between Bridging and AL was examined. AL occurred in 31.3% of the Tight Bridging group, 20% of the Sagging Bridging group, and 2.2% of the Resting group (P = 0.002). The incidence of AL was significantly higher in patients with Bridging than in those without (23.2% vs. 2.2%, P = 0.003). Multivariate analysis revealed that Bridging is an independent risk factor for AL (odds ratio = 6.97; 95% confidence interval: 1.45-33.6; P = 0.016). The presence of Bridging is a significant risk factor for AL following LAR for rectal cancer, suggesting the need for implementing preventive measures in patients with this condition.

Association Between Cross-Stapling Technique In Mechanical Colorectal Anastomosis and Short-term Outcomes.

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described aiming to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered as possible risk factors for anastomotic leakage. The purpose of this study was to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis following minimally invasive surgery. A systematic review was undertaken of the published literature. PubMed/MEDLINE, Web of Science, and EMBASE databases were screened up to July 2023. Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction as compared to the conventional method of double-stapled anastomosis were included. Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared. The rate of anastomotic leak was the primary endpoint of interest. Perioperative details including postoperative morbidity were also appraised. There were 2537 patients from 12 studies included for data extraction, with no significant differences on age, body mass index and proportion of high American Society of Anesthesiologists Score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure compared to the conventional procedure (odds ratio = 0.38 [95% CI: 0.26, 0.56]. The incidences of overall postoperative morbidity (odds ratio = 0.57 [95% CI: 0.45, 0.73] and major morbidity (odds ratio = 0.48 [95% CI: 0.32, 0.72] following were significantly lower than following conventional double-stapled anastomosis. The retrospective nature of most included studies is a main limitation, essentially due to the lack of randomization, and the risk of selection and detection bias. The available evidence supports the modification of the conventional double-stapled technique with elimination of one of both dog-ears as it is associated with lower incidence of anastomotic-related morbidity.

Constructing a personalized nomogram model for predicting anastomotic leakage after laparoscopic radical resection of rectal cancer

The purpose of this study was to explore the risk factors for anastomotic leakage (AL) after laparoscopic radical resection of rectal cancer and to construct a nomogram prediction model for AL after laparoscopic radical resection of rectal cancer. We selected 366 patients with rectal cancer who underwent laparoscopic radical resection for rectal cancer in our hospital between January 2021 and December 2023 as the research subjects. Logistic regression analysis was used to screen the risk factors for AL after laparoscopic radical resection for rectal cancer, and a nomogram model for AL after radical resection for rectal cancer was constructed and validated. Our results showed among 366 patients with rectal cancer, 42 patients developed AL after surgery, and the incidence rate of AL was 11.48%. Logistic regression analysis results showed that gender, preoperative intestinal obstruction, distance between the tumor and the anal edge ≤7 cm, and diabetes were risk factors for AL after laparoscopic radical resection of rectal cancer (P < 0.05). The calibration curve of the nomogram model for AL after laparoscopic radical resection of rectal cancer showed that the model's predicted value and actual value fit well, and the area under the curve of the model was 0.859, (95%CI: 0.807–0.912). Overall, gender, preoperative intestinal obstruction, distance between the tumor and the anal verge ≤7 cm, and diabetes are risk factors for AL after laparoscopic radical resection of rectal cancer. The nomogram model of AL after laparoscopic radical resection of rectal cancer has high accuracy and has a certain guiding significance for formulating prevention and treatment strategies in advance.

C-reactive protein-to-albumin ratio as a risk factor for anastomotic leakage after anterior resection for rectal cancer with intraoperative use of indocyanine green fluorescence imaging.

Indocyanine green fluorescence imaging (ICG-FI) reduces anastomotic leakage (AL) in rectal cancer surgery. However, no studies investigating risk factors for anastomotic leakage specific to the group using ICG-FI have ever previously been conducted. The purpose of this retrospective multicenter study was to ascertain the risk factors for AL in the group using ICG-FI. A total of 638 patients who underwent laparoscopic or robotic anterior resection for rectal cancer between April 2018 and March 2023 were included in this study. Patients were divided into two groups: the ICG-FI group (n = 269) and the non-ICG-FI group (n = 369) for comparative analysis. The effects of clinicopathological and treatment-related factors on AL in the ICG-FI group were evaluated using both univariate and multivariate analyses. The incidence of AL in the ICG-FI group was 4.8%. Although there was no significant difference in the incidence of AL between the two groups, it was observed to be lower in the ICG-FI group. A multivariate analysis revealed a preoperative C-reactive protein-to-albumin ratio (CAR) ≥ 0.049 (odds ratio, 3.73; 95% confidence interval, 1.01-13.70; p = 0.048) as an independent risk factor for AL in the ICG-FI group. In this study, CAR was the only identified risk factor for AL in the ICG-FI group. It was suggested that CAR could be a criterion for early surgical intervention, prior to the escalation of risks, or for considering interventions such as diverting stoma creation.

