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Vinchurkar K, Togale M, Maste P, Chaudhary S, Ahmed I, Krishnamurthy S, Bhise R, Mane J, Kumbar P. Truly Inevitable—Our Perspective on the Complications After Surgery for Rectal Cancer. Indian J Surg Oncol 2024. [DOI: 10.1007/s13193-024-02125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 10/22/2024] [Indexed: 01/04/2025] Open
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Gozalichvili D, Fournel I, Sow AK, Guiraud A, Moreno-Lopez N, Orry D, Facy O, Ortega-Deballon P. Management of patients with high C-reactive protein levels after elective colorectal surgery: Pilot study on a proactive diagnostic and therapeutic approach (GESPACE). J Visc Surg 2024; 161:237-243. [PMID: 38908988 DOI: 10.1016/j.jviscsurg.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
STUDY OBJECTIVE To evaluate the feasibility and benefit of a diagnostic and therapeutic algorithm for management of patients presenting with a high C-reactive protein (CRP) level after colorectal surgery. PATIENTS AND METHODS Prospective study including patients with CRP>125mg/L at the 4th postoperative day following elective colorectal surgery. The protocol involved CT-scan of which the results were to orient subsequent management: antibiotics, radiological drainage, endoscopy or surgical redo. Success (primary endpoint) consisted in the proportion of patients with total duration of hospitalization fewer than 15d. Secondary endpoints were: applicability of the protocol in real-life conditions, number of stomas created, duration of hospitalization in an intensive care unit. RESULTS One hundred and six (106) patients were included: 51 patients (48%) presented with postoperative complications, of which 21 (41%) were severe. No death occurred. Among the included patients, 68% had a hospital stay<15d. Major deviations from the management algorithm occurred in 38% of cases. No patients had an early endoscopy. There was no significant difference with regard to the secondary endpoints according to whether or not the protocol was strictly observed. CONCLUSION It is necessary to define a protocol for management of patients presenting with high CRP levels after colorectal surgery, the objective being to reduce the impact of complications and to avoid excessive lengthening of hospital stay. The protocol begins with CT-scan, which is to orient subsequent management.
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Affiliation(s)
| | - Isabelle Fournel
- Clinical Investigation Centre, Dijon University Hospital, Dijon, France; INSERM, CIC 1432, Clinical Epidemiology Module, Dijon, France
| | - Amadou Khalilou Sow
- Clinical Investigation Centre, Dijon University Hospital, Dijon, France; INSERM, CIC 1432, Clinical Epidemiology Module, Dijon, France
| | - Adeline Guiraud
- Digestive Surgery Department, Dijon University Hospital, Dijon, France
| | | | - David Orry
- Cancer Surgery Department, Georges-François Leclerc Cancer Centre, Dijon, France
| | - Olivier Facy
- Digestive Surgery Department, Dijon University Hospital, Dijon, France; INSERM UMR 1231, University of Burgundy, Dijon, France
| | - Pablo Ortega-Deballon
- Digestive Surgery Department, Dijon University Hospital, Dijon, France; Clinical Investigation Centre, Dijon University Hospital, Dijon, France; INSERM, CIC 1432, Clinical Epidemiology Module, Dijon, France; INSERM UMR 1231, University of Burgundy, Dijon, France.
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Yao Z, Tian W, Huang M, Xu X, Zhao R. Effect of placing double-lumen irrigation-suction tube on closure of anastomotic defect following rectal cancer surgery. Surg Endosc 2023; 37:412-420. [PMID: 35984523 DOI: 10.1007/s00464-022-09523-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/31/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE This study aimed to investigate the effect of placement of double-lumen irrigation-suction tubes (DLIST) on the closure of anastomotic defect (AD) after rectal cancer surgery. METHODS The study was carried out at two centers managed by one surgeon, both adopted the same treatments. Patients with postoperative AD after rectal cancer surgery from January 2011 to June 2020 were eligible and were divided into a passive drainage (PD) group and a DLIST group according to whether the PD, placed in the rectal cancer surgery, had been replaced with the DLIST. The effect of DLIST on the AL was evaluated. RESULT There distributed 76 patients in the DLIST group and 52 in the PD group. A higher closure rate was reported in the DLIST group (46 patients in DLIST group, for a closure rate of 60.5%, and 21 patients in PD group, for a closure rate of 40.4%. HR = 3.05; 95% CI: 1.79-5.19; P < 0.001). Both length of stay and costs of the treatment in the DLIST group were lower (54 days [interquartile range, IQR: 41-17] days vs. 112 days [IQR: 66-27] days, P = 0.005; and $18,721 [IQR: $14,982-4,960] vs. $40,840 [IQR: $20,932-50,529], P < 0.001). CONCLUSION Placement of DLIST might serve as an effective method for treating AD following rectal cancer surgery. In comparison with PD, it costs lower to apply DLIST in the treatment of AD and the length of stay is shorter.
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Affiliation(s)
- Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China. .,Department of Enterocutaneous Fistula Surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, China.
| | - Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - Ming Huang
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China. .,Department of Enterocutaneous Fistula Surgery, Jiangning Hospital, Hushan Road NO.169, Nanjing, Jiangsu, China.
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Gozalichvili D, Binquet C, Boisson C, Guiraud A, Facy O, Ortega-Deballon P. Early detection of anastomotic leak with C-reactive protein increases the chances of anastomotic salvage. Colorectal Dis 2022; 25:728-737. [PMID: 36323646 DOI: 10.1111/codi.16399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/16/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
AIM Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C-reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis. METHOD Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010-2013) and 'after' (2016-2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis. RESULTS Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien-Dindo Grade III to IV, 66.7% vs. 56.9; p = 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p = 0.058) and anastomotic stenosis (p = 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR = 2.37 [1.08-5.17]) and increased the number of days out of hospital (p = 0.0002). CONCLUSION A CRP-based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay.
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Affiliation(s)
- David Gozalichvili
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Christine Binquet
- INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | - Cyril Boisson
- INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France
| | - Adeline Guiraud
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France.,INSERM UMR 1231, University of Bourgogne-Franche-Comté, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France.,INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Dijon University Hospital, Dijon, France.,INSERM UMR 1231, University of Bourgogne-Franche-Comté, Dijon, France
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Kalvach J, Ryska O, Martinek J, Hucl T, Pazin J, Hadac J, Foltan O, Kristianova H, Ptacnik J, Juhasova J, Ryska M, Juhas S. Randomized experimental study of two novel techniques for transanal repair of dehiscent low rectal anastomosis. Surg Endosc 2022; 36:4050-4056. [PMID: 34495386 DOI: 10.1007/s00464-021-08726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Anastomotic leak after low anterior rectal resection is a dreadful complication. Early diagnosis, prompt management of sepsis followed by closure of anastomotic defect may increase chances of anastomotic salvage. In this randomized experimental study, we evaluated two different methods of trans-anal anastomotic repair. METHODS A model of anastomotic leak was created in 42 male pigs. Laparoscopic low anterior resection was performed with anastomosis created using a circular stapler with half of the staples removed. Two days later, animals were randomized into a TAMIS (trans-anal minimally invasive surgery) repair, endoscopic suture (ENDO) or control group with no treatment (CONTROL). Signs of intraabdominal infection (IAI), macroscopic anastomotic healing and burst tests were evaluated to assess closure quality after animals were sacrificed on the ninth postoperative day. RESULTS Closure was technically feasible in all 28 animals. Two animals had to be euthanized due to progressive sepsis at four and five days after endoscopic closure. Healed anastomosis with no visible defect was observed in 10/14 and 11/14 animals in TAMIS and ENDO groups, respectively, versus 2/14 in CONTROL (p < 0.05). Overall IAI rate was significantly lower in TAMIS (4/14; p = 0.006) and ENDO (5/14; p = 0.018) compared to CONTROL (12/14). Burst tests confirmed sealed closure in healed anastomosis with a median failure pressure of 190 (110-300) mmHg in TAMIS and 200 (100-300) mmHg in ENDO group (p = 0.644). CONCLUSION In this randomized experimental study, we found that both evaluated techniques are effective in early repair of dehiscent colorectal anastomosis with a high healing rate.
