Risk Factors For Anastomotic Leakage Research Articles

Significant morbidity is associated with proximal fecal diversion among high-risk patients who undergo colectomy: A NSQIP analysis

BackgroundThe value of proximal fecal diversion for patients undergoing colectomies is an ongoing debate. Previous studies have shown a benefit in decreased anastomotic leak rates and mitigation of the morbidity of a leak, especially in high-risk populations. However, more recent data suggests increased morbidity with fecal diversion, creating a complication with an unknown degree of anastomotic leak reduction. Therefore, we aimed to determine the impact on morbidity of a diverting loop ileostomy (DLI) in patients with a high risk of anastomotic leak. MethodsThe ACS-NSQIP database was queried (via CPT code) for adult patients (age ≥18 years) who underwent a colectomy only or colectomy with ileostomy (CWI) between Jan 2013 and Dec 2016. We compared thirty-day outcomes between a 3:1 propensity-matched colectomy only group to patients who had a CWI. We used risk factors for anastomotic leak as a basis of our propensity match which included preoperative smoking, steroid use, preoperative weight loss, preoperative transfusion, hypoalbuminemia, and leukocytosis; intraoperative match variables included indication for surgery, wound class, duration of operation, primary CPT code, elective vs. emergent, and inpatient vs. outpatient surgery. ResultsWe identified 39,588 patients from the NSQIP database who had a colectomy only or a CWI. The colectomy only group was older (age 63 vs 52 years p < 0.001), overweight (BMI 34 vs 26.7, p < 0.001), more likely to be diabetic (16% vs 9.5%, p < 0.001) and hypertensive (49.3% vs 31.4%). However, the CWI group had higher steroid use (36.8% vs 10%, p < 0.001), preoperative sepsis (13.2% vs 2.5%, p < 0.001), smoking rate (25.7% vs 15.4%, p < 0.001), and preoperative weight loss (12.5% vs 4.9%, p < 0.001). Our propensity analysis matched 2274 colectomy only patients and 758 CWI patients. Baseline demographics were similar between groups. While the mortality rate was similar between groups (1.5% vs 1.8%, p = 0.8), CWI patients had longer length of stay (median 8 vs 7 days, p < 0.001), higher renal injury rates (3.2% vs 0.9%, p < 0.001), higher readmission rates (18.8% vs 11%, p < 0.001) and higher overall NSQIP morbidity (44.5% vs 37.6%, p = 0.001). The anastomotic leak rate was 3.8% in the CWI group and 5.1% in the colectomy only group (p = 0.09). ConclusionsSignificant thirty-day morbidity exists with a diverting ileostomy among high-risk colectomy patients with minimal benefit in anastomotic leak rates.

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Risk factors of anastomotic leakage after robotic surgery for low and mid rectal cancer

