Risk Factors For Anastomotic Leakage Research Articles

Analysis of surgical outcomes and risk factors for anastomotic leakage following trans-hiatal resection of esophagogastric junction cancer.

The trans-hiatal lower esophagectomy is considered less invasive than the trans-thoracic esophagectomy for resection of esophagogastric junction (EGJ) cancer. However, the optimal procedure remains controversial and should be determined while considering both oncological and safety aspects. This retrospective study comprised 124 patients that underwent curative resection for EGJ cancer. The study analysis included 93 patients with tumor centers located within 2 cm of the EGJ. Clinicopathological findings and surgical outcomes were compared between patients treated using trans-hiatal and trans-thoracic approaches. Sixty-three patients underwent lower esophagectomy using the trans-hiatal approach (TH-G). The remaining 30 patients underwent esophagectomy using the trans-thoracic approach (TT-E). The TH-G group were older, had a lower prevalence of lymphatic spread, shorter length of esophageal invasion, and shorter operative duration compared to the TT-E group. Although no significant differences in the frequency of postoperative complications, a higher proportion of patients in the TH-G group developed anastomotic leakage (16% vs. 7%, p = 0.33). Univariate and multivariate analyses demonstrated that cardiac comorbidity was an independent risk factor for anastomotic leakage (odds ratio, 5.24; 95% CI, 1.06-25.9; P < 0.05) in TH-G group. Further examination revealed that preoperative cardiothoracic ratio (CTR) with 50% or greater could be surrogate marker as risk factor for anastomotic leakage in TH-G group (35% vs. 7.5%, p < 0.05). The 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.

Prediction model using risk factors associated with anastomotic leakage after minimally invasive esophagectomy.

To explore the risk factors of anastomotic leakage after minimally invasive esophagectomy (MIE) and to build a prediction model of the probability of postoperative anastomotic leakage. Clinical data of patients undergoing MIE, admitted in the Fourth Hospital of Hebei Medical University from March 2018 to March 2022, were retrospectively selected, and risk factors of anastomotic leakage after MIE were analyzed by univariate and multivariate logistic regression. A prediction nomogram model was established based on the independent risk factors, and its prediction effect was evaluated. A total of 308 patients were included. Thirty patients had postoperative anastomotic leakage, with an incidence of 9.74%. Logistic regression analysis showed that age, postoperative delirium, pleural adhesion, postoperative pulmonary complications, high postoperative white blood cell count and low lymphocyte count were risk factors for postoperative anastomotic leakage. A nomograph prediction model was constructed based on these risk factors. The predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The calculated C-index value (Bootstrap method) was 0.9609, indicating that the nomograph prediction model had a good discrimination ability. By drawing the receiver operating characteristic (ROC) curve, we showed that the area under the curve (AUC) of the nomograph prediction model was 0.9609 (95%CI: 0.937-0.985), which indicated a good prediction efficiency of the model. The nomograph prediction model based on the independent risk factors of anastomotic leakage after MIE can accurately predict the probability of postoperative anastomotic leakage.

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.

Perioperative Blood Transfusions and Anastomotic Leak After Colorectal Surgery for Cancer in an Australian Hospital

PurposePeri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery.MethodsThis retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not.ResultsA total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001).ConclusionPerioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer.

Is preoperative hypoalbuminemia or hypoproteinemia a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery in an enhanced recovery after surgery (ERAS) program?

PurposePreoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL).MethodsThe Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis, was interrogated. Preoperative serum albumin and protein levels (measured within 1 week of surgery) were plotted on receiver operating characteristic curves (ROC curves) and statistically analyzed for cutoff values, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).ResultsThe incidence of AL was 4.4% (16/361). Overall mortality was 1.4% (5/361), 6.3% (1/16) in the AL group, and 1.2% (4/345) in the no AL group. The median preoperative albumin and protein level in the AL group were 39 g/L and 75 g/L, respectively. The median preoperative albumin and protein level in the no AL group were 38 g/L and 74 g/L, respectively. The Mann–Whitney U test showed no statistically significant difference in albumin levels (p = 0.4457) nor protein levels (p = 0.6245) in the AL and no AL groups. ROC curves demonstrated that preoperative albumin and protein levels were not good predictors of anastomotic leak. Cutoff values for albumin (38 g/L) and protein (75 g/L) both had poor PPV for AL (4.8% and 3.8% respectively).ConclusionIn patients undergoing elective colorectal surgery as part of an ERAS program, preoperative serum albumin and protein levels are not reliable in predicting AL. This may be because of nutritional supplementation provided as part of an ERAS program may correct nutritional deficits to protect against AL or that low albumin/protein is not as robust a marker of AL as previously reported.

Anatomical and anastomotic viability indexes for stratifying the risk of anastomotic leakage in esophagectomy with retrosternal reconstruction.

Risk prediction of anastomotic leakage using anatomical and vascular factors has not been well established. This study aimed to assess the anatomical and vascular factors affecting the hemodynamics of the gastric conduit and develop a novel risk stratification system in patients undergoing esophagectomy with retrosternal reconstruction. This retrospective cohort study analyzed 202 patients with esophageal cancer who underwent subtotal esophagectomy with gastric tube retrosternal reconstruction between January 2008 and December 2020. Risk factors for anastomotic leakage (AL), including the anatomical index (AI) and anastomotic viability index (AVI), were evaluated using a logistic regression model. According to the logistic regression model, the independent risk factors for AL were preoperative body mass index ≥23.6 kg/m2 (odds ratio [OR], 7.97; 95% confidence interval [CI], 2.44-26.00; P < 0.01), AI <1.4 (OR, 23.90; 95% CI, 5.02-114.00; P < 0.01), and AVI <0.62 (OR, 8.02; 95% CI, 2.57-25.00; P < 0.01). The patients were stratified into four AL risk groups using AI and AVI as follows: low-risk group (AI ≥1.4, AVI ≥0.62 [2/99, 2.0%]), intermediate low-risk group (AI ≥1.4, AVI <0.62 [2/29, 6.9%]), intermediate high-risk group (AI <1.4, AVI ≥0.62 [8/53, 15.1%]), and high-risk group (AI <1.4, AVI <0.62 [11/21, 52.4%]). The combination of AI and AVI strongly predicted AL. Additionally, the use of AI and AVI enabled the stratification of the risk of AL in patients who underwent esophagectomy with retrosternal reconstruction.

Anastomotic leakage after resection of the rectosigmoid colon in primary ovarian cancer

BackgroundThe aim of the study is to evaluate the risk factors of anastomotic leakage (AL) and develop a nomogram to predict the risk of AL in surgical management of primary ovarian cancer.MethodsWe retrospectively reviewed 770 patients with primary ovarian cancer who underwent surgical resection of the rectosigmoid colon as part of cytoreductive surgery between January 2000 to December 2020. AL was defined based on radiologic studies or sigmoidoscopy with relevant clinical findings. Logistic regression analyses were performed to identify the risk factor of AL, and a nomogram was developed based on the multivariable analysis. The bootstrapped-concordance index was used for internal validation of the nomogram, and calibration plots were constructed.ResultsThe incidence of AL after resection of the rectosigmoid colon was 4.2% (32/770). Diabetes (OR 3.79; 95% CI, 1.31–12.69; p = 0.031), co-operation with distal pancreatectomy (OR, 4.8150; 95% CI, 1.35–17.10; p = 0.015), macroscopic residual tumor (OR, 7.43; 95% CI, 3.24–17.07; p = 0<001) and anastomotic level from the anal verge shorter than 10 cm (OR, 6.28; 95% CI, 2.29–21.43; p = 0.001) were significant prognostic factors for AL on multivariable analysis. Using four variables, the nomogram has been developed to predict anastomotic leakage: https://ALnomogram.github.io/.ConclusionFour risk factors for AL after resection of the rectosigmoid colon are identified from the largest ovarian cancer study cohort. The nomogram from this information provides a numerical risk probability of AL, which could be used in preoperative counseling with patients and intraoperative decision for accompanying surgical procedures and prophylactic use of ileostomy or colostomy to minimize the risk of postoperative leakage.Trial registrationRetrospectively registered.

