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Kshirsagar VV, Mp H. A Comparative Study of Hand-Sewn and Stapled Anastomosis in Gastrointestinal Surgeries. Cureus 2024; 16:e71264. [PMID: 39525136 PMCID: PMC11550869 DOI: 10.7759/cureus.71264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 10/11/2024] [Indexed: 11/16/2024] Open
Abstract
Background Bowel anastomosis is a key part of gastrointestinal surgery where two sections of the intestines are connected. It is a critical step as it restores the digestive tract's continuity after removing damaged or diseased bowel. Stapler devices are a new method that helps connect bowel loops faster and with less tissue damage. This study aimed to evaluate and compare the safety and effectiveness of stapled anastomosis versus hand-sewn anastomosis in surgeries involving the bowel. Methods In this prospective non-randomized study, the study population included 60 patients with various gastrointestinal surgeries admitted to our institution from August 2022 to June 2024 within a single unit. The inclusion criteria included all patients aged over 18 years who underwent surgeries such as gastrojejunostomy, hemicolectomy, and small bowel resection with anastomosis. The exclusion criteria were age under 18, pregnancy, and immunocompromised states. Patients were divided into two groups based on how their digestive tract was reconstructed: 28 had stapled anastomoses and 32 had hand-sewn anastomoses, either as elective or emergency surgery. We examined multiple outcomes such as surgery duration in hours, time until bowel function returned post surgery, length of hospital stay in days, anastomotic leak rate, albumin levels to leak rate, post-surgery pain, and surgical site infection (SSI) rate for the two groups. Southampton wound grading system and the visual analog scale (VAS) were used to assess the SSI and pain score, respectively. Results When comparing the operation time for the suture and staple groups among the elective cases, the p-value was significant (0.02), with 15 patients having prolonged surgery in the suture group compared to only five in the staple group. Regarding the time until the return of bowel sounds post surgery, the p-value was significant (0.02) for elective cases in the two groups, with nine patients having their bowel sounds returning after the third postoperative day (POD) in the suture group. When comparing the duration of stay in the hospital for elective cases for the staple and suture groups, the p-value was significant (0.04), with eight patients staying after the seventh POD in the suture group. When comparing the leak rates for the two groups for elective cases, the p-value was significant (0.04), with four leaks in the suture group and no leaks in the staple group. On comparing the association between the albumin level and anastomotic leak, the p-value was significant at 0.001 and 0.0006 for the suture and staple groups, respectively, with more leaks associated with an albumin level of <3 mg/dl. When comparing pain scores of the suture and staple groups separately in elective and emergency settings, the p-values were both 0.4, which is not significant. Among the elective cases comparing SSIs for the suture and staple groups, the p-value was significant (0.04), with six patients having SSIs in the suture group compared to one patient in the staple group. Among the emergency cases, when comparing SSIs for the suture and staple groups, the p-value was not significant (0.1). Conclusion In elective surgeries, stapled anastomosis reduces surgery time, accelerates bowel function recovery, enables earlier discharge, and lowers anastomotic leak rates compared to sutures. The staples group showed no difference from sutures in the leak rate to albumin levels and pain while offering superior SSI prevention.
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Affiliation(s)
- Vinayak V Kshirsagar
- Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Himashree Mp
- Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Kávási SB, Iov DE, Rancz A, Zolcsák Á, Veres DS, Lenti K, Miheller P, Hegyi P, Ábrahám S. End-to-end anastomosis provides similar quality-of-life, compared with other reconstructive techniques six months following total mesorectal excision: Systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108599. [PMID: 39154431 DOI: 10.1016/j.ejso.2024.108599] [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] [Received: 05/25/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024]
Abstract
Colorectal malignancy ranked third globally in cancer incidence with 1.9 million cases and nearly 1 million deaths in 2020. Rectal cancer is primarily treated with total mesorectal excision (TME). This study examines surgical, functional, and quality-of-life (QoL) outcomes for different anastomosis types. Pre-registered on PROSPERO (CRD42022368907), the systematic search on November 8, 2022, covered three databases: MEDLINE (via PubMed), Embase, and Cochrane Central. Randomized controlled trials (RCT) assessing adults post-TME, comparing end-to-end anastomosis (EEA) to colonic J-pouch (CJP) and/or side-to-end anastomosis (SEA) were eligible. 29 studies out of 4459 were included. EEA vs. CJP showed no significant differences in anastomotic leakage (AL) (RR: 1.03; CI: [0.84-1.26]) or mortality (RR: 0.77; CI: [0.30-1.98]). At 12 months, the mean bowel movement difference was 1.59/day (CI: [(-)0.66-3.84]). QoL at six and 12 months was similar (SMD: -0.22; CI: [(-)0.82-0.37]). Compared with SEA, EEA had similar AL ratios (RR: 1.59; CI: [0.54-4.72]) and QoL at six months (SMD: -0.04; CI: [(-)0.66-0.58]). EEA demonstrates surgical efficacy comparable to other techniques. Six months postoperatively, EEA's impact on QoL appears similar to CJP or SEA, irrespective of daily stool frequency.