Objective: To investigate the risk factors associated with anastomotic leakage after robotic surgery in mid-low rectal cancer. Methods: A retrospective case-control study method was conducted. Inclusion criteria: (1) 18 to 80 years old; (2) pathologically confirmed rectal cancer; (3) distance <10 cm from tumor to anal margin; (4) robotic anterior rectal resection. Patients with previous history of colorectal cancer surgery, distant metastases or other malignant tumors, undergoing emergency surgery, with severe abdominal adhesions or those receiving combined organ resection were excluded. Based on the above criteria, 636 patients undergoing robotic radical sphincter-preserving surgery for mid-low rectal cancer in Zhongshan Hospital from January 2015 to December 2018 were included in this study, including 398 males (62.6%) and 238 females (37.4%) with a mean age of (61.9±11.3) years. Sixty-eight cases (10.7%) received neoadjuvant chemoradiotherapy. Amony the 636 included patients, 123(19.3%) underwent natural orifice specimen extraction surgery (NOSES) and 15 (2.3%) underwent preventive stoma. According to the cirteria developed by the International Rectal Cancer Research Group in 2010, the anastomotic leakage was classified as grade A (no requirement of intervention), B (requirement of intervention), and C (requirement of operation). Logistic regression was used to analyze the relationship between anastomotic leakage and clinicopathological factors. Factors in univariate analysis with P<0.05 were included in the multivariate analysis. Results: Anastomotic leakage occurred in 38 cases (6.0%). The grading of anastomotic leakage was grade A in 13 cases (2.0%), grade B in 19 cases (3.0%), and grade C in 6 cases (0.9%). The 3-year disease-free survival rate of patients with anastomotic leakage and without anastomotic leakage was 83.5% and 83.6% respectively (P=0.862); the 3-year overall survival rate of the two group was 85.1% and 87.5% respectively (P=0.296). The results of univariate logistic regression analysis showed that male (P=0.011), longer operation time (P=0.042), distance ≤5 cm from tumor to anal margin (P=0.012), more intraoperative blood loss (P=0.048) were associated with anastomotic leakage (all P<0.05). NOSES was not associated with anastomotic leakage (P=0.704). Multivariate analysis confirmed that male (OR=3.03, 95%CI: 1.37 to 7.14, P=0.010), operation time ≥180 minutes (OR=2.04, 95%CI: 1.03 to 3.99, P=0.040), distance ≤5 cm from tumor to anal margin (OR=2.56, 95%CI:1.28 to 5.26, P=0.008) were independent risk factors for anastomotic leakage. Conclusion: Male, short distance from tumor to anal margin, and long operation time are independent risk factors for anastomotic leakage in patients undergoing robotic mid-low rectal cancer radical surgeries. These patients need to be cautiously treated during surgery.

Urine colour as an indicator for anastomotic leakage after robot-assisted radical prostatectomy

Objectives: To determine whether macroscopic haematuria predicts urethrovesical anastomotic leakage after robot-assisted laparoscopic radical prostatectomy (RALP) as well as a cystogram.Patients and methods: Participants were recruited before cystogram and catheter removal 5–14 days after RALP surgery. Urine colour in the collection bag was classified according to a three-step scale (clear, light red and dark red) and leakages in cystogram were graded with a four-step scale (Grade 0–3). Diagnostic accuracy parameters were calculated for urine colour. A multivariate logistic regression model was used to evaluate other leakage risk factors.Results: Of 214 patients, 201 (94%) had clear, six (3%) had light red and seven (3%) had dark red coloured urine. In the cystogram, 20 (9%) patients had leakage; 14 had Grade 1, five Grade 2 and one Grade 3 leakage. Overall, specificity and sensitivity of urine colour in predicting anastomotic leakage were 0.97 (95% CI = 0.95–100) and 0.38 (95% CI = 0.17–0.59), respectively. Negative and positive predictive values were 94% and 62%, respectively. Other significant risk factors for anastomotic leakage were previous transurethral resection or radiation therapy to the prostate, non-waterproof anastomosis at surgery, postoperative pelvic haematoma, long catheterization and surgeon’s inexperience. In patients with no other risk factors, test sensitivity improved to 0.80 (95% CI = 0.45–1.15) and negative and positive predictive values to 99% and 44%, respectively.Conclusion: This prospective single-arm trial indicates that in patients with clear urine and no other risk factors for anastomotic leakage, a cystogram examination before urethral catheter removal can be safely omitted.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis

BackgroundA variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery. MethodsWe performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period. ResultsOne hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified. ConclusionHJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

Modifying Risk Factors for Anastomotic Leak in Gynecologic Oncology Surgery

Modifying Risk Factors for Anastomotic Leak in Gynecologic Oncology Surgery

Correction of Dysbiosis in Diversion Proctitis: Possibilities of Intraluminal Sanitation and the Prevention of Complications after Reconstructive Surgery

