Severity Of Anastomotic Leakage Research Articles

Mechanical Bowel Preparation Does Not Affect Clinical Severity of Anastomotic Leakage in Rectal Cancer Surgery.

Previous multicenter randomized trials demonstrated that omitting mechanical bowel preparation (MBP) did not increase anastomotic leakage rates or other infectious complications. However, the most serious concern regarding the omission of MBP is ongoing fecal peritonitis after anastomotic leakage occurs. The aim of this study was to compare the clinical manifestations and severity of anastomotic leakage between patients who underwent MBP and those who did not. This study was a single-center retrospective review of a prospectively maintained database. From January 2006 to September 2013, 1369 patients who underwent elective rectal cancer resection with primary anastomosis were identified and analyzed. Anastomotic leakage rates were not significantly different between patients who did not undergo MBP (77/831, 9.27%) and those who did (42/538, 7.81%). However, a significantly lower rate of clinical leakage requiring surgical exploration was observed in the leakage without MBP group (30/77, 39.0%) compared with the leakage with MBP group (30/42, 71.4%) (P=0.001). There were no significant differences in the clinical severity of anastomotic leakage as assessed by the length of hospital stay, time to resuming a normal diet, length of antibiotic use, ileus rate, transfusion rate, ICU admission rate, and mortality rate between the leakage without MBP and leakage with MBP groups. MBP was not found to affect the clinical severity of anastomotic leakage in elective rectal cancer surgery.

Does a severe anastomotic leak after esophageal resection adversely impact the long-term survival?

Does a severe anastomotic leak after esophageal resection adversely impact the long-term survival?

Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis: A case controlled study.

Background and aimsThe aim of this study was to investigate the clinical usefulness of the placement of a transanal drainage tube to prevent anastomotic leakage in colorectal anastomoses.Material and methodsThis single-center retrospective trial included all patients treated with surgery for benign or malign colorectal disease between January 2009 and December 2012. The transanal drainage tube was immediately placed after colorectal anastomosis until day five and was routinely used since 2010. Patients treated with a transanal drainage tube were compared with the control group. Statistical analysis was performed using Fisher's exact or Chi-square tests for group comparison and a linear regression model for multivariate analysis.ResultsThis study included 242 patients (46% female; median age 63 years; range 18–93); 34% of the patients underwent a laparoscopic procedure, and 57% of the patients received a placement of a transanal drainage tube. Anastomotic leakage occurred in 19 patients (7.9%). Univariate analysis showed a higher rate of anastomotic leakage in patients with an ASA score 4 (p = 0.02) and a lower rate in patients with transanal drainage placement (3.6% vs. 13.6%; p = 0.007). The grading of the complication of anastomotic leakage was reduced with transanal drainage (e.g., Dindo ≧ 3b: 20.0% vs. 92.9%; p = 0.006), and the hospital stay was shortened (17.6 ± 12.5 vs. 22.1 ± 17.6 days; p = 0.02). Multivariate analysis revealed that transanal drainage was the only significant factor (HR = −2.90; −0.168 to −0.032; p = 0.007) affecting anastomotic leakage.ConclusionsPlacement of a transanal drainage tube in patients with colorectal anastomoses is a safe and simple technique to perform and reduces anastomotic leakage, the severity of the complication and hospital stay.

Peer review report 1 on “Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis”

Peer review report 1 on “Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis”

A Novel Technique for Managing Pancreaticojejunal Anastomotic Leak after Pancreaticoduodenectomy.

Pancreaticoduodenectomy (Whipple's procedure) remains the only definitive treatment option for tumors of the periampullary region. The most common and life-threatening complications following the procedure are pancreatic anastomotic leakage and subsequent fistula formation. When these complications occur, treatment strategy depends on the severity of anastomotic leakage, with patients with severe leakages requiring reoperation. The optimal surgical method used for reoperation is selected from among different options such as wide drainage, definitive demolition of the pancreaticojejunal anastomosis and performing a new one, or completion pancreatectomy. Here we present a novel, simple technique to manage severe pancreatic leakage via ligamentum teres hepatis patch.