Risk factors for anastomotic leakage in colonic procedures within an ERAS-protocol. A retrospective cohort study from the Swedish part of the international ERAS-database.

Research on anastomotic leakage (AL) in colonic procedures within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL after colonic surgery. The study included all consecutively recorded patients operated with colonic resection surgery in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between September 2009 and June 2022. The cohort was analyzed and evaluated regarding risk factors for AL. Altogether 10,632 patients were included, 10,219 were without AL and 413 (3.9%) were with AL. After adjusted analysis, male sex (4.6% AL), OR: 1.49; 95% CI (1.16-1.90), obesity (4.8% AL), OR: 1.62; 95% CI (1.18-2.24), previous surgery (4.4% AL), OR: 1.45; 95% CI (1.14-1.86), open surgery (4.4% AL), OR: 1.36; 95% CI (1.02-1.83), anastomosis between small bowel and rectum (13.1% AL), OR: 3.97; 95% CI (2.23-7.10), stapled anastomosis (5.3% AL), OR: 2.46; 95% CI (1.79-3.38), inhalation anesthesia (4.2% AL), OR: 1.80; 95% CI (1.26-2.57), and conversion to open surgery (5.5% AL), OR 1.49; 95% CI (1.02-2.19) were significant risk factors for AL. Although pre and intraoperative compliance to the ERAS-protocol was similar, excess of fluids day 0 was an independent predictor for AL. Male sex, obesity, previous surgery, open surgery, stapled anastomotic technique, anastomosis between small bowel and rectum, inhalation anesthesia, conversion to open surgery, and among ERAS interventions, excess of fluids day 0, were significant risk factors for AL.

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.

Risk factors of anastomotic leak in colorectal cancer: a multicentric study in a Latin American country.

The anastomotic leak (AL) is one of the most feared complications of colorectal surgery, since it is associated with a high rate of morbidity, mortality, length of hospital stay and cost of care. Our aim was to determine the risk factors associated with anastomosis leak in colorectal cancer patients who underwent surgical resection with anastomosis. A multicentre observational, analytical, retrospective and case-control study was carried out. For each case, two controls were included from three national hospitals from Lima, Peru during the period 2021-2022. To determine the degree of association, multivariate logistic regression model was carried out. A total of 360 patients were included, 120 from each hospital. The mean age of the population was 68.03 ± 14.21 years old. The majority were 65 years old or older (66.1%), 52.8% were female, and 63.3% had clinical stage III. The 40% of the patients had albumin levels lower than 3.5 g/dL. Regarding the surgery, 96.4% were elective, 68.9% underwent open approach, and 80.8% had an operative time of more than 180 minutes. Most of them had right colon cancer (50.8%). In the multivariate analysis, a significant association was found with the age variable (OR = 2.48; 95%CI:1.24-4.97), clinical tumour level (OR = 2.71; 95%CI:1.34-5.48), American Society of Anesthesiologists (ASA) Score (OR = 3.23; 95%CI:1.10-9.50), preoperative serum albumin (OR = 22.2; 95%CI:11.5-42.9). The most important independent risk factors associated with AL among patients with colorectal cancer were pre-operative such as lower preoperative serum albumin levels, followed by a higher ASA Score, clinical-stage III-IV, and an age ≥65 years old.

Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome.

Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.

Risk factors for anastomotic leakage after low anterior resection for obese patients with rectal cancer.

We aimed to analyze the risk factors for anastomotic leakage (AL) after low anterior resection (LAR) in obese patients (body mass index [BMI] ≥ 25kg/m2) with rectal cancer. Data were collected from four hundred two obese patients who underwent LAR for rectal cancer in 51 institutions. Forty-six (11.4%) patients had clinical AL. The median BMI (27kg/m2) did not differ between the AL and non-AL groups. In the AL group, comorbid respiratory disease was more common (p = 0.025), and the median tumor size was larger (p = 0.002). The incidence of AL was 11.5% in the open surgery subgroup and 11.4% in the laparoscopic surgery subgroup. Among the patients who underwent open surgery, the AL group showed a male predominance (p = 0.04) in the univariate analysis, but it was not statistically significant in the multivariate analysis. Among the patients who underwent laparoscopic surgery, the AL group included a higher proportion of patients with comorbid respiratory disease (p = 0.003) and larger tumors (p = 0.007). Comorbid respiratory disease and tumor size were risk factors for AL in obese patients with rectal cancer. Careful perioperative respiratory management and appropriate selection of surgical procedures are required for obese rectal cancer patients with respiratory diseases.