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Affiliation(s)
- J Kalvach
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic. .,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic.
| | - O Ryska
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, NHS Foundation Trust, Lancaster, UK
| | - J Martinek
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - T Hucl
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Pazin
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - J Hadac
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - O Foltan
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - H Kristianova
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - J Ptacnik
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - J Juhasova
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic
| | - M Ryska
- Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - S Juhas
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic
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Robb BW, Guzman M. Anastomotic leak won't fix itself. What are the options for management of anastomotic leak? SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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An evaluation of short-term outcomes after reoperations for anastomotic leakage in colon cancer patients. Int J Colorectal Dis 2022; 37:113-122. [PMID: 34559290 PMCID: PMC8760208 DOI: 10.1007/s00384-021-03996-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Scarce data are available on differences among index colectomies for colon cancer regarding reoperation for anastomotic leakage (AL) and clinical consequences. Therefore, this nationwide observational study aimed to evaluate reoperations for AL after colon cancer surgery and short-term postoperative outcomes for the different index colectomies. METHODS Patients who underwent resection with anastomosis for a first primary colon carcinoma between 2013 and 2019 and were registered in the Dutch ColoRectal Audit were included. Primary outcomes were mortality, ICU admission, and stoma creation. RESULTS Among 39,565 patients, the overall AL rate was 4.8% and ranged between 4.0% (right hemicolectomy) and 15.4% (subtotal colectomy). AL was predominantly managed with reoperation, ranging from 81.2% after transversectomy to 92.4% after sigmoid resection (p < 0.001). Median time to reoperation differed significantly between index colectomies (range 4-8 days, p < 0.001), with longer and comparable intervals for non-surgical reinterventions (range 13-18 days, p = 0.747). After reoperation, the highest mortality rates were observed for index transversectomy (15.4%) and right hemicolectomy (14.4%) and lowest for index sigmoid resection (5.6%) and subtotal colectomy (5.9%) (p < 0.001). Reoperation with stoma construction was associated with a higher mortality risk than without stoma construction after index right hemicolectomy (17.7% vs. 8.5%, p = 0.001). ICU admission rate was 62.6% overall (range 56.7-69.2%), and stoma construction rate ranged between 65.5% (right hemicolectomy) and 93.0% (sigmoid resection). CONCLUSION Significant differences in AL rate, reoperation rate, time to reoperation, postoperative mortality after reoperation, and stoma construction for AL were found among the different index colectomies for colon cancer, with relevance for patient counseling and perioperative management.
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Tan X, Zhang M, Li L, Wang H, Liu X, Jiang H. Retrospective study of active drainage in the management of anastomotic leakage after anterior resection for rectal cancer. J Int Med Res 2021; 49:3000605211065942. [PMID: 34918983 PMCID: PMC8721718 DOI: 10.1177/03000605211065942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Anastomotic leakage (AL) is the most serious postoperative complication following anterior resection for rectal cancer. We aimed to investigate the efficacy of active drainage for the management of AL. Methods This was a retrospective study using information from a database of patients who underwent colorectal resection without a defunctioning ileostomy at our center between September 2013 and January 2021. We identified 122 cases with definitive AL who did not require revision emergent laparotomy. Among these patients, we evaluated those who received active drainage to replace the original passive drainage. Results There were 62 cases in the active drainage group and 60 cases in the passive drainage group. The active drainage group had a shorter mean AL spontaneous resolution time (26.9 ± 3.3 vs. 32.2 ± 4.8 days) and lower average hospitalization costs (82,680.6 vs. 92,299.3 renminbi (RMB)) compared with the passive drainage group, respectively. Moreover, seven patients in the passive drainage group subsequently underwent diverting stoma to resolve the Al, while all ALs resolved spontaneously after replacing the passive drainage with active drainage. Conclusions Our study suggests that active drainage may accelerate the spontaneous resolution of AL.
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Affiliation(s)
- Xiaojie Tan
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Mei Zhang
- Department of Gastrointestinal Surgery, the People's Hospital of Jimo District of Qingdao, Shandong Province, 266200, China
| | - Lai Li
- Department of General Surgery, the Second Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266042, China
| | - He Wang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Xiaodong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Haitao Jiang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
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Abstract
Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.
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Affiliation(s)
- Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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Paral J, Odlozilova S, Sirovy M, Zajak J, Kotek J, Lochman P. Perioperative intrapelvic hyaluronate application as prophylaxis against complications following rectal anastomotic dehiscence: An experimental study. Asian J Surg 2021; 45:1246-1252. [PMID: 34625335 DOI: 10.1016/j.asjsur.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/22/2021] [Accepted: 09/20/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The aim of this experimental study was to test the method of prevention of postoperative complications, especially infectious, in partial dehiscence following stapler anastomosis in rectal surgeries. METHODS The method includes the application of a hyaluronic acid-based gel in combination with triclosan, which has antibacterial properties. The gel was applied to the space around the rectum with an artificial, precisely defined dehiscence so that the dehiscence was separated from the rest of pelvis and the peritoneal cavity to avoid the spread of infection. The study included 30 female pigs. The rectosigmoid colon was mobilized and transected completely. Anastomosis was constructed with circular staplers. A perforator was then used to create precisely defined artificial dehiscence. Subsequently the lesser pelvis was filled with hyaluronic gel such that the site of artificial dehiscence was covered completely. RESULTS All animals survived for 14 days until the second-look revision with no signs of failure in the anastomosis healing, local inflammation, and sepsis or postoperative complications, such as chills, refusal of liquid or feed, abdominal distension, and bowel obstruction. CONCLUSION Hyaluronic acid applied as a precursor solution around the rectal anastomosis fills the lesser pelvis perfectly. It prevents the leakage of intestinal contents in the lesser pelvis. Triclosan as an antibacterial substance prevents the spread of inflammation in the pelvis or even in the abdominal cavity.
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Affiliation(s)
- Jiri Paral
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic.
| | - Sarka Odlozilova
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Miroslav Sirovy
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Jan Zajak
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Jiri Kotek
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Petr Lochman
- Department of Military Surgery, University of Defence, Faculty of Military Health Sciences, Hradec Kralove, Czech Republic; Department of Surgery, University Hospital and Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
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C reactive protein to albumin ratio (CAR) as predictor of anastomotic leakage in colorectal surgery. Surg Oncol 2021; 38:101621. [PMID: 34126521 DOI: 10.1016/j.suronc.2021.101621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 06/06/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most severe complications in colorectal surgery. Currently, no predictive biomarkers of AL are available. The aim of this study was to investigate the role of C reactive protein (CRP) to albumin ratio (CAR) as a predictor of AL in patients undergoing elective surgery for colorectal cancer. MATERIALS AND METHODS Data on 1183 consecutive patients surgically treated for histologically proven colorectal cancer in the surgical units involved in the study were collected. Data included sex, age, BMI, ASA score, Charlson comorbidity index, localization, histology and stage of the disease, as well as blood tests including albumin and CRP at the 4th postoperative day. Differences in CAR between patients who developed AL and those who did not were analyzed, and the ability of CAR to predict AL was investigated with ROC analysis. RESULTS CAR was significantly higher in patients with AL in comparison to those without, at the 4th postoperative day. In ROC analysis CAR showed a good ability in detecting AL (AUC 0.825, 95%CI: 0,786-0,859), greater than those of CRP and albumin alone. CAR also showed a high ability in detecting postoperative deaths (AUC 0.750, 95% CI 0,956-0,987). These findings were confirmed in multivariate analysis including the most relevant risk factors for AL. CONCLUSION Our study evidenced that CAR, an inexpensive and widely available laboratory biomarker, adequately predicts AL and death in patients who underwent elective surgery for colorectal cancer.
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12
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Lam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. Best Pract Res Clin Gastroenterol 2020; 48-49:101705. [PMID: 33317788 DOI: 10.1016/j.bpg.2020.101705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/19/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.
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Affiliation(s)
- David Lam
- Senior Clinical Fellow in Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - Oliver Jones
- Consultant Colorectal Surgeon and Clinical Director of Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
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A double-lumen irrigation-suction tube placed during operation could reduce the risk of grade C anastomotic leakage resulting from selective sigmoid colon cancer radical resection. Langenbecks Arch Surg 2020; 405:1007-1016. [PMID: 32785785 DOI: 10.1007/s00423-020-01959-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/05/2020] [Indexed: 12/11/2022]
Abstract
AIM This study investigated the effect of a double-lumen irrigation-suction tube in reducing the incidence of grade C anastomotic leakage (AL) resulting from a selective sigmoid colon cancer radical resection. METHOD This multicenter retrospective cohort study reviewed data of patients receiving sigmoid colon cancer radical resection from January 2010 to November 2019. The enrolled patients were divided into the passive drainage tube group and the double-lumen irrigation-suction tube group, based on the use of a double-lumen irrigation-suction tube or a passive drainage tube during the surgery. The effect of double-lumen irrigation-suction tube on the incidence of grade C anastomotic leakage was evaluated. RESULTS Of the 761 patients included in the study, 56 patients (7.36%) experienced AL. Of the 56 patients, 22 were diagnosed with grade C AL. The double-lumen irrigation-suction tube was a protective factor for forming a grade C AL compared with the passive drainage tube (OR = 0.194, 95% CI: 0.055-0.686, p = 0.011). Of the 34 patients with grade A or B AL, 26 patients had spontaneous closure-19 in the double-lumen irrigation-suction tube group and 7 in the passive drainage tube group. The double-lumen irrigation-suction tube (multivariable HR = 3.418, 95% CI: 1.43-11.203, p = 0.038) was associated with spontaneous closure of grade A or B AL. CONCLUSION Placing a double-lumen irrigation-suction tube may reduce the risk of grade C AL resulting from a selective sigmoid colon cancer radical resection. However, this study had substantial selection bias and the results should be reconfirmed by a randomized clinical trial.