Analysis of Risk Factors and Management of Anastomotic Leakage After Rectal Cancer Surgery: An Indian Series.

The primary objective of this study was to determine whether sphincter preservation is possible among patients who develop anastomotic leakage after rectal cancer surgery. The secondary objective was to determine the factors that may contribute to anastomotic leakage. This is a retrospective review of a prospectively maintained database. All patients with rectal cancer who underwent restorative proctectomy over 1year were included in the study. The parameters analyzed were age, preoperative hemoglobin and albumin, neoadjuvant therapy, type of surgery, level of ligation of inferior mesenteric pedicle, technique of anastomosis, and defunctioning proximal stoma. In this study, 176 cases of anterior resection were included,of which15 (8.5%) had anastomotic leakage. None of the factors contributing to anastomotic leakage reached statistical significance on univariate analysis. Among the patients who had proximal defunctioning ileostomy (n=9), five (56%) required re-surgery whereas other four were managed with antibiotics and presacral drainage alone (44%). Among the patients who didnot have proximal defunctioning ileostomy (n=6), all (100%) required re-surgery. Among the 12 eligible patients, stoma reversal was successful in eight (67%) patients. This study highlights the importance of defunctioning proximal stoma in reducing the incidence and severity of anastomotic leakage as well as the need and extent of re-surgery for low rectal cancer. Sphincter preservation is possible in majority of patients who develop anastomotic leakage after rectal cancer surgery.

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

Background and Purpose Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated.MethodsPopulation-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction.ResultsOf all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals’ adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals’ adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates.ConclusionsA high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.

Postoperative hyperbilirubinemia suggests the occurrence of complications after esophagectomy for esophageal cancer.

Serum bilirubin levels frequently increase after esophagectomy for esophageal cancer. Several studies have reported hyperbilirubinemia in patients with postoperative complications. We aimed to perform a detailed large-scale analysis to clarify this association. We compared postoperative serum bilirubin levels of 200 patients with esophageal cancer who underwent esophagectomy, with and without postoperative complications, from January 2008 to July 2013 at Keio University Hospital, Tokyo, Japan. We also analyzed other risk factors for postoperative hyperbilirubinemia by univariate and multivariate analyses in an attempt to determine the mechanism of postoperative hyperbilirubinemia. Hyperbilirubinemia (total bilirubin >2.0 mg/dL) occurred in 71 patients (35.5 %). The mean total bilirubin peak level was 1.5 mg/dL in patients without complications, 2.0 mg/dL in those with at least one complication, 2.1 mg/dL in those with pneumonia, and 2.3 mg/dL in those with anastomotic leakage. Bilirubin levels were significantly higher in each complication group than in the non-complication group (p < 0.05 for all). Risk factors of postoperative hyperbilirubinemia by univariate analysis were the preoperative bilirubin level, video-assisted thoracoscopic surgery, three-field lymph node dissection, thoracic duct resection, prolonged surgical duration, severe complications (Clavien-Dindo grade ≥3), and severe anastomotic leakage (Clavien-Dindo grade ≥3). In contrast, the pT factor and postoperative enteral nutrition were negatively associated with postoperative hyperbilirubinemia. Risk factors by multivariate analysis were the preoperative bilirubin level, prolonged surgical duration, severe complications, and postoperative enteral nutrition. Although various factors impact postoperative hyperbilirubinemia, postoperative complications were most significantly associated with postoperative hyperbilirubinemia. Patients with postoperative hyperbilirubinemia after esophagectomy must be managed more carefully because unnoticed complications may be associated with hyperbilirubinemia.

Does ghost ileostomy have a role in the laparoscopic rectal surgery era? A randomized controlled trial.

