Treatment Of Anastomotic Leakage Research Articles

330. PRE-EMPTIVE ENDOLUMINAL VACUUM THERAPY WITH A SURGICAL DRAIN FOR REDUCTION OF ANASTOMOTIC LEAK RATE FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Endoluminal vacuum therapy (EVT) is an effective treatment for anastomotic leak (AL) following esophagectomy. A novel application of EVT is to utilise its effect to improve microcirculation and granulation at the anastomosis pre-emptively to reduce the risk of AL. We describe a unique method of positioning a fenestrated surgical drain with applied vacuum suction at the level of the anastomosis following minimally invasive esophagectomy (MIE), with the aim of reducing AL rate and postoperative morbidity. Methods A retrospective cohort comparison was performed on consecutive MIEs from 2019 to 2023. All operations were performed by experienced esophagogastric surgeons at a tertiary centre in the UK. Included patients were all adults undergoing MIE for esophageal cancer. Patients who underwent pre-emptive EVT (pEVT) with surgical drain following MIE were compared with a control group who underwent MIE alone. All patients followed the same enhanced recovery protocol with pEVT removed two to five days post-operatively. The primary outcome assessed was AL, secondary outcomes included: length of stay (LOS), readmission to Intensive care, complications (Clavien-Dindo) and 90-day mortality with minimum 90-days follow-up. Results 72 patients were included, 25 patients underwent MIE with pEVT compared with 47 in the control. The AL rate in the pEVT group was 8% compared with 21.3% in the control (RRR 62%, p = 0.13). All ALs following pEVT were managed successfully with EVT alone. There was a reduced risk of aspiration pneumonia (RR:0.37, p = 0.22) and readmission to ICU (RR:0.24, p = 0.049) following pEVT. There was 0%, 90-day mortality in both groups and no significant difference in median LOS (7 vs 9 days, p = 0.72 (pEVT vs Control)). However, a higher risk of stricturing following pEVT was noted (RR:3.76, p = 0.04). Conclusion Our data suggests pEVT with a surgical drain may be a safe and effective method of reducing AL rate following MIE. Additionally, it confers the benefit of being an effective treatment for AL should this complication arise. There was significant increase in benign stricturing requiring dilatation following pEVT, however, this may be attributable to other operative factors. Our results support the need for further prospective studies such as a randomised controlled trial.

Assessing the environmental impact of an anastomotic leak care pathway

BackgroundThe healthcare sector faces increasing pressure to improve environmental sustainability whilst continuing to meet the needs of patients. One strategy is to lower the avoidable demand on healthcare services, by reducing the number of surgical complications, such as anastomotic leak (AL). The aim of this study was to assess the environmental impact associated with the care pathway of AL. MethodsAn environmental impact assessment was performed according to the Sustainable Healthcare Coalition (SHC) guidelines. A care pathway, describing the typical steps involved in the diagnosis and treatment of AL was developed. Activity and emission data for each stage of the care pathway were used to calculate the climate, water and waste impact of the treatment of AL patients. ResultsThe environmental impact assessment shows that AL is associated with an average climate, water and waste impact per patient of 1303 kg CO2-eq, 1803 m3 of water and 123 kg waste, respectively. Grade C leaks are associated with the greatest environmental impact, contributing to 89.3 %, 79.4 % and 97.9 % of each impact, respectively. A breakdown of the environmental impact of each activity shows that stoma home management is the largest contributor to the total climate (46.6 %) and waste (47.3 %) impact of AL patients, whilst in-patient hospital stay contributes greatest to the total water impact (46.7 %). ConclusionsThe treatment of AL is associated with a substantial environmental impact. This study is, to our knowledge, the first to assess the environmental impact associated with the treatment of AL.

Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections?

Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL. All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma). A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions). In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: A case-vignette study

International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: A case-vignette study

Comparison of proactive and conventional treatment of anastomotic leakage in rectal cancer surgery: a multicentre retrospective cohort series

PurposeComparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR.MethodsThis retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up.ResultsOverall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008).ConclusionProactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable.