Risk factors for postoperative anastomotic leakage after repair of esophageal atresia: a retrospective nationwide database study.

Postoperative anastomotic leakage is the most frequent short-term complication of esophageal atresia repair in neonates. We conducted this study using a nationwide surgical database in Japan to identify the risk factors for anastomotic leakage in neonates undergoing esophageal atresia repair. Neonates diagnosed with esophageal atresia between 2015 and 2019 were identified in the National Clinical Database. Postoperative anastomotic leakage was compared among patients to identify the potential risk factors, using univariate analysis. Multivariable logistic regression analysis included sex, gestational age, thoracoscopic repair, staged repair, and procedure time as independent variables. We identified 667 patients, with an overall leakage incidence of 7.8% (n = 52). Anastomotic leakage was more likely in patients who underwent staged repairs than in those who did not (21.2% vs. 5.2%, respectively) and in patients with a procedure time > 3.5h than in those with a procedure time < 3.5h (12.6% vs. 3.0%, respectively; p < 0.001). Multivariable logistic regression analysis identified staged repair (odds ratio [OR] 4.89, 95% confidence interval [CI] 2.22-10.16, p < 0.001) and a longer procedure time (OR 4.65, 95% CI 2.38-9.95, p < 0.001) as risk factors associated with postoperative leakage. Staged procedures and long operative times are associated with postoperative anastomotic leakage, suggesting that leakage is more likely after complex esophageal atresia repair and that such patients require refined treatment strategies.

High and low inferior mesenteric artery ligation in laparoscopic low anterior rectal resections: Aretrospective study.

The high or low inferior mesenteric artery (IMA) ligation in rectal cancer remains a great debate. This study retrospectively discussed the outcomes of the perioperative period, defecation and urinary function and long-term prognosis in rectal cancer patients with high or low IMA ligation. This study enrolled 220 consecutive rectal cancer cases, including 134 with high IMA ligation and 86 with low ligation. A comparison between the two groups was made for anastomotic leakage, low anterior resection syndrome (LARS), international prostate symptom score (IPSS), 5-year disease-free survival (DFS) and 5-year overall survival (OS). Low-ligation group had a longer operative time, and larger intraoperative blood loss. No significant difference was noted in anastomotic leakage incidence. In multivariable analysis, the male gender and tumor located at the lower rectum were identified as risk factors for anastomotic leakage. No significant differences were observed between groups in their LARS and IPSS questionnaire responses. The high-ligation vs. the low-ligation 5-year OS and DFS were 78.3% vs. 82.4% and 72.4% vs. 76.6%, respectively, which were not statistically different. The ligation level of the IMA had no significant effect on the anastomotic leakage incidence, defecation, urinary function, and long-term prognosis.

Perioperative Low-Dose Prednisolone Treatment Has Beneficial Effects on Postoperative Recovery and Anastomotic Healing in a Murine Colitis Model.