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Abet E, Drissi F, Couëtte C, Jean MH, Denimal F, Podevin J, Duchalais E, Meurette G. Predictive value of inflammatory markers for postoperative recovery following colorectal surgery. Int J Colorectal Dis 2020; 35:1125-1131. [PMID: 32291509 DOI: 10.1007/s00384-020-03594-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Using biological markers to predict serious complications and global postoperative recovery, to ensure safe and timely patient discharge after elective colorectal surgery represents a major challenge. The aim of this study was to demonstrate that C-reactive protein levels < 172 mg/l on postoperative day 3 were associated with postoperative recovery within 5 days. METHODS This is a prospective study of a consecutive bicentric cohort. Successive patients scheduled for bowel resection with anastomosis, without stoma, were included. The main composite endpoint for overall postoperative recovery included absence of fever, absence of pain > 2 on the visual analog scale, intestinal gas transit, and patient autonomy for mobility and body care. RESULTS One hundred sixty-height patients, with a mean age of 65 years old, were analyzed. Ninety patients (53%) underwent right colectomy and 131 (77%) were operated on by laparoscopy. Severe postoperative complications were observed in 11 patients (6%). One hundred twenty patients (71%) recovered within 5 days. C-reactive protein levels < 172 mg/L on postoperative day 3 had a negative predictive value of 80% to predict recovery within 5 days. Ninety-five percent of patients with C-reactive protein < 172 mg/L at postoperative day 3 had no severe postoperative complications. CONCLUSION Levels of C-reactive protein < 172 mg/L at postoperative day 3 corresponded with an early recovery in 80% of cases, thus allowing safe and early discharge without risk of serious complications.
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Affiliation(s)
- Emeric Abet
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Farouk Drissi
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France. .,Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France.
| | - Clément Couëtte
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Marc-Henri Jean
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Fabrice Denimal
- Department of Digestive Surgery, Vendée Medical Center, Les Oudairies, 85000, La Roche-sur-Yon, France
| | - Juliette Podevin
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
| | - Emilie Duchalais
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
| | - Guillaume Meurette
- Department of Digestive and Endocrine Surgery, University Hospital of Nantes, 1, Place Alexis Ricordeau, 44093, Nantes, France
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15
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Diaconescu B, Uranues S, Fingerhut A, Vartic M, Zago M, Kurihara H, Latifi R, Popa D, Leppäniemi A, Tilsed J, Bratu M, Beuran M. The Bucharest ESTES consensus statement on peritonitis. Eur J Trauma Emerg Surg 2020; 46:1005-1023. [PMID: 32303796 DOI: 10.1007/s00068-020-01338-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care. METHODS Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis. CONCLUSION This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.
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Affiliation(s)
- Bogdan Diaconescu
- Anatomy Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania.
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, 200025, P.R. China
| | - Mihaela Vartic
- Intensive Care Unit, Emergency Clinic Hospital Bucharest, Bucharest, Romania
| | - Mauro Zago
- General and Emergency Surgery Division, Department of Emergency and Robotic Surgery, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Hayato Kurihara
- Emergency Surgery and Trauma Section, Department of General Surgery, Humanitas Clinical and Research Hospital Head, Milan, Italy
| | - Rifat Latifi
- Westchester Medical Center, Valhalla, New York, USA
| | - Dorin Popa
- Surgery Department, University Hospital Linkoping, Linköping, Sweden
| | - Ari Leppäniemi
- Division of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Jonathan Tilsed
- Honorary Senior Lecturer Hull York Medical School, Chairman UEMS Division of Emergency Surgery, Heslington, UK
| | - Matei Bratu
- Anatomy Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania
| | - Mircea Beuran
- Surgery Department, Carol Davila University of Medicine and Phamacy, Bucharest, Romania
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16
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Tsai YY, Chen WTL. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019; 10:1229-1237. [PMID: 31949944 DOI: 10.21037/jgo.2019.07.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.
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Affiliation(s)
- Yuan-Yao Tsai
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - William Tzu-Liang Chen
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
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17
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Vu L, Penter C, Platell C. Long‐term significance of an anastomotic leak in patients undergoing an ultra‐low anterior resection for rectal cancer. ANZ J Surg 2019; 89:1291-1295. [DOI: 10.1111/ans.15373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/01/2019] [Accepted: 06/22/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Linda Vu
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
| | - Cheryl Penter
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
| | - Cameron Platell
- Colorectal UnitSt John of God Health Care Perth Western Australia Australia
- Department of SurgeryThe University of Western Australia Perth Western Australia Australia
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18
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Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study. Dis Colon Rectum 2019; 62:542-548. [PMID: 30489322 DOI: 10.1097/dcr.0000000000001289] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Data on anastomotic leak rates after stapled versus handsewn ileocolic anastomosis are conflicting. In a Cochrane review, the combined estimate favored the stapled technique, but recent cohort studies demonstrated a 2-fold increase in anastomotic leak with the stapled approach. OBJECTIVE The purpose of this study was to investigate anastomotic leak rates following stapled versus handsewn ileocolic anastomosis. DESIGN This was a nationwide, retrospective cohort study. SETTING Data were obtained from the Danish Colorectal Cancer Group and National Patient Registry databases. PATIENTS Danish patients, ≥18 years of age, undergoing right hemicolectomy for a first-time diagnosis of adenocarcinoma in the right colon with primary anastomosis between October 2014 and December 2015 were included. MAIN OUTCOME MEASURES The primary outcome was anastomotic leak rate. Secondary outcomes included 30-day mortality. Covariates included demographics, comorbidity, tumor stage, and surgical variables. Multivariable logistic regression and propensity score matching were used to adjust for confounding. RESULTS The 1414 patients included 391 (28%) in the stapled group and 1023 (72%) in the handsewn group. Forty-five patients (3.2%) developed anastomotic leak: 21 of 391 (5.4%) and 24 of 1023 (2.4%) in the stapled and handsewn group (p = 0.004). This difference was confirmed in multivariable analysis (adjusted OR, 2.91; 95% CI, 1.53-5.53; p < 0.001), and after propensity score matching (OR, 2.41; 95% CI, 1.24-4.67; p = 0.009). Thirty-day mortality was 15.6% (7/45) and 2.1% (29/1369) in patients with and without anastomotic leak (p < 0.001), with no difference between the stapled and handsewn approach. LIMITATIONS The study's design was retrospective, with no information on allocation to the stapled or handsewn approach. CONCLUSIONS The present study demonstrated a 2-fold increase in anastomotic leak after stapled versus handsewn ileocolic anastomoses. Previous opinions on the optimal anastomosis technique for colon cancer should be scrutinized given the devastating short-term outcome of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A819.
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19
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Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA. Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Affiliation(s)
- R E Clifford
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK.
| | - H Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - N Govindarajah
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - D Vimalachandran
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - P A Sutton
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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20
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Voron T, Bruzzi M, Ragot E, Zinzindohoue F, Chevallier JM, Douard R, Berger A. Anastomotic Location Predicts Anastomotic Leakage After Elective Colonic Resection for Cancer. J Gastrointest Surg 2019; 23:339-347. [PMID: 30076589 DOI: 10.1007/s11605-018-3891-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) is a potential feared complication after colorectal resection, which is associated with an increased risk of postoperative mortality and frequently requires additional surgery. The aim of this study was to assess major independent risk factors for AL after elective colonic resection for cancer, including anastomotic location. METHODS Among 1940 consecutive patients referred to our institution for colorectal adenocarcinoma, 1025 patients had elective colonic resection with intraperitoneal anastomosis without diverting stoma. Risk factors were assessed among preoperative, operative, and histological data. RESULTS Clinical AL was observed in 36 patients (3.5%) with 24 patients requiring revisional surgery (67%). In multivariate analysis, endoscopic impassable tumor and colo-colic or ileo-colic anastomosis were independent risk factors for AL. The occurrence of AL was associated with poor overall (43.1 months vs. 146.4 months; p < 0.001) and disease-free survival (40.5 months vs. 137.3 months; p = 0.003). CONCLUSION Anastomotic leakage occurs more frequently after colo-colic and ileo-colic anastomosis than after intraperitoneal colorectal anastomosis. The right colectomy appears to be at higher risk of AL, with a greater risk of surgical intervention than after an elective left colectomy. Ileo-colic anastomosis should be avoided in cases of suboptimal conditions.