Challenges in the interdisciplinary treatment of leakages after left-sided colorectal surgery: endoscopic negative pressure therapy, open-pore film drainage therapy and beyond

PurposeThe treatment of anastomotic leakage after left colorectal surgery remains challenging. Since its introduction, endoscopic negative pressure therapy (ENPT) has proven to be advantageous, reducing the necessity of surgical revision. The aim of our study is to present our experience with endoscopic treatment of colorectal leakages and to identify potential factors influencing treatment outcome.MethodsPatients who underwent endoscopic treatment of colorectal leakage were retrospectively analyzed. Primary endpoint was the healing rate and success of endoscopic therapy.ResultsWe identified 59 patients treated with ENPT between January 2009 and December 2019. The overall closure rate was 83%, whereas only 60% of the patients were successfully treated with ENPT and 23% needed further surgery. The time between diagnosis of leakage and uptake of endoscopic treatment did not influence the closure rate, but patients with chronic fistula (> 4 weeks) showed a significantly higher reoperation rate than those with an acute fistula (94% vs 6%, p = 0.01).ConclusionENPT is a successful treatment option for colorectal leakages, which appears to be more favorable when started early. Further studies are still needed to better describe its healing potential, but it deserves an integral role in the interdisciplinary treatment of anastomotic leakages.

Assessment of the efficacy of Handmade Vacuum-Assisted Sponge Drain for Treatment of Anastomotic leakage after Low Anterior Rectal Resection.

Anastomotic leakage is one of the major complications of colorectal surgery, which might lead to reoperation, increased hospital stays, further intervention and mortality. Vacuum-assisted closure by devices such as Endo-SPONGE® produced by (B-Braun Medical B.V.) is currently being used to treat leakage and fistula. In this study, we aimed to assess the handmade vacuum-assisted sponge drain for anastomotic leakage following low anterior resection. This prospective study included 22 patients who had undergone sponge drain placement to treat anastomotic leakage. All patients had anastomotic leaks or defects after left anterior rectal resection (LAR) without ileostomy. They were treated with neo-adjuvant chemotherapy before the surgery and then subjected to rigid recto-sigmoidoscopy for 30days following the operation. Any sign of leakage, such as perianal and pelvic pain, was immediately identified and followed up with a CT scan and another recto-sigmoidoscopy. Twenty-two patients were enrolled in this study, 12 men (54.5%) and 10 women (47.4%). All patients had received neo-adjuvant chemotherapy with an average follow-up of 22.30 ± 3.81. 75% of patients (15 cases) were successfully treated, and 17 patients (85%) underwent successful ostomy closure. Treatment failed in 5 patients (25%), including three men and two women. This study shows that handmade vacuum-assisted sponge drain is a cost-effective method of anastomotic leakage management with efficacy similar to that of Endo-SPONGE®.

Risk factors and conservative therapy outcomes of anastomotic leakage after gastrectomy: Experience of 3,926 patients from a single gastric surgical unit.

Anastomotic leakage (AL) after gastrectomy is one of the severest postoperative complications and is related to increasing mortality. In addition, no consensus guidelines about strategies of AL treatment have been established. This large cohort study aimed to inspect the risk factors and efficacy of the conservative treatment for AL in patients with gastric cancer. We reviewed the clinicopathological data of 3,926 gastric cancer patients undergoing gastrectomy between 2014 and 2021. Results contained the rate, risk factors, and conservative therapy outcomes of AL. In total, 80 patients (2.03%, 80/3,926) were diagnosed with AL, and esophagojejunostomy was the most frequent AL site (73.8%, 59/80). Among them, one patient (2.5%, 1/80) died. Multivariate analysis indicated that low albumin concentration (P = 0.001), presence of diabetes (P = 0.025), laparoscopic method (P < 0.001), total gastrectomy (P = 0.003), and proximal gastrectomy (P = 0.002) were predicting factors for AL. The closure rate for the conservative treatment of AL in the first month after AL diagnosis was 83.54% (66/79), and the median time from leakage diagnosis to the closure of leakage was 17 days (interquartile range 11-26 days). Low level of plasma albumin (P = 0.004) was associated with late leakage closures. In terms of 5-year overall survival, no significant difference was observed between patients with and without AL. The incidence of AL after gastrectomy is associated with low albumin concentration, diabetes, the laparoscopic method, and extent of resection. The conservative treatment is relatively safe and effective for the AL management in patients after gastric cancer surgery.