Background. Repeated surgical interventions aimed at the colostomy closure and restoration of intestinal continuity after obstructive resections are traumatic and complex reconstructive operations on the colon. The complications of recovery operations largely feature wound abscesses (30–60 %) and anastomotic leakage (5–23 %), with the mortality levels from these complications reaching 0.4–2.8 %. Pronounced dysbiotic changes, the progression of catarrhal or erosive diversion colitis and proctosigmoiditis are the risk factors for anastomotic leakage and postoperative bowel dysfunction. This determines the need for a therapeutic algorithm of intestine sanitation and the introduction of methods for preventing the anastomotic leakage after obstructive resection of the distal colon (Hartmann’s operation). Aim. To evaluate the capability and efficiency of the intraluminal application of rifaximin- α (Alfa Normix ® preparation, Alphasigma company) as a sanitising intestinal antiseptic for relieving diversion colitis and prevening postoperative complications of restorative operations after obstructive resection of the colon (Hartmann’s operation). Material and methods. A prospective comparative controlled study of the results of surgical treatment in 63 patients was conducted. The patients were divided into 2 groups, which were compared using the case-control principle. The operations included the colostomy closure and the restoration of intestinal continuity by applying a colonic anastomosis. In group I (main group, 30 patients), the original “Method of postoperative prevention of colonic anastomotic leakage” (Russian patent No. 2523822) was applied. In the control group (33 patients), routine methods for preventing anastomotic leakage and antibiotic prophylaxis were used. A comparative analysis of the number and severity of purulent-septic complications (taking into account the possibility of their relief), as well as the quality and rate of intestinal dysbiosis relief and the manifestations of diversion proctitis, was carried out. Results. The main group indicated the best results in terms of the main analysed parameters, fewer complications and anastomotic leakage. Thus, the total number of complications in groups I and II was 16.7 % and 27.3 %, respectively. The proportion of complications associated with the anastomotic leakage, inflammatory changes in this area and impaired patency in groups I and II was 6.7 % and 12.1 %, respectively. Rifaximin- α (Alpha Normix ® ) intolerance and pathological reactions associated with its use were not observed. The possibility for effective relief of the violations of quantitative and qualitative composition of the microflora in the colon stump was revealed. The main group showed better results in terms of eliminating local manifestations of diversion colitis and anorectal dysfunction compared to group II, where traditional schemes of postoperative therapy were used. Conclusions. Intraluminal dosed use of the Alpha Normix ® suspension with the rifaximin concentration of 100 mg per 5 ml is an effective method of postoperative prevention of purulent-septic complications associated with anastomotic leakage during reconstructive operations on the distal colon. The introduction of Alpha Normix ® in the scheme of postoperative treatment allows its results to be stabilised due to the sanitation of the intestinal lumen, the elimination of dysbiosis, the relief of inflammatory reaction and the elimination of factors supporting the development of diversion proctitis.

Defunctioning Protective Stoma Can Reduce the Rate of Anastomotic Leakage after Low Anterior Resection in Rectal Cancer Patients.

This study aimed to identify risk factors for anastomotic leakage and to evaluate the impact of protective stoma on the rate of anastomotic leakage and subsequent management. This retrospective study analyzed data from 4,282 patients who underwent low anterior resection between 2007 and 2014. Among these, 1,367 (31.9%) underwent surgery to create protective diverting stoma and 232 (5.4%) experienced anastomotic leakage. At 6-month timepoints, data were evaluated to identify any correlation between the presence of diverting stoma and the incidence of anastomotic leakage. In addition, clinicopathological parameters were investigated to identify risk factors for anastomotic leakage. Diverting stomas significantly reduced the rate of anastomotic leakage [HR 0.334, 95% CI 0.212.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Risk factors for leakage after total gastrectomy