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Affiliation(s)
- Thibault Voron
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France. .,Faculté de Médecine Paris Descartes, Paris, France.
| | - Matthieu Bruzzi
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France.,Faculté de Médecine Paris Descartes, Paris, France
| | - Emilia Ragot
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France
| | - Franck Zinzindohoue
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France.,Faculté de Médecine Paris Descartes, Paris, France
| | - Jean-Marc Chevallier
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France.,Faculté de Médecine Paris Descartes, Paris, France
| | - Richard Douard
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France.,Faculté de Médecine Paris Descartes, Paris, France
| | - Anne Berger
- Department of General, Digestive and Oncological Surgery, Georges Pompidou European Hospital, AP-HP, Assistance Publique-Hôpitaux de Paris, 20-40 rue Leblanc, 75908, Paris, France.,Faculté de Médecine Paris Descartes, Paris, France
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21
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Inoue K, Ueno T, Akishige N, Soeta T, Tsuchiya T, Nakayama S, Shima K, Goto S, Takahashi M, Naitoh T, Naito H. What is the optimal risk scoring for predicting complications after colorectal surgery in elderly patients? INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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22
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Shalaby M, Thabet W, Buonomo O, Lorenzo ND, Morshed M, Petrella G, Farid M, Sileri P. Transanal Tube Drainage as a Conservative Treatment for Anastomotic Leakage Following a Rectal Resection. Ann Coloproctol 2018; 34:317-321. [PMID: 30572421 PMCID: PMC6347340 DOI: 10.3393/ac.2017.10.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/18/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose We evaluate the role of transanal tube drainage (TD) as a conservative treatment for patients with anastomotic leakage (AL). Methods Patients treated for AL who had undergone a low or an ultralow anterior resection with colorectal or coloanal anastomosis for the treatment of rectal cancer between January 2013 and January 2017 were enrolled in this study. The data were collected prospectively and analyzed retrospectively. The primary outcomes were the diagnosis and the management of AL. Results Two hundred thirteen consecutive patients, 122 males and 91 females, were included. The mean age was 66.91 ± 11.15 years, and the median body mass index was 24 kg/m2 (range, 20–35 kg/m2). The median tumor distance from the anal verge was 8 cm (range, 4–12 cm). Ninety-three patients (44%) received neoadjuvant therapy for nodal disease and/or locally advanced rectal cancer. Only 13 patients (6%) developed AL. Six patients developed subclinical AL as they had a defunctioning ileostomy at the time of the initial procedure. They were treated conservatively with TD under endoscopic guidance in the endoscopy unit and received intravenous antibiotics. Six weeks after discharge, these 6 patients underwent follow-up flexible sigmoidoscopy which showed a completely healed anastomotic defect with no residual stenosis. Seven patients developed a clinically significant AL and required reoperation with pelvic abscess drainage and Hartmann colostomy formation. Conclusion These results suggest that TD for management of patients with AL is safe, cheap, and effective. Salvaging the anastomosis will help decrease the need for Hartmann colostomy formation. Proper patient selection is important.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy.,Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Waleed Thabet
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Oreste Buonomo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Di Lorenzo
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mosaad Morshed
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Giuseppe Petrella
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Mohamed Farid
- Department General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome, Italy
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23
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Xie T, Zhao C, Ding C, Zhang L, Cheng M, Chun C, Yu W, Gong J, Zhu W. Postoperative Interleukin-6 Predicts Intra-abdominal Septic Complications at an Early Stage After Elective Intestinal Operation for Crohn's Disease Patients. Inflamm Bowel Dis 2018; 24:1992-2000. [PMID: 29912382 DOI: 10.1093/ibd/izy090] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of interleukin-6 (IL-6) in the prediction of intra-abdominal septic complications (IASCs) in patients with Crohn's disease (CD) remains unclear. We assessed the serum IL-6 time course and its association with postoperative IASCs in patients undergoing elective intestinal operations for CD. METHODS In total, 118 patients who underwent intestinal operations for CD were prospectively evaluated. They were divided into an IASC group and non-IASC group. Multivariate analyses were used to identify risk factors, and receiver operating characteristic curve analysis was performed. RESULTS Multivariate analysis showed that a high IL-6 concentration of >137.25 pg/mL on postoperative day (POD) 1 was independently associated with IASCs (odds ratio, 5.74; 95% confidence interval [CI], 1.46-22.67; P = 0.012) and a longer postoperative length of hospitalization (6 vs 9 days, P < 0.001). The median interval between surgery and IASCs (interquartile range) was 6 (4-22) days, and the IL-6 concentration was significantly different between patients with and without IASCs on PODs 1, 3, and 5. The ideal IL-6 cutoff value on POD 1 for the prediction of postoperative IASCs was 137.25 pg/mL, yielding a sensitivity of 81%, specificity of 58%, and area under the curve of 0.71 (95% CI, 0.59-0.83), with a negative predictive value of 0.93. CONCLUSIONS A high IL-6 concentration on POD 1 is independently associated with the occurrence of postoperative IASCs in patients undergoing elective surgery for CD and could allow for earlier diagnosis and earlier intervention for IASCs compared with C-reactive protein.
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Affiliation(s)
- Tingbin Xie
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Chenyan Zhao
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.,Department of Medical School, Nanjing University, Nanjing, China
| | - Chao Ding
- Department of Medical School, Nanjing University, Nanjing, China.,Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Liang Zhang
- Department of General Surgery, Xuzhou Central Hospital, Xuzhou, China
| | - Minhua Cheng
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.,Department of Medical School, Nanjing University, Nanjing, China
| | - Cao Chun
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.,Department of Medical School, Nanjing University, Nanjing, China
| | - Wenkui Yu
- Department of Medical School, Nanjing University, Nanjing, China.,Department of Intensive Care, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jianfeng Gong
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.,Department of Medical School, Nanjing University, Nanjing, China
| | - Weiming Zhu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.,Department of Medical School, Nanjing University, Nanjing, China
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24
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Eriksen JR, Ovesen H, Gögenur I. Short- and long-term outcomes after colorectal anastomotic leakage is affected by surgical approach at reoperation. Int J Colorectal Dis 2018; 33:1097-1105. [PMID: 29754169 DOI: 10.1007/s00384-018-3079-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leakage is the most serious surgical complication following colorectal resection, and surgical intervention is often required. The purpose of the study was to investigate short- and long-term outcomes after reoperation for anastomotic leakage. METHOD Patients with a symptomatic anastomotic leakage following a laparoscopic colorectal cancer resection from January 2009 to December 2014 were identified from our local prospective database. Patients were grouped according to the management of anastomotic leaks: local, lap, or open approach. Primary outcomes were length of stay, chance of bowel continuity, and overall mortality. RESULTS A total of 113 patients were included. The median follow-up time was 40 months (0-82 months). Overall mortality was significantly associated with UICC stage III-VI disease (vs. UICC stage I-II disease) [adj. HR 5.35 (CI 2.32-12.4), p = 0.0001] and minimal invasive reoperation compared with open approach [local: adj. HR 0.12 (CI 0.03-0.52), p = 0.004; lap: adj. HR 0.32 (CI 0.12-0.86), p = 0.024]. Chance of bowel continuity was significantly increased in younger patients below 67 years [adj. OR 6.15 (1.76-21.5), p = 0.004] and following a local procedure [adj. OR 7.45 (1.07-51.8), p = 0.043]. Patients in the open group had significantly longer length of stay and time to initiation of adjuvant chemotherapy compared with those in the lap group. CONCLUSION Our data confirms that minimal invasive reoperation for anastomotic leakage is a safe and feasible approach associated with short- and long-term advantages and can be chosen in selected cases.
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Affiliation(s)
- Jens Ravn Eriksen
- Department of Surgery, Colorectal Cancer Unit, Zealand University Hospital, Roskilde, Sygehusvej 10, 4000, Roskilde, Denmark.
| | - Henrik Ovesen
- Department of Surgery, Colorectal Cancer Unit, Zealand University Hospital, Roskilde, Sygehusvej 10, 4000, Roskilde, Denmark
| | - Ismail Gögenur
- Department of Surgery, Colorectal Cancer Unit, Zealand University Hospital, Roskilde, Sygehusvej 10, 4000, Roskilde, Denmark
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25
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Assessment of Bowel End Perfusion After Mesenteric Division: Eye Versus SPY. J Surg Res 2018; 232:179-185. [PMID: 30463716 DOI: 10.1016/j.jss.2018.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 05/02/2018] [Accepted: 06/01/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Anastomotic complications related to tissue ischemia cause morbidity in gastrointestinal (GI) surgery. Surgeons' standard practice to predict bowel perfusion is inspection of mesenteric perfusion before anastomosing bowel ends. Augmenting this assessment with fluorescent imaging is under study. A standardized system to evaluate this imaging has not yet been developed. This study compared the surgeon's intraoperative assessment to a novel GI-specific imaging analysis method. MATERIALS AND METHODS Forty-nine consecutive patients undergoing open or laparoscopic-assisted bowel resections were enrolled. After mesenteric division, the surgeon marked the site for bowel transection. Near-infrared fluorescence imaging was performed on the marked bowel ends. Imaging analysis identified theoretical transection sites based on the quantification of arterial and microvascular inflow (Perfusion) and venous outflow (Timing). The primary outcome was the measured disparity between the site marked by the surgeon using current standard of care parameters and the imaging-determined site. No clinical outcomes were assessed. RESULTS Seventy-two bowel end segments from 46 patients were analyzed. Disparity was found in 11 of 72 (15%) bowel end segments. In five (7%), the disparity was due to either Perfusion or Timing (single), and in six (8%), due to both Perfusion and Timing (combined). In the single disparity group, the median disparity distance was 2.0 cm by Perfusion and 4.0 cm by Timing, and in the combined group, 3.8 cm by Perfusion and 3.5 cm by Timing. Disparity (either single or combined) was in 25% of colon and 11.5% of small bowel (P = NS). Combined and single disparity had equivalent lengths of disparity distance (P = NS). CONCLUSIONS Imaging coupled with this GI-specific analysis provides objective, real-time, and interpretable data of intramural blood supply. A 15% disparity rate from current clinical practice was observed.