Internal drainage for interdisciplinary management of anastomotic leakage after pancreaticogastrostomy

BackgroundAnastomotic leakage and postoperative pancreatic fistula (POPF) may occur after pancreatic head resection, also in the setting of pancreato-gastric reconstruction. For adequate complication management, a variety of non-standardized treatments are available. Still, data on clinical evaluation of endoscopic methods remain scarce. Based on our interdisciplinary experience on endoscopic treatment of retro-gastric fluid collections after left-sided pancreatectomies, we developed an innovative endoscopic concept with internal peri-anastomotic stent placement for patients with anastomotic leakage and/or peri-anastomotic fluid collection.MethodsOver the period of 6 years (2015–2020) we retrospectively evaluated 531 patients after pancreatic head resections at the Department of Surgery, Charité–Unversitätsmedizin Berlin. Of these, 403 received reconstruction via pancreatogastrostomy. We identified 110 patients (27.3%) with anastomotic leakage and/or peri-anastomotic fluid collection and could define four treatment groups which received either conservative treatment (C), percutaneous drainage (PD), endoscopic drainage (ED), and/or re-operation (OP). Patients were grouped in a step-up approach for descriptive analyses and in a stratified, decision-based algorithm for comparative analyses. The study’s primary endpoints were hospitalization (length of hospital stay) and clinical success (treatment success rate, primary/secondary resolution).ResultsWe characterized an institutional, post-operative cohort with heterogenous complication management following pancreato-gastric reconstruction. The majority of patients needed interventional treatments (n = 92, 83.6%). Of these, close to one-third (n = 32, 29.1%) were treated with endoscopy-guided, peri-anastomotic pigtail stents for internal drainage as either primary, secondary and/or tertiary treatment modality. Following a decision-based algorithm, we could discriminate superior primary—(77,8% vs 53.7%) and secondary success rates (85.7% vs 68.4%) as well as earlier primary resolutions (11.4 days, 95%CI (5.75–17.13) vs 37.4 days, 95%CI (27.2–47.5)] in patients receiving an endoscopic compared to percutaneous management.ConclusionThis study underscores the importance of endoscopy-guided approaches for adequate treatment of anastomotic leakage and/or peri-anastomotic fluid collections after pancreatoduodenectomy. We herein report a novel, interdisciplinary concept for internal drainage in the setting of pancreato-gastric reconstruction.

The economic impact of anastomotic leak after colorectal cancer surgery

ObjectiveTo determine the economic impact of the incremental consumption of resources for the diagnosis and treatment of anastomotic leak (AL) in patients after resection with anastomosis for colorectal cancer compared to patients without AL on the Spanish health system.MethodThis study included a literature review with parameters validated by experts and the development of a cost analysis model to estimate the incremental resource consumption of patients with AL versus those without. The patients were divided into three groups: 1) colon cancer (CC) with resection, anastomosis and AL; 2) rectal cancer (RC) with resection, anastomosis without protective stoma and AL; and 3) RC with resection, anastomosis with protective stoma and AL.ResultsThe average total incremental cost per patient was €38,819 and €32,599 for CC and RC, respectively. The cost of AL diagnosis per patient was €1018 (CC) and €1030 (RC). The cost of AL treatment per patient in Group 1 ranged from €13,753 (type B) to €44,985 (type C + stoma), that in Group 2 ranged from €7348 (type A) to €44,398 (type C + stoma), and that in Group 3 ranged from €6197 (type A) to €34,414 (type C). Hospital stays represented the highest cost for all groups. In RC, protective stoma was found to minimize the economic consequences of AL.ConclusionsThe appearance of AL generates a considerable increase in the consumption of health resources, mainly due to an increase in hospital stays. The more complex the AL, the higher the cost associated with its treatment.Interest of the studyit is the first cost-analysis study of AL after CR surgery based on prospective, observational and multicenter studies, with a clear, accepted and uniform definition of AL and estimated over a period of 30 days.

Suction Drainage for Anastomotic Leakage After Ivor Lewis Esophagectomy.

Anastomotic leakage is one of the most life-threatening complications after Ivor Lewis esophagectomy (ILE), with various treatment strategies. Endoscopic techniques are emerging as a less invasive alternative to surgery. Among the current endoscopic techniques, a single placement of an endoluminal nasogastric tube inside the cavity with controlled suction drainage (SD) seems to be an attractive option. The aim of this study was to evaluate the efficacy of SD as treatment for anastomotic leakage after ILE. This retrospective analysis was performed among patients who underwent ILE in a high-volume esophageal cancer center in the Netherlands. Patients with an anastomotic leakage that received SD as primary treatment were selected. A nasogastric tube was endoscopically placed into the cavity of the leakage for controlled suction with 15mmHg. A total of 34 patients received SD and was successful in 26 patients (77%). Seven patients (21%) developed empyema despite the SD for which additional video-assisted thoracoscopic surgery was performed. Mortality was 5.9% (2 patients) and median intensive care unit and hospital stay were 3 days (1 to 9) and 25 days (14 to 43), respectively. The median time to closure of the leak was 41 days (23 to 65). A total of 16 patients underwent home treatment for a median of 23 (14 to 42) days. Controlled SD seems to be an effective treatment for anastomotic leakage after ILE. This therapy can safely and effectively be completed in an ambulant, outpatient setting.