High-dose glucocorticoid treatment has been identified as a risk factor for anastomotic leakage in patients with inflammatory bowel disease [IBD] undergoing bowel resection surgery. By contrast, active disease during surgery is also associated with elevated morbidity. Perioperative low-dose treatment might be beneficial regarding postoperative outcomes by controlling disease activity. The present study is the first to investigate the dose-dependent effect of perioperative prednisolone therapy in a murine IBD model combining dextran sodium sulphate [DSS] colitis with intestinal anastomosis surgery. In 84 10-week-old wild-type mice, a colorectal anastomosis was performed using a microsurgical technique. Half the animals received induction of chemical colitis with 2% DSS via drinking water prior to surgery. In both groups, one-third of the animals received daily oral administration of high-dose [0.533 mg/kg] and one-third low-dose [0.133 mg/kg] prednisolone. Evaluation was performed on postoperative days 3 and 7. While high-dose prednisolone treatment led to an increased anastomotic leakage rate in mice under colitis, low-dose prednisolone treatment limited preoperative disease activity and did not influence the leakage rate. Histological examination showed a beneficial effect of low-dose prednisolone treatment on microscopic abscess formation at the anastomotic site in DSS mice as well as an increased anastomotic healing score. We demonstrate a beneficial effect of perioperative short-term low-dose prednisolone treatment on intestinal anastomotic healing in the context of colitis. Perioperative use of short-term low-dose prednisolone treatment might be beneficial in IBD patients who need to undergo surgery during active disease.

Small bowel anastomosis in peritonitis compared to enterostomy formation: a systematic review.

Anastomotic leakage after small bowel resection in emergency laparotomy is a severe complication. A consensus on the risk factors for anastomotic leakage has not been established, and it is still unclear if peritonitis is a risk factor. This systematic review aimed to evaluate if an entero-entero/entero-colonic anastomosis is safe in patients with peritonitis undergoing abdominal acute care surgery. A systematic literature review based on PRISMA guidelines was performed, searching the databases Pubmed/MEDLINE, Cochrane Library, and Science Direct for studies of anastomosis in peritonitis. Patients with an anastomosis after non-planned small bowel resection (ischemia, perforation, or strangulation), including secondary peritonitis, were included. Elective laparotomies and colo-colonic anastomoses were excluded. Due to the etiology, traumatic perforation, in-vitro, and animal studies were excluded. This review identified 26 studies of small-bowel anastomosis in peritonitis with a total of 2807 patients. This population included a total of 889 small-bowel/right colonic resections with anastomoses, and 242 enterostomies. All studies, except two, were retrospective reviews or case series. The overall mortality rates were 0-20% and anastomotic leakage rates 0-36%. After performing a risk of bias evaluation there was no basis for conducting a meta-analysis. The quality of evidence was rated as low. There was no evidence to refute performing a primary small-bowel anastomosis in acute laparotomy with peritonitis. There is currently insufficient evidence to label peritonitis as a risk factor for anastomotic leakage in acute care laparotomy with small-bowel resection. The review was registered with the PROSPERO register of systematic reviews on 14/07/2020 with the ID: CRD42020168670.

Ulcer Scarring in the Gastric Conduit Is a Risk Factor for Anastomotic Leakage After Esophagectomy for Esophageal Cancer

BackgroundAnastomotic leakage (AL) is a serious complication after esophagectomy for esophageal cancer. The objective of this study was to identify the risk factors for AL. MethodsPatients with esophageal cancer who underwent curative esophagectomy and cervical esophagogastric anastomosis between 2009 and 2019 (N = 346) and those between 2020 and 2022 (N = 17) were enrolled in the study to identify the risk factors for AL and the study to assess the association between the risk factors and blood flow in the gastric conduit evaluated by indocyanine green (ICG) fluorescence imaging, respectively. ResultsAL occurred in 17 out of 346 patients (4.9%). Peptic or endoscopic submucosal dissection (ESD) ulcer scars were independently associated with AL (OR 6.872, 95% CI 2.112–22.365) in addition to diabetes mellitus. The ulcer scars in the anterior/posterior gastric wall were more frequently observed in patients with AL than in those without AL (75.0% vs. 17.4%, P = 0.042). The median flow velocity of ICG fluorescence in the gastric conduits with the scars was significantly lower than in those without the scars (1.17 cm/s vs. 2.23 cm/s, P = 0.004). ConclusionsPeptic or ESD ulcer scarring is a risk factor for AL after esophagectomy in addition to diabetes mellitus. The scars in the anterior/posterior gastric wall are significantly associated with AL, impairing blood flow of the gastric conduit. Preventive interventions and careful postoperative management should be provided to minimize the risk and severity of AL in patients with these risk factors.