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Affiliation(s)
- Sarolta Beáta Kávási
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Toldy Ferenc Hospital, Department of Surgery, Törteli street 1-3, 2700, Cegléd, Hungary.
| | - Diana-Elena Iov
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Grigore T. Popa University of Medicine and Pharmacy, Universității street 16, 700115, Iași, Romania.
| | - Anett Rancz
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Semmelweis University, Medical School, Department of Internal Medicine and Hematology, Szentkirályi street 46, 1088, Budapest, Hungary.
| | - Ádám Zolcsák
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Semmelweis University, Department of Biophysics and Radiation Biology, Tűzoltó street 37-47, 1094, Budapest, Hungary.
| | - Dániel Sándor Veres
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Semmelweis University, Department of Biophysics and Radiation Biology, Tűzoltó street 37-47, 1094, Budapest, Hungary.
| | - Katalin Lenti
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Semmelweis University, Faculty of Health Sciences, Department of Morphology and Physiology, Vas street 17, 1088, Budapest, Hungary.
| | - Pál Miheller
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; Semmelweis University, Department of Surgery, Transplantation, and Gastroenterology, Üllői street 78, 1082, Budapest, Hungary.
| | - Péter Hegyi
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; University of Pécs, Medical School, Institute for Translational Medicine, Szigeti street 12, 2nd floor, 7624, Pécs, Hungary; Semmelweis University, Institute of Pancreatic Diseases, Tömő street 25-29, 1083, Budapest, Hungary.
| | - Szabolcs Ábrahám
- Semmelweis University, Centre for Translational Medicine, Tűzoltó street 37-47, 1094, Budapest, Hungary; University of Szeged, Department of Surgery, Semmelweis street 8, 6725, Szeged, Hungary.
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Scardino A, Riva CG, Sorrentino L, Lauricella S, Aiolfi A, Rottoli M, Bonitta G, Vitellaro M, Bonavina L, Bona D, Kelly M, Rausa E. Effect of powered circular stapler in colorectal anastomosis after left-sided colic resection: systematic review and meta-analysis. Int J Colorectal Dis 2024; 39:152. [PMID: 39331160 PMCID: PMC11436432 DOI: 10.1007/s00384-024-04729-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
PURPOSE Anastomotic leak (AL) remains the most important complication after left-sided colic anastomoses and technical complications during anastomotic construction are responsible of higher leakage incidence. Powered circular stapler (PCS) in colorectal surgery has been introduced in order to reduce technical errors and post-operative complications due to the manual circular stapler (MCS). METHODS A systematic review and meta-analysis were performed. An electronic systematic search was performed using Web of Science, PubMed, and Embase of studies comparing PCS and MCS. The incidence of AL, anastomotic bleeding (AB), conversion, and reoperation were assessed. PROSPERO Registration Number: CRD42024512644. RESULTS Five observational studies were eligible for inclusion reporting on 2379 patients. The estimated pooled Risk Ratios for AL and AB rates following PCS were significantly lower than those observed with MCS (0.44 and 0.23, respectively; both with p < 0.01). Conversion and reoperation rate did not show any significant difference: 0.41 (95% CI 0.09-1.88; p = 0.25) and 0.78 (95% CI 0.33-1.84; p = 0.57); respectively. CONCLUSION The use of PCS demonstrates a lower incidence of AL and AB compared to MCS but does not exhibit a discernible influence on reintervention or conversion rates. The call for future randomized clinical trials aims to definitively clarify these issues and contribute to further advancements in refining surgical strategies for left-sided colonic resection.
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Affiliation(s)
- Andrea Scardino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy.