Endoscopic Concept for Internal Drainage and Treatment of Anastomotic Leakage after Pancreaticogastrostomy

Endoscopic Concept for Internal Drainage and Treatment of Anastomotic Leakage after Pancreaticogastrostomy

Novel techniques for the management of esophageal anastomotic leaks

Anastomotic leaks (ALs) after esophageal resection remain a dreaded complication and are associated with high morbidity and mortality, along with an increased cost of care and prolonged hospitalization. Management strategies include confirming conduit viability, controlling sepsis with drainage/antibiotics, and maintaining nutrition. Traditional treatment of ALs has given way to nonoperative management including endoscopic and radiological techniques, which are associated with decreased morbidity. This article aims to review novel technologies and techniques for the management of esophageal ALs, including self-expandable metal stents, endoluminal vacuum therapy, leak content drainage, and radiology-guided drain placement.

Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

IntroductionAnastomotic leakage after esophagectomy with gastric-pullup is the most feared postoperative complication associated with high morbidity and mortality rates. Management of anastomotic leakage underwent an evolution in the last decade from surgical and conservative to an endoscopic management. However, to date there is no clear consensus on management and if endoluminal vacuum therapy (EVT) is the most superior therapy. Material and methodsBetween 2012 and 2022 all patients that underwent Ivor-Lewis esophagectomy for an underlying malignancy were included in this study. Patients that developed an anastomotic leakage and received endoscopic vacuum therapy were further analysed. ResultsA total of 17 patients were treated with EVT following AL after esophagectomy. The median duration of EVT was 23 days with a median number of 5,5 vacuum sponge changes per patient. EVT-systems were placed 12 times intraluminal and 5 times extraluminal. Successful closure of the defect was achieved in 14 patients. ConclusionEndoscopic vacuum therapy can be successfully applied in the treatment of anastomotic leakage after esophagectomy even in septic patients with an extraluminal cavity. Event-related complications are present but rare.

Analysis of Prevention and Treatment of Anastomotic Leakage after Sphincter-Preserving Surgery for Middle- and Low-Grade Rectal Cancer under Laparoscopy.

Anastomotic leakage is one of the most serious complications that can occur after laparoscopic-assistedsphincter-preserving surgery for middle- and low-grade rectal cancer. To explore the cause, prevention, and treatment of anastomotic leakage after sphincter-preserving surgery for middle- and low-grade rectal cancer under laparoscopy. The clinical data from patients with mid- and low-grade rectal cancer who underwent laparoscopic-assistedanus-preserving surgery in the anorectal surgery department of our hospital have been analyzed. Patients with a definite diagnosis, indications for laparoscopic surgery, and sphincter-preserving surgery were included in the analysis, and patients with a protective loop ileostomy and laparotomy were excluded. Among the 126 patients with middle- and low-grade rectal cancer undergoing sphincter-preserving surgery under laparoscopy. There were 75 male patients and 51 female patients, ranging in age from 37 to 89 years old, with an average age of 60.2 ± 6.7. The distance from the lower edge of the rectal tumor to the anal edge was ≤10 cm. 6 developed anastomotic leakage after the operation (leakage rate of 4.7%). Moreover, turbid purulent fluid was drained from the abdominal drainage tube in three patients on the third and fourth days after the operation, and the abdominal drainage tube drained serous drainage in three more patients on the fifth and sixth days, with signs of peritonitis appearing locally. All patients received continuous flushing and negative pressure drainage with a self-made double cannula and symptomatic treatment, and all were cured and discharged. Many factors can cause anastomotic leakage after this operation, and adequate perioperative preparation, meticulous operation during surgery, and careful postoperative management are key factors in preventing it.

Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis.

