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Bhama AR, Maykel JA. Diagnosis and Management of Chronic Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:406-411. [PMID: 34853562 DOI: 10.1055/s-0041-1732322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.
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Affiliation(s)
- Anuradha R Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Wooster, Massachusetts
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Sato S, Chinda D, Tanaka Y, Kaizuka N, Higuchi N, Ota S, Miyazawa K, Kikuchi H, Aizawa S, Iwamura H, Fukuda S. Effective Endoscopic Closure of Cholecysto-duodenal and Transverse Colon Fistulas Due to Squamous Cell Carcinoma of the Gallbladder Using Polyglycolic Acid Sheets and a Covered Metal Stent. Intern Med 2021; 60:1723-1729. [PMID: 33390496 PMCID: PMC8222133 DOI: 10.2169/internalmedicine.6384-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
An 81-year-old woman presented with abdominal distension and right hypochondrial pain. Abdominal contrast computed tomography and magnetic resonance imaging revealed an 11-cm gallbladder tumor. The patient was diagnosed with squamous cell carcinoma of the gallbladder by endoscopic ultrasound-guided fine-needle aspiration from the gastric antrum. Thereafter, the gallbladder tumor enlarged, and cholecysto-duodenal and transverse colon fistulas were formed. A covered metal stent was placed on the transverse colon, and polyglycolic acid sheets were injected into the duodenum to close the fistulas endoscopically. Endoscopic closure is less invasive than surgery and considered effective for patients with poor general health conditions.
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Affiliation(s)
- Satoshi Sato
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Daisuke Chinda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
- Department of Community Medicine, Hirosaki University Graduate School of Medicine, Japan
| | - Yusuke Tanaka
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Naotoshi Kaizuka
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Naoki Higuchi
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Shinji Ota
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Kuniaki Miyazawa
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Hidezumi Kikuchi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Syu Aizawa
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
| | - Hideki Iwamura
- Department of Gastroenterology, Hematology and Rheumatology, Tsugaru General Hospital, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
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Fang AH, Chao W, Ecker M. Review of Colonic Anastomotic Leakage and Prevention Methods. J Clin Med 2020; 9:E4061. [PMID: 33339209 PMCID: PMC7765607 DOI: 10.3390/jcm9124061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022] Open
Abstract
Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.
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Affiliation(s)
- Alex H. Fang
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Wilson Chao
- Texas Academy of Mathematics and Science, University of North Texas, Denton, TX 76203, USA; (A.H.F.); (W.C.)
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
| | - Melanie Ecker
- Department of Biomedical Engineering, University of North Texas, Denton, TX 76203, USA
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Kayano H, Nomura E, Ueda Y, Machida T, Uda S, Mukai M, Yamamoto S, Makuuchi H. Short-term outcomes of OTSC for anastomotic leakage after laparoscopic colorectal surgery. MINIM INVASIV THER 2020; 30:369-376. [PMID: 32196402 DOI: 10.1080/13645706.2020.1742743] [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] [Indexed: 02/06/2023]
Abstract
Introduction: There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC.Material and methods: Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated.Results: The average distance from the anal verge of the anastomosis site was 12 (5-18) cm. The average diameter of the dehiscent part was 10.9 (9.3-14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5-22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9-5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone.Conclusion: AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management.
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Affiliation(s)
- Hajime Kayano
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Eiji Nomura
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yasuhiko Ueda
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takashi Machida
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shuji Uda
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Masaya Mukai
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Seiichiro Yamamoto
- Department of Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hiroyasu Makuuchi
- Department of General and Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
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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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Sevim Y, Celik SU, Yavarifar H, Akyol C. Minimally invasive management of anastomotic leaks in colorectal surgery. World J Gastrointest Surg 2016; 8:621-626. [PMID: 27721925 PMCID: PMC5037335 DOI: 10.4240/wjgs.v8.i9.621] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/06/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
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Cereatti F, Fiocca F, Dumont JL, Ceci V, Vergeau BM, Tuszynski T, Meduri B, Donatelli G. Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients. Therap Adv Gastroenterol 2016; 9:180-8. [PMID: 26929780 PMCID: PMC4749852 DOI: 10.1177/1756283x15610052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases. METHODS From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula. RESULTS Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6-65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus. CONCLUSION FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.
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Affiliation(s)
- Fabrizio Cereatti
- Emergency Endoscopic Unit, Policlinico Umberto I, ‘SAPIENZA’ University of Rome, Rome, Italy
| | - Fausto Fiocca
- Emergency Endoscopic Unit, Policlinico Umberto I, ‘SAPIENZA’ University of Rome, Rome, Italy
| | - Jean-Loup Dumont
- Unité d’Endoscopie Interventionnelle, RamsayGénérale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Vincenzo Ceci
- Emergency Endoscopic Unit, Policlinico Umberto I, ‘SAPIENZA’ University of Rome, Rome, Italy
| | - Bertrand-Marie Vergeau
- Unité d’Endoscopie Interventionnelle, RamsayGénérale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Thierry Tuszynski
- Unité d’Endoscopie Interventionnelle, RamsayGénérale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Bruno Meduri
- Unité d’Endoscopie Interventionnelle, RamsayGénérale de Santé, Hôpital Privé des Peupliers, Paris, France
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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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