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26
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Chen WTL, Bansal S, Ke TW, Chang SC, Huang YC, Kato T, Wang HM, Fingerhut A. Combined repeat laparoscopy and transanal endolumenal repair (hybrid approach) in the early management of postoperative colorectal anastomotic leaks: technique and outcomes. Surg Endosc 2018; 32:4472-4480. [DOI: 10.1007/s00464-018-6193-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 04/20/2018] [Indexed: 12/18/2022]
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Stafford C, Francone TD, Marcello PW, Roberts PL, Ricciardi R. Is Diversion with Ileostomy Non-inferior to Hartmann Resection for Left-sided Colorectal Anastomotic Leak? J Gastrointest Surg 2018; 22:503-507. [PMID: 29119532 DOI: 10.1007/s11605-017-3612-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of left-sided colorectal anastomotic leaks often requires fecal stream diversion for prevention of further septic complications. To manage anastomotic leak, it is unclear if diverting ileostomy provides similar outcomes to Hartmann resection with colostomy. METHODS We identified all patients who developed anastomotic leak following left-sided colorectal resections from 1/2012 through 12/2014 using the American College of Surgeons National Surgical Quality Improvement Program. Then, we examined the risk of mortality and abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection. RESULTS There were 1745 patients who experienced an anastomotic leak in a cohort of 63,748 patients (3.7%). Two hundred thirty-five patients had a reoperation for anastomotic leak involving the formation of a diverting ileostomy (n = 77) or Hartmann resection (n = 158). There was no difference in mortality or abdominal reoperation in patients treated with diverting ileostomy (3.9, 7.8%) versus Hartmann resection (3.8, 6.3%) (p = 0.8). CONCLUSION There was no difference in the outcomes of mortality or need for second abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection for left-sided colorectal anastomotic leak. Thus, select patients with left-sided colorectal anastomotic leaks may be safely managed with diverting ileostomy.
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Affiliation(s)
- Caitlin Stafford
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Todd D Francone
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA
| | - Peter W Marcello
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Patricia L Roberts
- Department of Colon & Rectal Surgery, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Rocco Ricciardi
- Section of Colon & Rectal Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA.
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Systematic review and meta-analysis of the use of serum procalcitonin levels to predict intra-abdominal infections after colorectal surgery. Int J Colorectal Dis 2018; 33:171-180. [PMID: 29305753 DOI: 10.1007/s00384-017-2956-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE There has been much recent interest in the use of procalcitonin (PCT) as a marker of intra-abdominal infection (IAI) following colorectal surgery. However, the literature remains divided on the value of PCT in this setting. This meta-analysis aims to evaluate the value of PCT in predicting IAI after colorectal surgery. METHODS Systemic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews to identify studies evaluating the diagnostic accuracy of PCT as a predictor for detecting IAI on postoperative days (POD) 3 to 5 following colorectal surgery. A meta-analysis was performed using random effect model and pooled predictive parameters as well as cut-off values for POD 3 to 5 were derived. RESULTS Eight studies consisting 1629 patients were included. The pooled prevalence of IAI was 5.7% on POD 3, 9.7% on POD 4, and 6.3% on POD 5. The pooled AUC for POD 3 to 5 were 0.83 (95% CI 0.78-0.88), 0.79 (95% CI 0.64-0.93), and 0.94 (95% CI 0.91-0.97), respectively. The derived PCT cut-off values were 1.45 ng/ml on POD 3, 1.28 ng/ml on POD 4, and 1.26 ng/ml on POD 5. PCT had the highest diagnostic capability on POD 5 with diagnostic odds ratio of 32.9 (95% CI 15.01-69.88), sensitivity of 0.78 (95% CI 0.65-0.89), and specificity of 0.88 (95% CI 0.85-0.90). CONCLUSIONS PCT is a useful diagnostic predictor of IAI after colorectal surgery. It has the greatest diagnostic accuracy on POD 5 and can help guide safe discharge of patients after colorectal surgery.
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Lykke A, Andersen JFB, Jorgensen LN, Mynster T. Prevention of parastomal hernia in the emergency setting. Langenbecks Arch Surg 2017; 402:949-955. [PMID: 28612116 DOI: 10.1007/s00423-017-1596-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/29/2017] [Indexed: 01/08/2023]
Abstract
AIM This study assessed safety and efficacy associated with hernia prophylaxis using a retromuscular slowly resorbable synthetic mesh for stoma reinforcement. METHOD This was a cohort study with a historic reference group. The study took place in a high-volume surgical department. During a 2-year period (July 2012-July 2014), we included 109 patients undergoing emergency surgery with formation of ileostomy or colostomy. All patients received a retromuscular slowly resorbable synthetic mesh (TIGR®, Novus Scientific) at the stoma site. The reference group included 117 patients who underwent emergency stoma formation without a prophylactic mesh in the 2-year period prior to July 2012. The primary endpoint was effect on prevention of parastomal hernia within 1 year. Secondary endpoints were 30-day and 1-year complications including mortality. RESULTS The operative field was contaminated or dirty in 48% of the procedures. Operative time was significantly longer in the mesh group. The cumulative incidences of parastomal hernia at 1 year for the control and the mesh group were 8 and 7% (p = 0.424), respectively. The postoperative 30-day and 1-year rate of complications, reoperations and mortality were not different between the two groups. No patients underwent removal of the mesh and no clinical mesh infections were seen. CONCLUSION Use of a resorbable synthetic mesh during emergency ostomy formation showed no significant preventive effect on formation of parastomal hernia after 1 year. Although surgery was often conducted in a severely contaminated field, the procedure was without significantly increased complication rate.
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Affiliation(s)
- Anna Lykke
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Johnny F B Andersen
- Department of Radiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lars N Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Tommie Mynster
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark.
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Facy O, Paquette B, Orry D, Santucci N, Rat P, Rat P, Binquet C, Ortega-Deballon P. Inflammatory markers as early predictors of infection after colorectal surgery: the same cut-off values in laparoscopy and laparotomy? Int J Colorectal Dis 2017; 32:857-863. [PMID: 28386662 DOI: 10.1007/s00384-017-2805-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE C-reactive protein and procalcitonin are reliable early predictors of infection after colorectal surgery. However, the inflammatory response is lower after laparoscopy as compared to open surgery. This study analyzed whether a different cutoff value of inflammatory markers should be chosen according to the surgical approach. METHODS A prospective, observational study included consecutive patients undergoing elective colorectal surgery in three academic centers. All infections until postoperative day (POD) 30 were recorded. The inflammatory markers were analyzed daily until POD 4. Areas under the ROC curve and diagnostic values were calculated in order to assess their accuracy as a predictor of intra-abdominal infection. RESULTS Five-hundred-one patients were included. The incidence of intra-abdominal infection was 11.8%. The median levels of C-reactive protein (CRP) and procalcitonin (PCT) were lower in the laparoscopy group at each postoperative day (p < 0.0001). In patients without intra-abdominal infection, they were also lower in the laparoscopy group (p = 0.0036) but were not different in patients presenting with intra-abdominal infections (p = 0.3243). In the laparoscopy group, CRP at POD 4 was the most accurate predictor of overall and intra-abdominal infection (AUC = 0.775). With a cutoff of 100 mg/L, it yielded 95.7% negative predictive value, 75% sensitivity, and 70.3% specificity for the detection of intra-abdominal infection. CONCLUSION The impact of infection on inflammatory markers is more important than that of the surgical approach. Defining a specific cutoff value for early discharge according to the surgical approach is not justified. A patient with CRP values lower than 100 mg/L on POD 4 can be safely discharged.