The role of transanal tube after low anterior resection in patients with rectal cancer treated with neoadjuvant chemoradiotherapy: A propensity score-matched study

BackgroundThe protective efficacy of transanal tube for anastomosis was compared with that of diverting stoma in patients with rectal cancer treated with neoadjuvant chemoradiotherapy. MethodsWe included consecutive patients with rectal cancer treated with neoadjuvant chemoradiotherapy and curative surgery from January 2013 to December 2019. The patients were grouped into transanal tube or diverting stoma, according to the protection methods they received. Propensity score-matching with 1:1 ratio was done. The primary outcome was the incidence of anastomotic leakage. ResultsOf the 656 eligible patients, 207 (31.6%) and 385 (58.7%) patients were grouped into transanal tube and diverting stoma, respectively, and 64 (9.7%) patients who did not undergo either transanal tube or diverting stoma were excluded. After matching, the incidence of anastomotic leakage was 9.7% and 10.6% in diverting stoma and transanal tube, respectively (P = .871). The overall morbidity was 23.2% and 15.0% in diverting stoma and transanal tube, respectively (P = .045). In the multivariate analysis, tumor size >2.5 cm and level of anastomosis <4 cm were significant risk factors for anastomotic leakage. In a subgroup analysis for patients with the level of anastomosis >4 cm, the incidence of anastomotic leakage was not significantly different between the transanal tube and diverting stoma groups. However, for patients with a level of anastomosis <4 cm, the incidence of grade C anastomotic leakage was significantly greater in the transanal tube than in the diverting stoma group (2.5% vs 9.9%, P = .040). ConclusionThe protective efficacy of transanal tube may be comparable to diverting stoma, especially for those with a level of anastomosis >4 cm.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients.

Anastomotic leakage (AL) is one of the serious complications after anterior resection for rectal cancer. Defunctioning stoma (DS) is one of the most widely used approaches to prevent it; however, the effect of DS on the occurrence of AL remains controversial. This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients. A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019. The results showed the overall AL incidence was 7.5%. Multivariate analyses revealed that males [odds ratio (OR) 1.562] and T3-T4 stage (OR 1.729) were independent risk factors for all patients. After propensity score matching analysis, the AL incidence was 14.1% in the group with no DS and 6.4% in the DS group (P<0.001). The clinical AL (grade B + grade C) incidence was 12.4% in no DS group and 4.6% in the DS group (P<0.001). The study suggested that males and T3-T4 stage were independent risk factors of AL. In addition, DS could reduce the rate of symptomatic AL.

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.

Current status of influencing factors for postoperative anastomotic leakage in low rectal cancer

The incidence of anastomotic leakage, a common and serious postoperative complication of low rectal cancer, remains high. Clarifying the risk factors for anastomotic leakage in patients with low rectal cancer after surgery can help guide clinical treatment and help patients improve their prognosis. The current literature suggests that the risk factors affecting the occurrence of anastomotic leakage after low rectal cancer include three aspects: (1) individual factors: male gender, high body mass index, malnutrition, smoking, alcoholism, and metabolic diseases; (2) tumor factors: the lower margin of tumor <5 cm from the anal verge, tumor diameter >2.5 cm, late tumor stage, high level of tumor markers and preoperative intestinal obstruction; (3) surgical factors: long operative time (>180 min), intraoperative bleeding (≥70 ml), more than 2 cartridges of stapling for anastomosis, contamination of the operative field, epidural analgesia and intraoperative hypothermia. Notably, the surgical approach (laparoscopic, open and hand-assisted laparoscopic surgery) was not a factor influencing the occurrence of postoperative anastomotic leakage in low rectal cancer. The findings on the effects of receiving neoadjuvant therapy, gut microbiota,intestinal bowel preparation, insufficient time for preoperative antibiotic prophylaxis, left colonic artery dissection, intraoperative blood transfusion, pelvic drainage, transanal drainage and combined organ resection, and postoperative diarrhea on postoperative anastomotic leakage in low rectal cancer are controversial. However, clinical workers can still take measures to reduce the risk of anastomotic leakage according to the above risk factors by making a good assessment before surgery, actively avoiding them during and after surgery, and taking measures for each step, so as to bring maximum benefits to patients.