The present study assessed the factors associated with the maintenance of a functional anastomosis in a large consecutive series of patients with anastomotic leakage (AL). All consecutive patients presenting with AL after colorectal or coloanal anastomosis (2012-2019) were analyzed. The primary end point was a functional anastomosis without a stoma at 1year. A total of 156 patients were included. AL was initially treated by antibiotics (38%), drainage (43%) or urgent surgery (19%). Initial treatment of AL was not adequate in 24.3%, and reintervention in the form of drainage or surgery was required. A total of 60.9% of patients had a functional anastomosis without a stoma 1year after surgery. Factors associated with the risk of anastomotic failure at 1year were diabetes (odds ratio [OR] = 4.24 [95% confidence interval {CI} 1.39-14.24] p = 0.014), neoadjuvant chemoradiotherapy (OR = 3.03 [95% CI 1.14-8.63] p = 0.03) and Grade B (OR = 6.49 [95% CI 2.23-21.74] p = 0.001) or C leak (OR = 35.35 [95% CI 9.36-168.21] p < 0.001). Among patients treated initially by drainage, side-to-end or J-pouch anastomoses were significantly associated with revision of the anastomosis compared to end-to-end (OR = 12.90, p = 0.04). After acute AL following coloanal or colorectal anastomosis, 60.9% of patients had a functional anastomosis without a stoma at the 1year of follow-up. The type of treatment of AL influenced the risk of anastomotic failure.

S217 Use of Endoscopic Vacuum Therapy to Repair Colonic Anastomotic Leaks: A Meta-Analysis

Introduction: Endoscopic vacuum therapy (EVT) has recently emerged as a treatment modality for patients who experience anastomotic leak after surgery with an incidence of 6-30%. Treatment of anastomotic leaks using EVT in the upper gastrointestinal tract has been well documented. However, endoscopic vacuum therapy for colorectal leaks remains a somewhat less studied entity. EVT is based on applying sponges to the area of the leak and negative pressure is applied to draw off fluid from the leak and help promote granulation tissue formation and healing. In our study we aim to use prospective studies to assess the success and rates of adverse events using EVT for colo-rectal anastomotic leaks. Methods: Pubmed, Embase and Cochrane were searched from inception to April 2022 for studies reporting success and adverse event rates for EVT used for colo-rectal anastomotic leaks. We included only prospective studies in our analysis. Using I2 we assessed heterogeneity and calculated 95% confidence intervals using fixed or random effect models. Results: Seven studies involving 368 patients were included in our analysis. Indication for surgery was malignancy in all cases. The total clinical success rate was 90.5% (CI: 87.6-93.5. I2 = 0%). The adverse event rate among all studies was 7% (95% CI: 4.4-9.5%, I2 = 0%). Six patients required further surgical intervention and 2 required CT guided drain placement. No mortality with the procedure protocol was reported. (Figure) Conclusion: EVT is an emerging treatment option for anastomotic leak. Our study demonstrates the safety and efficacy of EVT as an option for patients who experience colorectal anastomotic leak, however large prospective studies are warranted for further evaluation in this area.Figure 1.: Success rate of EVT for anastomotic leaks

486. ENDOSCOPIC VACUUM THERAPY FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGEAL RESECTION—A RETROSPECTIVE SINGLE-CENTER ANALYSIS

Abstract Esophagectomy still comes with a high rate of anastomotic leakage resulting in a persisting high postoperative mortality. Endoscopic vacuum therapy (EVT) is an upcoming technique for the treatment of anastomotic leakages. We aimed to evaluate our experience with the efficacy of EVT for anastomotic leakages after esophagectomy for cancer. We retrospectively analyzed all 96 patients who had undergone Ivor-Lewis resection for esophageal malignancy from January 2015 until December 2021 for the need of EVT within the same hospital stay. Patients demographics, perioperative parameters, treatment efficacy and success were analyzed. Patient data were expressed as mean ± standard deviation. We included fourteen patients treated with EVT following Ivor-Lewis resection for esophageal malignancy within the same hospital stay. 12 EVTs were due to anastomotic leakage whereas two procedures were performed prophylactically. We started the EVT 10.71 ± 8.04 days after surgery with a mean duration of 13.86 ± 7.39 days and a mean number of 4.36 ± 2.37 endoscopies per patient. Successful treatment was achieved in 10 patients (71.4%), one patient needed an esophageal stenting and an additional surgery for re-anastomosis was needed in 3 patients (21.4%). EVT can prevent re-operation in a high proportion of patients with anastomotic leakage and therefore provides a good non-surgical option for these patients. The periinterventional risk and possible complications of repetitive endoscopies should be analyzed in larger studies.

International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study

PurposeLittle is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide.MethodsIn this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases).ResultsIn total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy.ConclusionThis TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery.

Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient’s presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.