Aim: Although many studies report risk factors for anastomotic leakage after gastrectomy for gastric cancer (GC), there are conflicting results in the literature. In this study, we aimed to identify the risk factors associated with anastomotic leakage after gastrectomy. Material and Methods: Patients who underwent total gastrectomy for gastric cancer in a single center between September 2015 and September 2018 were evaluated retrospectively. The relationship between anastomotic leakage and clinical variables, tumor characteristics and intraoperative characteristics of 18 parameters were analyzed. The relationship between anastomotic leakage and survival was evaluated.Results: A total of 102 patients were included in the study. Anastomotic leakage rate was 9.81% (10/102). A significant relationship was not determined between anastomotic leakage and age >60 (p:0.232), diabetes mellitus (p:0.334), ASA score >3 (p:0.587), albumin 300 (p:0.582), and operation duration >300 min (p:0.176). Multivariate regression analysis, showed female sex (p: 0.05), body mass index (BMI) >30 (p:0.024) and tumor localization (p:0.005) are independent risk factors for anastomotic leakage. There was a significant difference in mean survival between patients with and without anastomotic leakage (13.9 vs 34.9 months, p: 0.006). Conclusion: Anastomotic leakage was associated with female sex, obesity, and tumor location. We also found that anastomotic leakage adversely affects long-term survival. Detecting risk factors after gastrectomy guides us in the management of patients at the risk for anastomotic leakage.

Higher modified Glasgow Prognostic Score and multiple stapler firings for rectal transection are risk factors for anastomotic leakage after low anterior resection in rectal cancer.

Objective: Anastomotic leakage (AL) is one of the most devastating complications of rectal cancer surgery. Not only does AL result in reduced quality of life, extended hospitalization and impaired defecatory function, it also has a high local recurrence rate. In this study, we investigated risk factors for AL as it may help to decrease its occurrence and improve patient outcomes. Methods: This study was a retrospective, single-institution study of rectal cancer patients who underwent elective low anterior resection between April 2002 and February 2018 at Fukushima Medical University Hospital. Patients were divided into two groups according to the presence of AL. Patient-, tumor-, and surgery-related variables were examined using univariate and multivariate analyses. Results: One hundred sixty-one patients, average age 63.5±11.5 years, were enrolled in the study. The overall AL rate was 6.8% (11/161). In the univariate analysis, modified Glasgow Prognostic Score (mGPS)=2 (p=0.003), use of multiple staplers (≥3 firings) for rectal transection (p=0.001) and intraoperative bleeding (≥250 g) were significantly associated with AL incidence. Multivariate analysis identified that mGPS = 2 (odds ratio [OR]: 19.6, 95% confidence interval [CI]: 2.96-125.00, p=0.002) and multiple firings (OR: 18.19, CI: 2.31-111.11, p=0.002) were independent risk factors for AL.Conclusion: Higher mGPS score and multiple firings were independent risk factors for AL.

Factors influencing intestinal anastomotic leak and their predictive value

Background: Anastomotic leak after intestinal surgery is one of the major reasons behind postoperative morbidity and mortality. This prospective study was undertaken to evaluate various risk factors for anastomotic leakage.Methods: This study was conducted in B.R.D. Medical College, Gorakhpur, Department of surgery from May 2015 to October 2016. Patients who underwent intestinal anastomosis in emergency settings or routine operation were included in this study. Total of 156 patients were included.Results: Anastomotic leak was observed in 16.02% cases and was higher in males and in patients from low socioeconomic status. However, age, sex, and socioeconomic status were not found to be significant risk factors for anastomotic leak. Leak rate was higher in patients suffering from chronic diseases such as malignancy; COPD, DM, and patients with chronic corticosteroid use. Leak rate was significantly high in malnourished patients and in cases having sepsis as shown by their blood investigation report. After logistic regression analysis it was observe that various independent predictors for anastomotic leakages are peritonitis (p&lt;0.05; odds ratio 2.166), bowel obstructions (p&lt;0.05; odds ratio 2.844), blood transfusion&gt;2 u (p&lt;0.05; odds ratio 2.354), S. Albumin &lt;3.0 gm/di (p&lt;0.001; odds ratio 8.873), corticosteroid therapy (p&lt;0.001; odds ratio 4.857), serum creatinine &gt;1.2 mg/dl (p&lt;0.001; odds ratio 11.755), duration of surgery (&gt;4 hrs) (p&lt;0.01; odds ratio 3.0251) and ASA Grading (III&amp;IV) (p&lt;0.01; odds ratio 3.607).Conclusions: This study has identified the potential risk factors that affect the incidence of anastomotic leakage and the result of this study will be helpful in reducing the incidence of AL after surgeries.