Risk factors for anastomotic leakage and postoperative outcomes after total and subtotal colectomy: A nationwide retrospective cohort study (RIALTCOT Study Collaborative Group)

AbstractAimAnastomotic leakage (AL) following ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with a high morbidity. The identification of potential risk factors for AL could change operative planning and reduce further complications. This study assesses the rate, potential risk factors and management of AL after total colectomy (TC) and subtotal colectomy (STC).MethodsA nationwide, multicentre, retrospective cohort study involved 26 Spanish referral centres. It included TC and STC with IRA or ISA patients between January 2013 and December 2020. Clinical data, primary surgery and complications were collected. Univariate and multivariate analysis to identify risk factors for AL were performed. Management of Grade B–C AL and permanent stoma rate was assessed according to revisional surgeries.ResultsThe study included 1074 patients, 433 ISA group (40.3%) and 641 IRA group (59.7%). The overall incidence of AL was 14.3% with no differences between IRA and ISA (14.2% and 14.5% respectively), P = 0.871. Male sex, ASA score and lower total preoperative proteins were identified as independent risk factors for global and Grade B–C AL. Diverting ileostomy did not protect against AL (P = 0.084). Clavien–Dindo ≥IIIA complication was found in 251 patients (23.3%). Stoma reversal was not possible in 85 patients (8.1%), being more frequent after anastomosis excision and terminal ileostomy in AL Grade C.ConclusionTotal colectomy and STC with IRA or ISA are high‐risk procedures with an increased AL rate. Male sex, ASA score and lower preoperative protein level were associated with global AL and AL Grade B and C. A lower permanent stoma rate could be obtained when diverting ileostomy is performed in revision surgery.

Influence of interrupted versus continuous suture technique on intestinal anastomotic leakage rate in patients with Crohn’s disease — a propensity score matched analysis

PurposeIntestinal anastomosis is a crucial step in most intestinal resections, as anastomotic leakage is often associated with severe consequences for affected patients. There are especially two different techniques for hand-sewn intestinal anastomosis: the interrupted suture technique (IST) and the continuous suture technique (CST). This study investigated whether one of these two suture techniques is associated with a lower rate of anastomotic leakage.MethodsA retrospective review of 332 patients with Crohn’s disease who received at least one hand-sewn colonic anastomosis at our institution from 2010 to 2020 was performed. Using propensity score matching 183 patients with IST were compared to 96 patients with CST in regard to the impact of the anastomotic technique on patient outcomes.ResultsOverall anastomotic leakage rate was 5%. Leakage rate did not differ between the suture technique groups (IST: 6% vs. CST: 3%, p = 0.393). Multivariate analysis revealed the ASA score as only independent risk factor for anastomotic leakage (OR 5.3 (95% CI = 1.2–23.2), p = 0.026). Suture technique also showed no significant influence on morbidity and the re-surgery rate in multivariate analysis.ConclusionOur data suggest that the chosen suture technique (interrupted vs. continuous) has no influence on postoperative outcome, especially on anastomotic leakage rate. This finding should be confirmed by a randomized controlled trial.