Evaluation of Risk Factors for Anastomotic Leakage and Mortality Following Esophageal Cancer Surgery

Evaluation of Risk Factors for Anastomotic Leakage and Mortality Following Esophageal Cancer Surgery

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.

Blood flow ratio in the gastric conduit measured by laser Doppler flowmetry: A predictor of anastomotic leakage after esophagectomy.

Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.

Risk factors for anastomotic leak and postoperative morbidity after right hemicolectomy for colon cancer: results from a prospective, multi-centre, snapshot study in China.

Right hemicolectomy is the standard treatment for right-sided colon cancer. There is variation in the technical aspects of performing right hemicolectomy as well as in short-term outcomes. It is therefore necessary to explore best clinical practice following right hemicolectomy in expert centres. This snapshot study of right hemicolectomy for colon cancer in China was a prospective, multicentre cohort study in which 52 tertiary hospitals participated. Eligible patients with stage I-III right-sided colon cancer who underwent elective right hemicolectomy were consecutively enrolled in all centres over 10 months. The primary endpoint was the incidence of postoperative 30-day anastomotic leak. Of the 1854 patients, 89.9 per cent underwent laparoscopic surgery and 52.3 per cent underwent D3 lymph node dissection. The overall 30-day morbidity and mortality were 11.7 and 0.2 per cent, respectively. The 30-day anastomotic leak rate was 1.4 per cent. In multivariate analysis, ASA grade > II (P < 0.001), intraoperative blood loss > 50 ml (P = 0.044) and D3 lymph node dissection (P = 0.008) were identified as independent risk factors for postoperative morbidity. Extracorporeal side-to-side anastomosis (P = 0.031), intraoperative blood loss > 50 ml (P = 0.004) and neoadjuvant chemotherapy (P = 0.004) were identified as independent risk factors for anastomotic leak. In high-volume expert centres in China, laparoscopic resection with D3 lymph node dissection was performed in most patients with right-sided colon cancer, and overall postoperative morbidity and mortality was low. Further studies are needed to explore the optimal technique for right hemicolectomy in order to improve outcomes further.

Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model

Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid–low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15–5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20–4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid–low rectal cancer patients.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study

ObjectivesThe risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address...

Risk Factors for Rectal Stump Leakage following Discontinuity Resection: Stump Length Matters Most.

Discontinuity resection is commonly conducted to avoid anastomotic leakage in high-risk patients, but potentially results in rectal stump leakage. While risk factors for anastomotic leakage have been widely studied, data on rectal stump leakage rates and underlying risk factors are scarce. To determine rectal stump leakage rates following Hartmann's procedure and to identify patient- and surgery-associated risk factors. A retrospective study with univariate and multivariate analysis to identify risk factors of rectal stump leakage was performed. A subgroup analysis of scheduled operations was carried out. The study was conducted a Heidelberg University Hospital, Germany. Patients who underwent discontinuity resection with rectal stump formation between 2010 and 2020 were included. The main outcome measures included rectal stump leakage rates, 30-day mortality, length of hospitalization and necessity for further invasive treatment. Rectal stump leakage occurred in 11.78% of patients. Rectal stump leakage rates varied considerably depending on the surgical procedure performed and were highest following subtotal pelvic exenteration (34%). Diagnosis of rectal stump leakage peaked on postoperative day 7. A short rectal stump (p = 0.001), previous pelvic radiotherapy (p = 0.04), chemotherapy (p = 0.004) and previous laparotomy (p = 0.03) were independent risk factors for rectal stump leakage in the entire patient collective. In patients undergoing scheduled surgery, a short rectal stump was the only independent risk factor (p = 0.003). Rectal stump leakage was not associated with increased 30-day mortality, but prolonged length of hospitalization and frequently necessitated further invasive treatment. Study results are limited by the retrospective design, a high number of emergency operations and the mere inclusion of symptomatic leakages. Rectal stump leakage is a relevant complication after discontinuity resection. Risk factors should be considered during surgical decision making when both discontinuity resection and abdominoperineal resection are feasible..