P59 PREDICTORS FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY AND IMPACT ON SURVIVAL

Abstract Aim To identify predictors for anastomotic leakage after esophagectomy and to determine the influence of anastomotic leakage on short-term and long-term survival. Background and methods Identifying predictors of anastomotic leakage after esophagectomy may contribute to its prevention. The influence of anastomotic leakage on long-term survival is unclear. A retrospective cohort study was conducted in consecutive patients who underwent an esophagectomy with reconstruction in the Amsterdam UMC, location AMC, between January 1993 and January 2019. Logistic regression and Cox regression models were used to assess predictors for anastomotic leakage and to assess survival. Results 1747 patients were included, of which 326 (18.7%) developed anastomotic leakage. Independent predictors of cervical anastomotic leakage were diabetes mellitus, cT4-stage and a gastroesophageal junction tumor. ASA grade 3-5, a non-radical resection, pT2-stage, pN+ and hand sewn anastomosis were independent predictors of intrathoracic anastomotic leakage (table 1). 30-day mortality was 2% in patients without, and 4% of patients with anastomotic leakage (p=0.076). Anastomotic leakage did not significantly influence long-term survival when corrected for confounders (HR 0.96 95%CI 0.81 – 1.14, p=0.618). Conclusion Independent risk factors for anastomotic leakage after esophagectomy are diabetes mellitus, cT4-stage and a gastroesophageal junction tumor for cervical anastomosis, and ASA grade 3-5, a non-radical resection, pT2-stage, pN+ and hand sewn anastomosis for intrathoracic anastomosis. 30-day mortality was higher in the anastomotic leakage group. We found no correlation between anastomotic leakage and long term survival.

Preoperative prediction model of anastomotic leakage after colorectal surgery

Objective To analyze the preoperative risk factors of anastomotic leakage after colorectal surgery, construct a preoperative prediction model of anastomotic leakage after colorectal surgery, evaluate the probability of anastomotic leakage after surgery, and guide clinical decision-making. Methods From January 1, 2007 to December 31, 2016, 1 340 patients who underwent colorectal surgery and primary anastomosis in the Central Theater Command General Hospital of the Chinese People’s Liberation Army (formerly Wuhan General Hospital of Guangzhou Military Region) were collected. The risk factors of anastomotic leakage were analyzed by R-3.5.2. The forecasting model of contour map was drawn by RMS software package in R software. Results There are 123 cases of anastomotic leakage occurred in this study. The incidence of anastomotic leakage was 9.18% (123/1 340). Preoperative body mass index (BMI) was larger (Z=2.128, P 0.75 indicated that the model had good predictive ability. The AUC for predicting anastomotic leakage after colorectal surgery is 0.86, which has good predictive performance. Conclusion Large BMI, high NRS2002 score, no nutritional support at the lesion site in rectum and before operation are independent risk factors for anastomotic leakage. The constructed contour map prediction model is helpful to predict the probability of anastomotic leakage after operation. Key words: Colorectal; Anastomotic leakage; Risk factors; Prediction model

Value of intra-operative Doppler sonographic measurements in predicting post-operative anastomotic leakage in rectal cancer: a prospective pilot study.