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Affiliation(s)
- Olivier Facy
- Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France. .,INSERM, U866, Dijon, France. .,University of Bourgogne-Franche-Comté, UMR866, Dijon, France.
| | - Brice Paquette
- Department of Digestive Surgery, Besançon University Hospital, Besançon, France
| | - David Orry
- Department of Surgery, Anticancer Centre "Georges-François Leclerc", Dijon, France
| | - Nicolas Santucci
- Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France.,INSERM, U866, Dijon, France.,University of Bourgogne-Franche-Comté, UMR866, Dijon, France
| | - Paul Rat
- Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France.,INSERM, U866, Dijon, France.,University of Bourgogne-Franche-Comté, UMR866, Dijon, France
| | - Patrick Rat
- Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France.,INSERM, U866, Dijon, France.,University of Bourgogne-Franche-Comté, UMR866, Dijon, France
| | - Christine Binquet
- INSERM, U866, Dijon, France.,University of Bourgogne-Franche-Comté, UMR866, Dijon, France.,INSERM, CIC1432, Dijon, France.,Clinical Investigation Centre, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgery, Dijon University Hospital, 14, Rue Paul Gaffarel, 21079, Dijon Cedex, France.,INSERM, U866, Dijon, France.,University of Bourgogne-Franche-Comté, UMR866, Dijon, France
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Jensen KK, Oma E, Harling H, Krarup PM. Type of incision does not predict abdominal wall outcome after emergency surgery for colonic anastomotic leakage. Int J Colorectal Dis 2017; 32:865-873. [PMID: 28391448 DOI: 10.1007/s00384-017-2810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Most literature on abdominal incision is based on patients undergoing elective surgery. In a cohort of patients with anastomotic leakage after colonic cancer resection, we analyzed the association between type of incision, fascial dehiscence, and incisional hernia. METHODS Data were extracted from the Danish Colorectal Cancer Group database and merged with information from the Danish National Patient Register. All patients with anastomotic leakage after colonic resection in Denmark from 2001 until 2008 were included and surgical records on re-operations were retrieved. The primary outcome of the study was incisional hernia formation, and the secondary outcome was fascial dehiscence. Multivariable logistic, Cox, and competing risks regression analysis, as well as propensity score matching were used for confounder control. RESULTS A total of 363 patients undergoing reoperation for anastomotic leakage were included with a median follow-up of 5.4 years. Incisional hernia occurred in 41 of 227 (15.3%) patients undergoing midline incision compared with 14 of 81 (14.7%) following transverse incision, P = 1.00. After adjusting for confounders, there was no association between the type of incision and incisional hernia (transverse incision hazard ratio 1.36, 0.68-2.72, P = 0.390) or fascial dehiscence (transverse incision odds ratio 1.66, 0.57-4.49, P = 0.331). This conclusion was confirmed after propensity score matching, P = 0.507. CONCLUSIONS In the current study, type of incision did not predict abdominal wall outcome after emergency surgery for colonic anastomotic leakage.
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Affiliation(s)
- Kristian Kiim Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark.
| | - Erling Oma
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Henrik Harling
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Peter-Martin Krarup
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
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Diagnostic Accuracy of Procalcitonin and C-reactive Protein for the Early Diagnosis of Intra-abdominal Infection After Elective Colorectal Surgery: A Meta-analysis. Ann Surg 2017; 264:252-6. [PMID: 27049766 DOI: 10.1097/sla.0000000000001545] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery. METHODS This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity. RESULTS The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day. CONCLUSIONS Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.
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Should CT scan be performed when CRP is elevated after colorectal surgery? Results from the inflammatory markers after colorectal surgery study. J Visc Surg 2017; 154:5-9. [DOI: 10.1016/j.jviscsurg.2016.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
PURPOSE The aim of this study was to explore the choice of modality for diagnosis, treatments, and consequences of anastomotic leakage. METHODS This is a retrospective study of consecutive patients who underwent surgery that included a colorectal anastomosis due to colorectal cancer, diverticulitis, inflammatory bowel disease (IBD), or benign polyps. RESULTS A total of 600 patients were included during 2010-2012, and 60 (10%) had an anastomotic leakage. It took in mean 8.8 days (range 2-42) until the anastomotic leakage was diagnosed. A total of 44/60 of the patients with a leakage had a CT scan of the abdomen; 11 (25%) were initially negative for anastomotic leakage. Among all leakages, the anastomosis was taken down in 45 patients (76.3%). All patients with a grade B leakage (n = 6) were treated with antibiotics, and two also received transanal drainage. The overall complication rate was also significantly higher in those with leakage (93.3 vs. 28.5%, p < 0.001), and it was more common with more than three complications (70 vs. 1.5%, p < 0.001). There was a higher mortality in the leakage group. CONCLUSION This study demonstrated that one fourth of the CT scans that were executed were initially negative for leakage. Most patients with a grade C leakage will not have an intact anastomosis. An anastomotic leakage leads to significantly more severe postoperative complications, higher rate of reoperations, and higher mortality. An earlier relaparotomy instead of a CT scan and improved postoperative surveillance could possibly reduce the consequences of the anastomotic leakage.
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Abstract
Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. The aim of therapy is a rapid and effective control of the source of infection and antimicrobial therapy. After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.
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Affiliation(s)
- J F Lock
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - C Eckmann
- Klinik für Allgemein-, Viszeral-,Thorax- und Minimal-Invasive Chirurgie, Klinikum Peine, Peine, Deutschland
| | - C-T Germer
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
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Abstract
AIM OF DATABASE The aim of the database, which has existed for registration of all patients with colorectal cancer in Denmark since 2001, is to improve the prognosis for this patient group. STUDY POPULATION All Danish patients with newly diagnosed colorectal cancer who are either diagnosed or treated in a surgical department of a public Danish hospital. MAIN VARIABLES The database comprises an array of surgical, radiological, oncological, and pathological variables. The surgeons record data such as diagnostics performed, including type and results of radiological examinations, lifestyle factors, comorbidity and performance, treatment including the surgical procedure, urgency of surgery, and intra- and postoperative complications within 30 days after surgery. The pathologists record data such as tumor type, number of lymph nodes and metastatic lymph nodes, surgical margin status, and other pathological risk factors. DESCRIPTIVE DATA The database has had >95% completeness in including patients with colorectal adenocarcinoma with >54,000 patients registered so far with approximately one-third rectal cancers and two-third colon cancers and an overrepresentation of men among rectal cancer patients. The stage distribution has been more or less constant until 2014 with a tendency toward a lower rate of stage IV and higher rate of stage I after introduction of the national screening program in 2014. The 30-day mortality rate after elective surgery has been reduced from >7% in 2001-2003 to <2% since 2013. CONCLUSION The database is a national population-based clinical database with high patient and data completeness for the perioperative period. The resolution of data is high for description of the patient at the time of diagnosis, including comorbidities, and for characterizing diagnosis, surgical interventions, and short-term outcomes. The database does not have high-resolution oncological data and does not register recurrences after primary surgery. The Danish Colorectal Cancer Group provides high-quality data and has been documenting an increase in short- and long-term survivals since it started in 2001 for both patients with colon and rectal cancers.
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Affiliation(s)
- Peter Ingeholm
- Danish Colorectal Cancer Group Database, Copenhagen; Department of Pathology, Herlev University Hospital, Herlev
| | - Ismail Gögenur
- Danish Colorectal Cancer Group Database, Copenhagen; Department of Surgery, Roskilde University Hospital, Roskilde
| | - Lene H Iversen
- Danish Colorectal Cancer Group Database, Copenhagen; Department of Surgery P, Aarhus University Hospital, Aarhus C, Denmark
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Abstract
PURPOSE Anastomotic leakage (AL) after right hemicolectomy is a devastating complication, and risk factors for AL in this setting are rarely investigated exclusively. Recent reports suggest that anastomotic type may influence the rate of AL in ileocolic anastomoses. We investigated risk factors and short-term outcomes in patients subjected to right hemicolectomy. METHODS Data from all patients undergoing right hemicolectomy at our institution between 2009 and 2013 were collected in a database. Risk factors for clinical AL, 30-day mortality, hospital and intensive care unit stay were investigated. Stepwise logistic regression was used to adjust for confounding. RESULTS 22/445 (4.9 %) patients had AL. Median time to AL was 6 days (range 2-11 days). A stapled anastomosis was associated with an increased AL rate compared with the handsewn approach (adjusted odds ratio (aOR) 2.84; 95 % CI 1.14-7.07; P = 0.025). Other risk factors for AL were tobacco use (aOR 2.70; 95 % CI 1.06-6.86; P = 0.037) and diabetes (aOR 5.95; 95 % CI 2.23-15.90; P < 0.001). Anastomotic ischemia was present in 6/13 stapled and 1/9 handsewn leaking anastomoses, P = 0.081, while generalized peritonitis was observed after 4/13 stapled and 7/9 handsewn leaking anastomoses, P = 0.030. Thirty-day mortality was 2/22 (9.1 %) in patients with AL and 23/423 (5.4 %) in patients without AL, P = 0.468, and 13/160 (8.1 %) and 12/285 (4.2 %), P = 0.085, in stapled and handsewn anastomoses, respectively. CONCLUSIONS Risk factors for AL after right hemicolectomy were diabetes, tobacco use and stapled compared with handsewn anastomoses.