Anastomotic leakage following anterior rectal resection is the most important and most commonly faced complication of laparoscopy and open surgery. To prevent this complication, the construction of a preventing stoma is usually adopted. It is not easy to decide whether to construct a protective stoma in patients with a medium risk of anastomotic leakage. In these patients, ghost ileostomy (GI), a pre-stage ileostomy that can be externalized and opened if needed, has proved useful. We conducted a prospective, randomized, controlled study to evaluate the advantages of GI in laparoscopic rectal resection. All patients with surgical indications for laparoscopic rectal resection who were at medium risk for anastomotic leakage from January 2007 to January 2013 were included and were randomly divided in 2 groups. All of the patients were subjected to laparoscopic anterior rectal resection with the performance of GI (group A) or without the construction of any protective stoma (group B). The presence and severity of clinically evident postoperative anastomotic leakage and other postoperative complications and reinterventions were investigated. Of the 55 patients allocated to group A, 3 experienced anastomotic leakage compared with 4 in group B. The patients with GI experienced a lower severity of anastomotic leakage and shorter hospitalization compared with the patients in group B. None of the patients with GI and anastomotic leakage required laparotomy to treat the dehiscence. The use of GI in laparoscopic rectal resections in patients at medium risk for anastomotic leakage was useful because it allowed for the avoidance of stoma creation in all of the patients, thus reducing the number of stomas performed, improving the quality of life of the patients and preserving, in most cases, the benefits gained by laparoscopy.

Study protocol for the nutritional route in oesophageal resection trial: a single-arm feasibility trial (NUTRIENT trial)

IntroductionThe best route of feeding for patients undergoing an oesophagectomy is unclear. Concerns exist that early oral intake would increase the incidence and severity of pneumonia and anastomotic leakage. However,...

Exposure to an atomic bomb explosion is a risk factor for in-hospital death after esophagectomy to treat esophageal cancer

Esophagectomy, one of the most invasive of all gastrointestinal operations, is associated with a high frequency of postoperative complications and in-hospital mortality. The purpose of the present study was to determine whether exposure to the atomic bomb explosion at Hiroshima in 1945 might be a preoperative risk factor for in-hospital mortality after esophagectomy in esophageal cancer patients. We thus reviewed the outcomes of esophagectomy in 31 atomic bomb survivors with esophageal cancer and 96 controls (also with cancer but without atomic bomb exposure). We compared the incidences of postoperative complications and in-hospital mortality. Of the clinicopathological features studied, mean patient age was significantly higher in atomic bomb survivors than in controls. Of the postoperative complications noted, atomic bomb survivors experienced a longer mean period of endotracheal intubation and higher incidences of severe pulmonary complications, severe anastomotic leakage, and surgical site infection. The factors associated with in-hospital mortality were exposure to the atomic bomb explosion, pulmonary comorbidities, and electrocardiographic abnormalities. Multivariate analysis revealed that exposure to the atomic bomb explosion was an independent significant preoperative risk factor for in-hospital mortality. Exposure to the atomic bomb explosion is thus a preoperative risk factor for in-hospital death after esophagectomy to treat esophageal cancer.

891m: The Efficacy of Endoscopic Treatment for the Anastomotic Leak After Gastrectomy in Patients With Gastric Cancer

Gastrectomy with lymph nodes dissection is the primary treatment for the localized gastric cancer. The main complications include bleeding, gastric stasis, infection of the surgical wound, and anastomotic leak. An anastomotic leak after gastrectomy in gastric cancer patients have been reported to occur in 0.2% to 7.4% of cases. Conservative care may be sufficient for minimal leak. However controversy persists on treatment of the severe anastomotic leakage, re-laparotomy vs. conservative management.

Definition and grading of anastomotic leakage following anterior resection of the rectum: A proposal by the International Study Group of Rectal Cancer

Anastomotic leakage represents a major complication after anterior resection of the rectum. The incidence of anastomotic leakage varies considerably among clinical studies in part owing to the lack of a standardized definition of this complication. The aim of the present article was to propose a definition and severity grading of anastomotic leakage after anterior rectal resection. After a literature review a consensus definition and severity grading of anastomotic leakage was developed within the International Study Group of Rectal Cancer. Anastomotic leakage should be defined as a defect of the intestinal wall at the anastomotic site (including suture and staple lines of neorectal reservoirs) leading to a communication between the intra- and extraluminal compartments. Severity of anastomotic leakage should be graded according to the impact on clinical management. Grade A anastomotic leakage results in no change in patients' management, whereas grade B leakage requires active therapeutic intervention but is manageable without re-laparotomy. Grade C anastomotic leakage requires re-laparotomy. The proposed definition and clinical grading is applicable easily in the setting of clinical studies. It should be applied in future reports to facilitate valid comparison of the results of different studies.