Anastomotic leakage is a serious surgical complication in rectal cancer; however, effective evaluation methods for predicting anastomotic leakage individual risk in patients are not currently available. This study aimed to develop a method to evaluate the risk of leakage during surgery. The 163 patients with rectal cancer, who had undergone anterior resection and low-ligation procedures for Doppler sonographic hemodynamic measurement from April 2011 to January 2015 in Peking University Cancer Hospital, were prospectively recruited. A predictive model was constructed based on the associations between anastomotic leakage and alterations in the anastomotic blood supply in the patients, using both univariate and multivariate statistical analyses, as well as diagnostic methodology evaluation, including Chi-square test, logistic regression model, and receiver operating characteristic curve. The overall anastomotic leakage incidence was 9.2% (15/163). Doppler hemodynamic parameters whose reduction was significantly associated with anastomotic leakage were peak systolic velocity, pulsatility index, and resistance index. The areas under the receiver operating characteristic curve of residual rates of peak systolic velocity, pulsatility index, and resistance index in predicting anastomotic leakage were 0.703 (95% confidence interval [CI]: 0.552-0.854), 0.729 (95% CI: 0.579-0.879), and 0.689 (95% CI: 0.522-0.856), respectively. The predictive model revealed that the patients with severely reduced blood-flow signal exhibited a significantly higher incidence rate of anastomotic leakage than those with sufficient blood supply (19.6% vs. 3.7%, P = 0.003), particularly the patients with low rectal cancer (25.9% vs. 3.9%, P = 0.007) and those receiving neoadjuvant chemoradiotherapy (32.1% vs. 3.7%, P = 0.001), independent of prophylactic ileostoma. Multivariate analysis revealed that insufficient blood supply of the anastomotic bowel was an independent risk factor for anastomotic leakage (odds ratio: 10.37, 95% CI: 2.703-42.735, P = 0.001). Based on this explorative study, Doppler sonographic hemodynamic measurement of the anastomotic bowel presented potential value in predicting anastomotic leakage.

Risk factor analysis on anastomotic leakage after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy and establishment of a nomogram prediction model

Objective: To investigate the risk factors of anastomotic leakage (AL) after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy and construct a nomogram prediction model. Methods: This study was a retrospective case-control study that collected and reviewed the clinicopathological data of 359 patients who underwent laparoscopic surgery from January 2012 to January 2018, including 202 patients from the Department of General Surgery, Nanfang Hospital of Southern Medical University and 157 patients from the Department of Gastrointestinal Surgery of Fujian Provincial Cancer Hospital. Inclusion criteria: (1) age ≥ 18 years old; (2) diagnosis as rectal cancer by biopsy before treatment; (3) distance from tumor to anus within 12 cm; (4) locally advanced stage (T3-T4 or N+) diagnosed by imaging (CT, MRI, PET or ultrasound); (5) standardized neoadjuvant therapy followed by laparoscopic radical operation. Exclusion criteria: (1) previous history of colorectal cancer surgery; (2) short-term or incomplete standardized neoadjuvant therapy; (3) Miles, Hartmann, emergency surgery, palliative resection; (4) conversion to open surgery. Clinicopathological data, including age, gender, body mass index (BMI), preoperative albumin, distance from tumor to anus, operation hospital, American Society of Anesthesiologists score (ASA score), operation time, T stage, N stage, M stage, TNM stage, pathological complete response (pCR) were analyzed with univariate analysis to identify predictors for AL after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy. Then, incorporated predictors of AL, which were screened by multivariate logistic regression, were plotted by the "rms" package in R software to establish a nomogram model. According to the scale of the nomogram of each risk factor, the total score could be obtained by adding each single score, then the corresponding probability of postoperative AL could be acquired. The area under ROC curve (AUC) was used to evaluate the predictive ability of each risk factor and nomogram on model. AUC > 0.75 indicated that the model had good predictive ability. The Bootstrap method (1000 bootstrapping resamples) was applied as internal verification to show the robustness of the model. The discrimination of the nomogram was determined by calculating the average consistency index (C-index) whose rage was 0.5 to 1.0. Higher C-index indicated better consistency with actual risk. The calibration curve was used to assess the calibration of prediction model. The Hosmer-Lemeshow test yielding a non-significant statistic (P>0.05) suggested no departure from the perfect fit. Results: Of 359 cases, 224 were male, 135 were female, 189 were ≥ 55 years old, 98 had a BMI > 24 kg/m(2), 176 had preoperative albumin ≤ 40 g/L, 128 had distance from tumor to anus ≤ 5 cm, 257 were TNM 0-II stage, 102 were TNM III-IV stage, and 84 achieved pCR after neoadjuvant therapy. The incidence of postoperative AL was 9.5% (34/359). Univariate analysis showed that gender, preoperative albumin and distance from tumor to the anus were associated with postoperative AL (All P<0.05). Multivariate logistic regression analysis revealed that male (OR=2.480, 95% CI: 1.012-6.077, P=0.047), preoperative albumin ≤40 g/L (OR=5.319, 95% CI: 2.106-13.433, P<0.001) and distance from tumor to anus ≤ 5 cm (OR=4.339, 95% CI: 1.990-9.458, P<0.001) were significant independent risk factors for postoperative AL. According to these results, a nomogram prediction model was constructed. The male was for 55 points, the preoperative albumin ≤ 40 g/L was for 100 points, and the distance from tumor to the anus ≤ 5 cm was for 88 points. Adding all the points of each risk factor, the corresponding probability of total score would indicated the morbidity of postoperative AL predicted by this nomogram modal. The AUC of the nomogram was 0.792 (95% CI: 0.729-0.856), and the C-index was 0.792 after internal verification. The calibration curve showed that the predictive results were well correlated with the actual results (P=0.562). Conclusions: Male, preoperative albumin ≤ 40 g/L and distance from tumor to the anus ≤ 5 cm are independent risk factors for AL after laparoscopic surgery in rectal cancer patient with neoadjuvant therapy. The nomogram prediction model is helpful to predict the probability of AL after surgery.

