Risk Of Postoperative Leakage Research Articles

The effect of gastric fundus radiation dose on postoperative anastomotic leakage in esophageal cancer.

Standard-of-care treatment for locally advanced esophageal carcinoma (LAEC) includes neoadjuvant chemoradiotherapy followed by esophagectomy. A potentially catastrophic surgical complication is the development of a postoperative anastomotic leak. To date, the association with radiation dose exposure had been inconclusive. We examined the correlation between radiation exposure to the gastric fundus and risk of postoperative leakage using contemporary radiation doses and fractionation. A total of 69 consecutive patients with LAEC who underwent neoadjuvant chemoradiotherapy followed by esophagectomy in our tertiary center were prospectively followed (median, 27 months). Neoadjuvant regimen included 50.4 Gy in 28 fractions with 5-fluorouracil and cisplatin and 41.4 Gy in 23 fractions with carboplatin and paclitaxel. The gastric fundus was contoured and dosimetric and radiation technique parameters were retrospectively evaluated. Of the total number of patients, 71% and 29% had esophageal and gastroesophageal junction (GEJ) tumors, respectively. Fourteen patients (20.3%) experienced anastomotic leaks within a median of 2 days postoperatively, 78.6% of whom had lower third esophagus or GEJ primaries. Mean and minimum fundus dose did not significantly differ between those with and those without leakage (p = 0.42, p = 0.51). Mean fundus V25, V30, and V35 doses were numerically but not statistically higher in those with anastomotic leak (p = 0.58, p = 0.39, and p = 0.30, respectively). No correlation with incidence of leakage was seen between 3D and IMRT treatment modalities. In our comparatively large prospectively collected series of patients treated for LAEC, radiation dose to the gastric fundus during neoadjuvant combination therapy prior to surgery did not correlate with the risk of postoperative anastomotic leak.

Incontinence urinaire et prolapsus génital

Prolapse commonly coexists with lower urinary tract dysfunction. If symptomatic stress urinary incontinence is often described by patients with low stage pelvic organ prolapse, obstructive symptoms are common in patients with stage 3 or 4 prolapse. Positive preoperative reduction testing in stress continent women planning prolapse repair is associated with a higher risk for postoperative leakage and clearly identify a high risk population. To date it has not been proven that urodynamic testing may provide more precise data than physical examination to advocate an additional stress urinary surgery at the time of prolapse repair. A systematic prophylactic Burch colposuspension significantly reduces the risk of postoperative SUI. In patients with occult SUI, a concomitant TVT at the time of vaginal prolapse surgery significantly reduces the risk of postoperative SUI. In patients without leakage during reduction testing, there is no evidence for performing a concurrent TVT.

Laparoscopic radical prostatectomy: omitting a pelvic drain

Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Doxycycline-coated sutures improve mechanical strength of intestinal anastomoses

After resection and repair of the intestines, tissue degradation leads to weakening of the repair site and risk of postoperative leakage. Matrix metalloproteinases (MMPs) are thought to be responsible for collagenolysis in the direct vicinity of surgical sutures in many tissues. Several experimental studies show that MMP inhibitors administered systemically alleviate postoperative weakening of intestinal anastomoses. We hypothesised that local delivery of MMP inhibitors would achieve a similar effect. Implementing a novel method for the coating of biomaterials, we coated sutures with a cross-linked fibrinogen film and bound the MMP inhibitor doxycycline into this film. The sutures were then used in a standard rat model for evaluating mechanical properties of colonic anastomoses 3 days after surgery. The breaking strength of the anastomoses on the critical third day after operation was 17% higher with doxycycline-coated sutures compared to controls (P = 0.026). Energy uptake at failure was enhanced by 20% (P = 0.047). Drug delivery by means of MMP-inhibitor-coated sutures appears to improve tissue integrity during anastomotic repair and may reduce postoperative complications.

Laparoscopic duodenal atresia repair using surgical U-clips: a novel technique

Laparoscopic repair of duodenal atresia has been reported. Reports to date have indicated use of standard laparoscopic suturing and knot tying. Unfortunately, there has been a high leak rate associated with the technique. We report our technique of using U-clips for the duodenoduodenostomy, thus limiting trauma to the duodenum during the anastomosis and less risk for postoperative leakage.

Transvesical anastomosis after radical retropubic prostatectomy

In recent years radical prostatectomy has become the treatment of choice for early-stage prostate cancer. It is now a well-codified operation performed by most urologists. However, several steps remain difficult; among them, the vesicourethral anastomosis is perhaps the most fastidious. Everyone with experience in this kind of surgery has been confronted with leakage at the Because of the depth of the anastomosis, the surgeon must tie the knots in a blind fashion and the only way to know if they are correctly tied is by tactile sensation which requires a great amount of experience. If the knot is tied too loosely, the bladder and the urethra will not be coapted; if it is tied too tightly, disruption of the urethra can occur. Each case carries the risk of postoperative leakage.

Stapled colorectal anastomoses: peroperative integrity of the anastomosis and risk of postoperative leakage.

Eighty-two patients underwent colorectal anastomosis using the circular mechanical stapling instrument. Integrity of the anastomosis was assessed intraoperatively by the air test and examination of doughnuts for completeness. A proctogram using a water soluble contrast preparation was performed in 79 patients postoperatively. In 68 patients doughnuts were complete and no air leak was found in any case. Postoperatively three clinical and one radiological leak occurred. In 14 patients at least 1 doughnut was incomplete. Of these, 4 had an air leak whilst 10 did not. There was no leak postoperatively in these 10 patients but 2 of the 4 patients with an intraoperative air leak developed a radiological leak postoperatively. The data suggest that the air test is useful since absence of air leakage in cases with an incomplete doughnut was followed by sound anastomotic healing. Further, the demonstration of air leakage enables immediate repair of the anastomosis perhaps avoiding subsequent clinical leakage.