Endotherapy for Fistulae of the Upper GI Tract After Laparoscopic Bariatric Surgery

Endotherapy for Fistulae of the Upper GI Tract After Laparoscopic Bariatric Surgery Pierre Eisendrath, Michel Cremer, Olivier Le Moine, Jacques Himpens, Guy-Bernard Cadiere, Jacques Deviere Background: Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known if endoscopic treatment may help avoid reintervention in these difficult cases. This study shows for the first time the potential of endoscopic treatment in patients with severe anastomotic leaks after different types of laparoscopic procedures for morbid obesity. Methods: Between May 2004 and August 2005, 14 patients (8 women, mean age 46, BMI 41 before surgery) underwent endoscopic treatment using Self Expandable Metal Stents (SEMS) for large anastomotic leaks before considering redo surgery. Five patients had a gastric by-pass (GBP), 2 sleeve gastrectomy alone (SG), or combined with a duodenal switch in 7 (SDS). Fistulae were gastro-cutaneous, duodeno-cutaneous and gastro-bronchial in 11, 2 and 1 cases, respectively. The stents used to cover fistulae were partially covered SEMS of 12 to 15 cm length and of 18 to 22 mm diameter. Additional endoscopic procedures including abscess drainage and sealants injection were used in 5 patients. After closure of the fistula, because of hyperplasia developed at the uncovered parts of the stent, 3 patients needed a self expandable plastic stent (SEPS) insertion into SEMS to allow their retrieval. Results: In GBP patients, 4 with gastro-cutaneous fistula healed after insertion of 1, 2, or 3 stents for respectively 48, 49, 60 and 116 days. Healing of the gastro-bronchial fistula was only obtained after removal of the stent and sealant injection in the small residual tract. Out of the 7 patients with SDS, the 2 patients presenting a duodenocutaneous fistula were completely healed 41 and 62 days after insertion. Two other patients were healed after 35 and 48 days respectively. Endoscopic treatment failed in 3 patients because of acute bleeding from the leak requiring urgent laparotomy in one, relapse of the fistula 1 month after stenting and need for reoperation in a second, and sepsis relapse after transient improvement followed by death 3 months after insertion in the last case. Considering SG alone: one patient who clinically healed died from sudden pulmonary embolism 4 weeks after stent insertion; the other had relapsing fistula 1 month after SEMS retrieval. Conclusions: Endoscopic treatment for complications of bariatric surgery is feasible. Healing of severe leaks can be obtained in 64% of the patients (9/14), avoiding therefore the need for high risk reintervention in those patients. This clearly deserves further investigation, particulary after sleeve or SDS where the current results are non conclusive.

Loop ileostomy as temporary faecal diversion following total mesorectal excision

Aim: Anastomotic leakage following low anterior resection with total mesorectal excision carries a significant morbidity and mortality. Both loop ileostomy and loop transverse colostomy are common options of temporary faecal diversion to reduce the severity of anastomotic leakage. We use loop ileostomy routinely because of its ease of construction and closure, and low complication rate. Here, we reviewed our result of loop ileostomy.Methods: We reviewed the medical records of all patients who had temporary loop ileostomy constructed following low anterior resection with total mesorectal excision for CA rectum, from 1.1999 to 12.2003. Stoma related morbidity pre and post–closure of loop ileostomy were recorded.Results: Eighty‐eight patients had loop ileostomy constructed and later closed from 1.1999 to 12.2003. Seventeen of them required small bowel resection during closure of the loop ileostomy. Three patients (3.4%) had skin excoriation and one patient (1.1%) had prolonged ileus after the construction of ileostomy (3.4%). After closure of ileostomy, two patients (2.2%) had wound infection and two patients (2.2%) had anastomotic leakage. Six patients (6.8%) developed intestinal obstruction later. Post‐closure intestinal obstruction and anastomotic leakage were found to be associated with small bowel resection during the closure of ileostomy (P=0.042).Conclusion: Loop ileostomy and its closure are associated with low complication rates. We therefore continue to advocate the use of loop ileostomy as a temporary diversion procedure after total mesorectal excision.

Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: A controlled trial

Mechanical anastomosis has been claimed to reduce the rate of leakage compared with manual anastomosis. No randomized trials have been performed to date to prove this specifically in esophagogastric anastomosis. One hundred fifty-four patients, 139 men and 15 women ranging in age from 36 to 83 years (mean, 50 +/- 10 years) and undergoing elective resection of esophageal or cardial carcinoma, were included in this multiinstitutional (14 centers) randomized study comparing the rate of anastomotic leakage after esophagogastric anastomosis performed manually or mechanically. Eligible for this study were patients with esophageal or cardial carcinoma located between the esophagogastric junction (included) and the upper border of the aortic arch. The choice between resection with or without thoracotomy was left to the discretion of the operating surgeon. Proximal resection of the fundus was mandatory. Intestinal tract continuity was reestablished in a one-stage procedure by an esophagogastric anastomosis without interposition of either the jejunum or the colon. The site of the anastomosis could be either intrathoracic or cervical. The principal end point was anastomotic leakage as judged by (1) egress of intestinal fluids or orally ingested methylene blue through drains, (2) sodium diatrozate swallow prescribed either routinely for all patients between postoperative days 3 and 8 or because of signs of leakage, or (3) reoperation or autopsy. After two patients were withdrawn for protocol violation, 152 patients, 74 in the manual group and 78 in the mechanical group, were studied. The number of anastomotic leakages was identical in both groups (n = 12, 16% and 15%, respectively). Overall 30-day mortality was 11%. Fewer deaths occurred in the manual group (7%), which had three anastomotic leakages, than in the mechanical group (15%), which had five anastomotic leakages, and fewer repeat operations were done in the manual group (n = 9) than in the mechanical group (n = 13), but both of these differences were not statistically significant. The duration of anastomosis and of operation was similar in both groups. In the mechanical group 16 anastomoses (20%) gave rise to technical mishaps (either in the fashioning of the purse-string, dilation of the esophagus, or in stapling). Among the factors recognized as potentially preventing leakage, only testing for airtightness was significantly correlated with less postoperative leakage (p < 0.05). Eight postoperative strictures were recorded at 3 months in 62 (13%) patients in the manual group, whereas seven strictures occurred in 53 (13%) patients in the mechanical group. When mechanical staples rather than manual sutures are chosen, the disadvantages (technical mishaps and higher costs) are not counterbalanced by a gain of time or a decrease in the rate or severity of anastomotic leakage.

Results of gastric tube esophagoplasty in esophageal atresia

During the 11-year period 1975–1985, 20 gastric tube reconstructions were performed on patients with esophageal atresia. Ten had one or several associated anomalies; in 6 these were life-threatening or severe. The indications for replacement were: long gap in 12 patients, anastomotic leakage in 6, and failed colon interposition in 2. All reconstructions were made in two phases with antiperistaltic retrosternal tubes. There was no hospital mortality, but 2 tubes failed due to gross anastomotic insufficiency after the second phase. In addition, a third patient had a severe anastomotic leakage, which meant that the anastomosis had to be temporarily abandoned, a successful reanastomosis was later performed. Minor leakage occurred after the anastomosis in 8 patients, resulting in a cervical fistula in 7 and mediastinitis in 1. All complications resolved with conservative treatment. All successfully operated patients have had continuous follow-up for 2–12 years (mean 6 years). There was one late death in a patient who also had high anal atresia and died of an occlusive ileus 2 years after a Kiesewetter pull-through operation. Late complications included 5 anastomotic strictures 2 of which required resection and 3 that required prolonged dilatations. One anastomosis was perforated during routine dilatation, but was saved after two reoperations. Two patients had swallowed foreign bodies that required endoscopic removal. The subjective result, according to the criteria of Desjardins et al, was excellent in 7 patients and good in 10. All but 1 patient were within 2 standard deviations of height and weight of normal Finnish children at last measurement.