The Risk Factor of Anastomotic Hypoperfusion in Colorectal Surgery

BackgroundInadequate blood flow is an important risk factor for anastomotic leakage. Indocyanine green (ICG) fluorescence imaging allows intraoperative assessment of intestinal blood flow. This study determined the risk factor of anastomotic hypoperfusion in colorectal surgery using ICG fluorescence imaging. MethodsThis study included 74 consecutive patients who underwent colorectal surgery between April 2017 and March 2018. ICG was injected intravenously after dividing the mesentery and central vessels along the planned transection line, but before completing the anastomosis. Intraoperative blood flow was evaluated using ICG fluorescence imaging. With regard to the patient-, tumor-, and surgery-related factors, anastomotic perfusion was evaluated based on the changed transection line and prolonged (more than 60 s) perfusion time. ResultsIntraoperative ICG fluorescence imaging was performed in all patients, and no adverse events were associated with ICG injection. Based on the perfusion assessment, we changed the transection line in six patients (8.1%). The prolonged perfusion time was observed in nine patients (12.2%). The postoperative course was uneventful in 63 (85.1%) patients, but one patient (1.4%) had postoperative anastomotic leakage. The changed transection line was significantly associated with anticoagulation therapy (P = 0.029). Well-known risk factors, including surgical site, sex, smoking, blood loss, operative time, and preoperative chemoradiotherapy, were not related to the changed transection line. Prolonged ICG perfusion time was not associated with any patient-, tumor-, or surgery-related factors. ConclusionsThe evaluation of intraoperative blood flow using ICG fluorescence imaging may be able to detect anastomotic hypoperfusion, and anticoagulation therapy is a risk factor of anastomotic hypoperfusion in colorectal surgery.

Risk factors for anastomotic leak after esophagectomy for cancer: A NSQIP procedure-targeted analysis.

Anastomotic leak is the most common major complication after esophagectomy. We investigated the 2016 American College of Surgeons National Surgical Quality Improvement Program esophagectomy targeted database to identify risk factors for anastomotic leak. Patients who underwent esophagectomy for cancer were included. Patients experiencing an anstomotic leak were identified, and univariate and multivariable logistic regression was performed to identify variables independently associated with anastomotic leak. Of 915 patients included, 83% were male and the median age was 64 years. Patients with anastomotic leak more frequently had additional complications (87% vs 36%, P < .001). Rates of reoperation (64% vs 11%, P < .001) and mortality (8% vs 2%, P = .001) were higher in patients with anastomotic leak. After adjusting for patient and procedure characteristics, prolonged operative time (for each additional 30-minutes; adjusted odds ratios (AOR) 1.068, 95% CI, 1.022-1.115, P = .003), increased preoperative WBC count (for each 3000/µL increase; AOR 1.323, 95% CI, 1.048-1.670, P = .019), pre-existing diabetes (AOR 1.601, 95% CI, 1.012-2.534, P = .045), and perioperative transfusion (AOR 1.777, 95% CI, 1.064-2.965, P = .028) were independently associated with anastomotic leak. Both patient and procedure-related factors are associated with anastomotic leak. Though frequently non-modifiable, these findings could facilitate risk stratification and early detection of anastomotic leak to reduce associated morbidity.