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Luigi De M, Brice P, David O, Olivier F, Giovanni di G, Patrick R, Christine B, Pablo OD. Preoperative inflammation increases the risk of infection after elective colorectal surgery: results from a prospective cohort. Int J Colorectal Dis 2016; 31:1611-7. [PMID: 27357511 PMCID: PMC5517619 DOI: 10.1007/s00384-016-2620-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Septic complications after colorectal surgery are frequent and sometimes life threatening. It is well known that inflammation impairs the healing process. It has been suggested that preoperative ongoing inflammation could increase the risk of postoperative infections. This study aimed to elucidate the role of preoperative inflammation on postoperative infectious complications and to understand if, through biological markers, it is possible to identify preoperatively patients at higher risk of infection. METHODS A prospective, observational study was conducted in three centers from November 2011 to April 2014. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. Any ongoing infection was an exclusion criterion. C-reactive protein, albumin, prealbumin, and procalcitonin plasma levels were measured preoperatively. Postoperative infections were recorded according to the definitions of the Centers for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the accuracy of each preoperative marker. RESULTS Four-hundred and seventy two patients were analyzed. Infectious complications occurred in 118 patients (25 %) and mortality in 6 patients (1.3 %). In the univariate analysis, preoperative C-reactive protein and albuminemia were found significantly associated with postoperative infectious complications (P = 0.008 and P = 0.0002, respectively). Areas under the ROC curve for preoperative C-reactive protein and albuminemia were 0.57and 0.62, respectively. CONCLUSIONS This study confirms the association between preoperative inflammatory activity, hypoalbuminemia, and the onset of infections after surgery. Trials aiming to decrease the inflammatory activity before surgery in order to prevent postoperative complications are warranted.
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Affiliation(s)
- Magistris Luigi De
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon
| | - Paquette Brice
- Service de Chirurgie Digestive [CHU Besançon]
Centre Hospitalier Régional Universitaire [Besançon] - Université de Franche-Comté - Place Saint Jacques 25000 Besançon
| | - Orry David
- CRLCC - CGFL, Centre Régional de Lutte Contre le Cancer - Centre Georges-François Leclerc
1 rue du Professeur Marion, 21000 Dijon
| | - Facy Olivier
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon
| | - Giacomo Giovanni di
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon
| | - Rat Patrick
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon
| | - Binquet Christine
- Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon,CIC-EC, Centre d'Investigation Clinique 1432 (Dijon) - Epidemiologie Clinique/Essais Cliniques
Université de Bourgogne - Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - Institut National de la Santé et de la Recherche Médicale - Faculté de MédecineBP 87900 - 7 boulvard Jeanne d'Arc - 21079 Dijon Cedex
| | - Ortega-Deballon Pablo
- Service de Chirurgie Digestive, Cancérologique, Générale, Endocrinienne et Urgences (CHU de Dijon)
Centre Hospitalier Universitaire de Dijon - Hôpital François Mitterrand - CHU Dijon - 14 rue Paul Gaffarel - 21079 Dijon,Chimiothérapie et Réponse Immunitaire Anti-Tumorale (U866, Cancer, équipe 1)
Université de Bourgogne - Institut National de la Santé et de la Recherche Médicale - U866Université de Bourgogne - 21000 Dijon,* Correspondence should be addressed to Ortega-Deballon Pablo
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Tevis SE, Kennedy GD. Postoperative Complications: Looking Forward to a Safer Future. Clin Colon Rectal Surg 2016; 29:246-52. [PMID: 27582650 DOI: 10.1055/s-0036-1584501] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colorectal surgery patients frequently suffer from postoperative complications. Patients with complications have been shown to be at higher risk for mortality, poor oncologic outcomes, additional complications, and worse quality of life. Complications are increasingly recognized as markers of quality of care with more use of risk-adjusted national surgical databases and increasing transparency in health care. Quality improvement work in colorectal surgery has identified methods to decrease complication rates and improve outcomes in this patient population. Future work will continue to identify best practices and standardized ways to measure quality of care.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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Diagnostic Accuracy of Inflammatory Markers As Early Predictors of Infection After Elective Colorectal Surgery: Results From the IMACORS Study. Ann Surg 2016; 263:961-6. [PMID: 26135691 DOI: 10.1097/sla.0000000000001303] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intra-abdominal infections are frequent and life-threatening complications after colorectal surgery. An early detection could diminish their clinical impact and permit safe early discharge. OBJECTIVE This study aimed to find the most accurate marker for the detection of postoperative intra-abdominal infection and the appropriate moment to measure it. METHODS A prospective, observational study was conducted in 3 centers. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. C-reactive protein and procalcitonin were measured daily until the fourth postoperative day. Postoperative infections were recorded according to the definitions of the Centres for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the diagnostic accuracy of each marker. RESULTS Five-hundred and one patients were analyzed. The incidence of intra-abdominal infection was 11.8%, with 24.6% of patients presenting at least one infectious complication. Overall mortality was 1.2%. At the fourth postoperative day, C-reactive protein was more discriminating than procalcitonin for the detection of intra-abdominal infection (areas under the ROC curve: 0.775 vs 0.689, respectively, P = 0.03). Procalcitonin levels showed wide dispersion. For the detection of all infectious complications, C-reactive protein was also significantly more accurate than procalcitonin on the fourth postoperative day (areas under the ROC curve: 0.783 vs 0.671, P = 0.0002). CONCLUSIONS C-reactive protein is more accurate than procalcitonin for the detection of infectious complications and should be systematically measured at the fourth postoperative day. It is a useful tool to ensure a safe early discharge after elective colorectal surgery.
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Waterland P, Ng J, Jones A, Broadley G, Nicol D, Patel H, Pandey S. Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference? Int J Colorectal Dis 2016; 31:861-8. [PMID: 26951183 DOI: 10.1007/s00384-016-2547-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 02/04/2023]
Abstract
AIM C-reactive protein (CRP) has proven to be a useful adjunct in early diagnosis of anastomotic leak (AL) after colorectal surgery. It would be of considerable value to examine whether modality of surgery has influence upon postoperative CRP serum levels and their predictive value in the diagnosis of AL. METHODS All patients undergoing elective colorectal surgery with anastomosis were enrolled into a prospective database between 2011 and 2014. AL was defined with strict operative and radiological criteria. Outcomes between open and laparoscopic resections were assessed statistically and Receiver Operating Characteristic (ROC) curve analysis performed. RESULTS Seven hundred twenty-seven patients with an intestinal anastomosis were identified including 468 laparoscopic procedures (468/727; 64 %). There were 58 anastomotic leaks (58/727; 7.9 %) of which 29 (6.2 %) were laparoscopic and 29 (11.2 %) were open. Mean CRP levels were significantly higher in patients after open surgery compared with laparoscopic both with AL (p = 0.013), and without (p = 0.02). ROC curve analysis revealed postoperative day 3 (cut-off CRP 209) and day 4 (cut-off CRP 123.5) to be most predictive of leak in the open group with an area under the curve (AUC) 0.794 (sensitivity 80 %, specificity 80 %) and AUC 0.806 (sensitivity 94 %, specificity 60 %), respectively. In the laparoscopic group, day 2 proved to be the most accurate day for detection of leak with a cut-off CRP of 146.5 showing 75 % sensitivity and a 70 % specificity (AUC 0.766). CONCLUSION CRP levels are higher after open surgery compared with laparoscopic surgery, both with and without AL. AL generates a significant detectable increase in CRP within 2-4 days after surgery.
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Affiliation(s)
- P Waterland
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - J Ng
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK.
| | - A Jones
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - G Broadley
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - D Nicol
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - H Patel
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - S Pandey
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
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Cytokines as Early Markers of Colorectal Anastomotic Leakage: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2016; 2016:3786418. [PMID: 27051416 PMCID: PMC4804081 DOI: 10.1155/2016/3786418] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/13/2016] [Accepted: 02/18/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose. Colorectal anastomotic leakage (CAL) is one of the most severe complications after colorectal surgery. This meta-analysis evaluates whether systemic or peritoneal inflammatory cytokines may contribute to early detection of CAL. Methods. Systematic literature search was performed in the acknowledged medical databases according to the PRISMA guidelines to identify studies evaluating systemic and peritoneal levels of TNF, IL-1β, IL-6, and IL-10 for early detection of CAL. Means and standard deviations of systemic and peritoneal cytokine levels were extracted, respectively, for patients with and without CAL. The meta-analysis of the mean differences was carried out for each postoperative day using Review Manager. Results. Seven articles were included. The meta-analysis was performed with 5 articles evaluating peritoneal cytokine levels. Peritoneal levels of IL-6 were significantly higher in patients with CAL compared to patients without CAL on postoperative days 1, 2, and 3 (P < 0.05). Similar results were found for peritoneal levels of TNF but on postoperative days 3, 4, and 5 (P < 0.05). The articles regarding systemic cytokine levels did not report any significant difference accordingly. Conclusion. Increased postoperative levels of peritoneal IL-6 and TNF are significantly associated with CAL and may contribute to its early detection.