532. INDOCYANINE GREEN FLUORESCENCE DETECTED THE IMPAIRED BLOOD FLOW IN THE GASTRIC CONDUIT WITH ULCER SCARS: A PROSPECTIVE PRELIMINARY STUDY

Abstract We previously identified the presence of peptic or endoscopic submucosal dissection (ESD) ulcer scars in the stomach as a risk factor for anastomotic leakage of esophagogastric anastomosis after esophagectomy. In this study, we investigated the association between peptic or ESD ulcer scars and blood flow at the gastric conduit using indocyanine green (ICG) fluorescence imaging. We prospectively enrolled 17 patients who underwent cervical esophagogastric anastomosis after esophagectomy for thoracic esophageal cancer (15 men and 2 women with a median age of 70 years). Blood flow in the wall of gastric conduit was evaluated using ICG fluorescence imaging detected by a near-infrared camera system during the operation. The flow velocity of ICG fluorescence in the gastric wall was calculated by dividing the distance (cm) by moving time of ICG fluorescence (second) from the pylorus to the point of final branch of the right gastroepiploic artery. In 17 patients, four had peptic or ESD ulcer scars in the stomach. One patient with ESD ulcer scars in the lesser curvature side resected during the creation of conduit was included in 13 without ulcer scars. The median flow velocity was significantly lower in patients with ulcer scars than that in patients without ulcer scars (1.15 cm/s vs. 2.17 cm/s, P &amp;lt; 0.01). Anastomotic leakage was occurred only in two patients; one had ESD ulcer scar in the greater curvature side with the velocity of 1.17 cm/s, and one had no ulcer scars with the velocity of 1.67 cm/s. Peptic or ESD ulcer scars were associated with the impaired blood flow in the wall of gastric conduit. Intraoperative ICG fluorescence imaging is a promising modality to evaluate the risk of anastomotic leakage after esophagectomy.

290. ANALYTIC MORPHOMIC INDEX AND QUANTITATIVE GASTRIC PERFUSION ASSESSMENT FOR RISK STRATIFICATION OF ANASTOMOTIC LEAKS FOLLOWING ESOPHAGECTOMY

Abstract Sarcopenia, a reduction in muscle mass, has been considered a preoperative risk factor for complications after esophagectomy while impaired perfusion of the gastric conduit has been associated with anastomotic leaks. The aim of this study was to stratify patients by their risk of anastomotic leak following esophagectomy using morphomic factors and quantitative assessment of gastric conduit perfusion. Patients who underwent an esophagectomy with a cervical anastomosis and gastric conduit from 2015–2021 were included. Preoperative CT scans were processed using semiautomated algorithms (MATLAB; MathWorks, MA). Indocyanine green perfusion was assessed intraoperatively (SPY elite; Stryker, MI). Sarcopenia was defined using skeletal muscle area (Martin’s criteria). Decreased subcutaneous fat, decreased bone mineral density, and impaired conduit perfusion were defined as below the cutoff value from the ROC curve. The morphomic index was determined using the number of decreased morphomic factors present (0–3). The Fisher exact test, the Mann–Whitney U test, and multivariable logistic regression were used to make statistical comparisons. 140 patients with both perfusion and morphomic data were evaluated (Leak n = 27; No leak n = 113). Decreased subcutaneous fat, decreased bone mineral density, and impaired gastric conduit perfusion were associated with an anastomotic leak (p = 0.041, 0.017, and 0.010). Neoadjuvant chemoradiation was significantly more common in the leak group (p = 0.048). On multivariable analysis, a higher morphomic Index and impaired gastric perfusion were risk factors for anastomotic leak. The incidence of anastomotic leaks with a high morphomic index (2 or 3) and impaired gastric perfusion was 40.6% compared to 9.4% with a low morphomic index and without impaired gastric perfusion (p = 0.006). Impaired gastric conduit perfusion and decreased preoperative subcutaneous fat area, bone mineral density, and skeletal muscle area, likely surrogates for increased frailty and poor nutritional status, were associated with an increased risk of anastomotic leaks especially when multiple morphomic factors were simultaneously decreased. These findings may be useful in risk stratification and intraoperative decision making in patients undergoing esophagectomy.