Predictive risk factors for anastomotic leakage after anterior resection of rectal cancer in elderly patients over 80\u2009years old: an analysis of 288 consecutive patients

BackgroundAnastomotic leakage (AL) is a common complication after anterior resection of rectal cancer. Few studies have been conducted to determine whether the traditional predictors of AL can be applied to elderly patients (age ≥ 80) undergoing anterior resection (AR) or low anterior resection (LAR) of rectal cancer. This study was designed to explore the predictive factors for AL after anterior resection of rectal cancer in patients over 80 years old.MethodsFrom January 2007 to May 2019, consecutive elderly (age ≥ 80) rectal cancer patients undergoing AR or LAR at our institution were systematically reviewed. The general information, perioperative outcomes, and comorbidities were collected.ResultsA total of 288 consecutive patients were included in this study. The average age was 82.8 ± 2.4 years, and 30 (10.4%) patients developed AL. The univariate analyses showed that neoadjuvant therapy (50.0% vs. 27.9%, P = 0.013), the number of stapler firings ≥ 3 (60.0% vs. 36.0%, P = 0.011), and coronary heart disease (CHD) (46.7% vs. 17.8%, P < 0.001) were associated with an increased incidence of AL. The multivariate analysis showed that the number of stapler firings ≥ 3 (OR = 4.77, 95% CI = 1.33–15.21, P = 0.035) and CHD (OR = 8.33, 95% CI = 1.94–13.05, P = 0.003) were independent risk factors for AL.ConclusionThe number of stapler firings ≥ 3 and CHD were independent risk factors for AL in elderly patients (age ≥ 80) with rectal cancer. A temporary ileostomy or the Hartmann procedure is recommended for patients with CHD, male patients, patients considered to be obese, and patients with a lower tumor location, which may increase the number of stapler firings. Certainly, we recommend that the number of stapler firings should be minimized to alleviate the economic and physical burden of patients.

Independent perioperative predictive risk factors for the anastomotic leak after emergency bowel resection anastomosis

Background: Anastomotic disruption after bowel resection anastomosis is a devastating and a feared complication, so it is of utmost importance to identify perioperative parameters predisposing to such complication.Methods: A prospective cohort study was performed in two institutes, and there were 287 patients eligible and included in the study which done from April 2017 to December 2018, 87 patients underwent intervention in the first institute in Zagazig University Hospitals, Egypt. And 200 patients underwent intervention in Riyadh, KSA. Statistical analysis used: Percent of categorical variables were compared using Pearson’s Chi-square test or Fisher's exact test when was appropriate. Risk estimation was done by Odds ratio (OR) calculation. All tests were two sided. A p-value &lt;0.05 was considered significant. All statistics were performed using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA) and MedCalc windows (MedCalc Software bvba 13, Ostend, Belgium).Results: Of the parameters analyzed risk factors for anastomotic leakage that studied in 287 patients, 6 perioperative parameters have significant statistical difference: hypo-albuminaemia (Odd ratio: 6.544 and p-value &lt;0.001), acute intra-abdominal contamination (Odd ratio: 3.921 and P-value &lt;0.004), High WBC'S with high presepsin with p-value &lt;0.001, hyponatremia p&lt;0.004, perioperative blood transfusion and anastomotic tension were found to be independent factors.Conclusions: Knowledge of independent perioperative predictive factors for leakage is of utmost importance for its early detection, decision making for surgical time,our study concluded the possibility to detect a subgroup of high-risk patients for anastomotic leakage after emergency bowel resection anastomosis.