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Rutegård M, Boström P, Haapamäki M, Matthiessen P, Rutegård J. Current use of diverting stoma in anterior resection for cancer: population-based cohort study of total and partial mesorectal excision. Int J Colorectal Dis 2016; 31:579-85. [PMID: 26670673 DOI: 10.1007/s00384-015-2465-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE A diverting stoma is commonly used to reduce the risk of anastomotic leakage when performing total mesorectal excision (TME) in anterior resection for rectal cancer. The purpose of this study was to evaluate the impact of fecal diversion in relation to partial mesorectal excision (PME). METHODS A retrospective analysis was undertaken on a national cohort, originally created to study the impact of central arterial ligation on patients with increased cardiovascular risk. Some 741 patients operated with anterior resection for rectal cancer during the years 2007 through 2010 were followed up for 53 months. Multivariate logistic regression was used to evaluate the impact of diverting stoma on the risk of anastomotic leakage and permanent stoma, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS The risk of anastomotic leakage was increased in TME surgery when not using a diverting stoma (OR 5.1; 95% CI 2.2-11.6), while the corresponding risk increase in PME patients was modest (OR 1.8; 95% CI 0.8-4.0). At study completion or death, 26 and 13% of TME and PME patients, respectively, had a permanent stoma. A diverting stoma was a statistically significant risk factor for a permanent stoma in PME patients (OR 4.7; 95% CI 2.5-9.0), while less important in TME patients (OR 1.8; 95% CI 0.6-5.5). CONCLUSION The benefit of a diverting stoma concerning anastomotic leakage in this patient group seems doubtful. Moreover, the diverting stoma itself may contribute to the high rate of permanent stomas.
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Petrus Boström
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Markku Haapamäki
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Rudnicki Y, Shpitz B, White I, Wiener Y, Golani G, Avital S. The use of a T drain tube to treat anastomotic leaks. Tech Coloproctol 2016; 20:255-7. [PMID: 26886935 DOI: 10.1007/s10151-016-1439-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Y Rudnicki
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Shpitz
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - I White
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Y Wiener
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - G Golani
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Avital
- Department of Surgery B, Meir Medical Center, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Ortega-Deballon P. [How can we decrease mortality due to anastomotic fistula in colorectal surgery?]. Cir Esp 2016; 94:250-1. [PMID: 26874399 DOI: 10.1016/j.ciresp.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/06/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Pablo Ortega-Deballon
- Service de Chirurgie Digestive Cancérologique, CHU Bocage Central Unité de Recherche INSERM 866 «Thérapie locorrégionale en chirurgie», Dijon, Francia.
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Blumetti J, Abcarian H. Management of low colorectal anastomotic leak: Preserving the anastomosis. World J Gastrointest Surg 2015; 7:378-383. [PMID: 26730283 PMCID: PMC4691718 DOI: 10.4240/wjgs.v7.i12.378] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
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Daniels M, Merkel S, Agaimy A, Hohenberger W. Treatment of perforated colon carcinomas-outcomes of radical surgery. Int J Colorectal Dis 2015; 30:1505-13. [PMID: 26248792 DOI: 10.1007/s00384-015-2336-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE When patients present with a perforation of a colon cancer (CC), this situation increases the challenge to treat them properly. The question arises how to deal with these patients adequately, more restrictively or the same way as with elective cases. METHODS Between January 1995 and December 2009, 52 patients with perforated CC and 1206 nonperforated CC were documented in the Erlangen Registry of Colorectal Carcinomas (ERCRC). All these patients underwent radical resection of the primary including systematic lymph node dissection with CME. The median follow-up period was 68 months. RESULTS The median age of the patients in the perforated CC group was significantly higher than in the nonperforated CC group (p = 0.010). Significantly, more patients with perforated CC were classified in ASA categories 3 and 4 (p = 0.014). Hartmann procedures were performed significantly more frequently with perforation than with the nonperforated ones (p < 0.001). If an anastomosis was performed, the leakage rate of primary anastomoses did not differ (p = 1.0). Cancer-related survival was significantly lower with perforated cancer (difference 12.8 percentage points) and by 9.6 percentage points for observed survival, if postoperative mortality was excluded. CONCLUSIONS Perforated CC patients should be treated basically following the same oncologic demands, which are CME for colonic cancer including multivisceral resections, if needed. This strategy can only be performed if high-quality surgery is available, permanently.
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Affiliation(s)
- M Daniels
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany.
| | - S Merkel
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - A Agaimy
- Universitätsklinikum Erlangen, Pathologisches Institut, Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - W Hohenberger
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany
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Ji WB, Kwak JM, Kim J, Um JW, Kim SH. Risk factors causing structural sequelae after anastomotic leakage in mid to low rectal cancer. World J Gastroenterol 2015; 21:5910-5917. [PMID: 26019455 PMCID: PMC4438025 DOI: 10.3748/wjg.v21.i19.5910] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/31/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the risk factors causing structural sequelae after anastomotic leakage in patients with mid to low rectal cancer.
METHODS: Prospectively collected data of consecutive subjects who had anastomotic leakage after surgical resection for rectal cancer from March 2006 to May 2013 at Korea University Anam Hospital were retrospectively analyzed. Two subgroup analyses were performed. The patients were initially divided into the sequelae (stricture, fistula, or sinus) and no sequelae groups and then divided into the permanent stoma (PS) and no PS groups. Univariate and multivariate analyses were performed to identify the risk factors of structural sequelae after anastomotic leakage.
RESULTS: Structural sequelae after anastomotic leakage were identified in 29 patients (39.7%). Multivariate analysis revealed that diversion ileostomy at the first operation increases the risk of structural sequelae [odds ratio (OR) = 6.741; P = 0.017]. Fourteen patients (17.7%) had permanent stoma during the follow-up period (median, 37 mo). Multivariate analysis showed that the tumor level from the dentate line was associated with the risk of permanent stoma (OR = 0.751; P = 0.045).
CONCLUSION: Diversion ileostomy at the first operation increased the risk of structural sequelae of the anastomosis, while lower tumor location was associated with the risk of permanent stoma in the management of anastomotic leakage.
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50
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Brunner W, Rossetti A, Vines LC, Kalak N, Bischofberger SA. Anastomotic leakage after laparoscopic single-port sigmoid resection: combined transanal and transabdominal minimal invasive management. Surg Endosc 2015; 29:3803-5. [PMID: 25783831 DOI: 10.1007/s00464-015-4138-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 02/21/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic colorectal surgery has become the gold standard in the therapy of benignant and malignant colorectal pathologies. Anastomotic leakage is still a reason for laparotomy; applying a diverting stoma or performing a Hartman's procedure is common [1, 2]. Laparoscopic treatment of an early-detected anastomotic leakage is suggested from other authors [3, 4]. In our video we demonstrate a combined minimal invasive transabdominal and transanal treatment concept in patients with early-detected anastomotic leakage. METHODS Two consecutive patients developing an anastomotic leakage after single-port laparoscopic sigmoid resection for stage II/III diverticulitis (Hanson & Stock) were treated with a combined minimal invasive approach. Anastomotic leakage was diagnosed by triple contrast computed tomography on postoperative day 4 in patient one and on postoperative day 7 in patient two. Operative treatment was performed immediately on the same day without delay. RESULTS In both patients a combined transanal and transabdominal approach was performed. First step was a diagnostic laparoscopy in order to exclude fecal peritonitis. Using a single-port device (SILS Port Covidien), transanal inspection of the anastomosis was also performed: In both patients anastomotic tissue margins were vital, and the leakage affected only a quarter of the anastomotic circumference. Transanal stitches were placed to close the anastomotic leakage. Laparoscopic transabdominal irrigation was performed, and two suction drainages were placed in the pelvis. Postoperative antibiotic treatment and a gradual return to slid food were carried out. Functional result at follow-up of 102 and 112 days (with rectoscopy) showed no residual leak and no stricture of the anastomosis, and both of patients had a normal rectal function.
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Affiliation(s)
- Walter Brunner
- Kantonsspital St. Gallen - Clinic of Surgery, Rorschacherstrasse 95, 9000, St Gallen, Switzerland.
| | - Andrea Rossetti
- Kantonsspital St. Gallen - Clinic of Surgery, Rorschacherstrasse 95, 9000, St Gallen, Switzerland.
| | - Larissa Clea Vines
- Kantonsspital St. Gallen - Clinic of Surgery, Rorschacherstrasse 95, 9000, St Gallen, Switzerland.
| | - Nabil Kalak
- Kantonsspital St. Gallen - Clinic of Surgery, Rorschacherstrasse 95, 9000, St Gallen, Switzerland.
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