- General Surgery Residency Program, University of Milan, Milan, Italy.
| | - Carlo Galdino Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Luca Sorrentino
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Sara Lauricella
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Matteo Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Marco Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Michael Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Emanuele Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Huang W, Tan Z, Sun H. Successful treatment of anastomotic leakage with an intestinal obstruction catheter and stent by colonoscopy: a case report and brief literature review. Front Oncol 2024; 14:1428452. [PMID: 39355128 PMCID: PMC11442532 DOI: 10.3389/fonc.2024.1428452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/02/2024] [Indexed: 10/03/2024] Open
Abstract
Background Anastomotic leakage (AL) is one of the most common, severe, and difficult-to-treat complications after colorectal cancer surgery. However, to date, the best treatment options for AL remain elusive. Case description Here, we report the case of a 70-year-old man who had previously undergone Hartmann's surgery and developed a large AL after a colostomy reversal surgery in an external hospital. The condition mainly manifested as passage of the fecal material through the abdominal drainage tube accompanied by fever after intestinal surgery. We used a new method involving a transanal obstruction catheter combined with an anastomotic stent, along with fasting, administration of parenteral nutrition, and anti-infection treatment. By following this approach, AL was successfully cured without any complications. Conclusion To the best of our knowledge, this is the first case of the use of a transanal intestinal obstruction catheter combined with an anastomotic stent for treating colorectal AL; the findings may guide clinicians to better treat and manage AL.
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Affiliation(s)
- Wang Huang
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Zhenzong Tan
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Hao Sun
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China
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Pompeu BF, Pasqualotto E, Pigossi BD, Marcolin P, de Figueiredo SMP, Bin FC, Formiga FB. Turnbull-Cutait pull-through coloanal anastomosis versus standard coloanal anastomosis plus diverting ileostomy for low anterior resection: a meta-analysis and systematic review. Langenbecks Arch Surg 2024; 409:187. [PMID: 38888662 DOI: 10.1007/s00423-024-03379-9] [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] [Received: 04/27/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained popularity in the effort to offer patients a reconstructive option. In this context, we aimed to compare both techniques. METHODS PubMed, Cochrane, and Scopus were searched for studies published until January 2024. Odds ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I2 statistics, with p-values inferior to 0.10 and I2 >25% considered significant. Statistical analysis was conducted in RStudio version 4.1.2 (R Foundation for Statistical Computing). Registered number CRD42024509963. RESULTS One randomized controlled trial and nine observational studies were included, comprising 1,743 patients, of whom 899 (51.5%) were submitted to TCA and 844 (48.5%) to CAA. Most patients had rectal cancer (52.2%), followed by megacolon secondary to Chagas disease (32.5%). TCA was associated with increased colon ischemia (OR 3.54; 95% CI 1.13 to 11.14; p < 0.031; I2 = 0%). There were no differences in postoperative complications classified as Clavien-Dindo ≥ IIIb, anastomotic leak, pelvic abscess, intestinal obstruction, bleeding, permanent stoma, or anastomotic stricture. In subgroup analysis of patients with cancer, TCA was associated with a reduction in anastomotic leak (OR 0.55; 95% CI 0.31 to 0.97 p = 0.04; I2 = 34%). CONCLUSION TCA was associated with a decrease in anastomotic leak rate in subgroups analysis of patients with cancer.
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Affiliation(s)
- Bernardo Fontel Pompeu
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil.
- USCS - University of São Caetano do Sul, Rua Santo Antônio, 50 - Centro, São Caetano do Sul, SP, 09521-160, Brazil.
| | | | | | | | | | - Fang Chia Bin
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
| | - Fernanda Bellotti Formiga
- Department of Colorectal Surgery, Heliopolis Hospital, São Paulo, Brazil
- Department of Colorectal Surgery, Medical Science College of Santa Casa de São Paulo, São Paulo, Brazil
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Yue Y, Zhang X, Qu Y, Zhao X, Ding F, Li J, Zheng B. Effectiveness of anastomotic reinforcement sutures in reducing anastomotic leakage risk after laparoscopic rectal cancer surgery: a pooled and integration analysis. Front Oncol 2024; 14:1337870. [PMID: 38894871 PMCID: PMC11183793 DOI: 10.3389/fonc.2024.1337870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/16/2024] [Indexed: 06/21/2024] Open
Abstract
Background and objectives Anastomotic leakage (AL) is one of the most serious complications after laparoscopic anus-preserving surgery for rectal cancer, which significantly prolongs the patient's hospital stay, leads to dysfunction, and even increases the patient's perioperative morbidity and mortality, and little is known about the effectiveness of anastomotic reinforcement sutures to prevent AL. Thus, this study was conducted to evaluate the efficacy of anastomotic reinforcement sutures as a means to prevent AL during laparoscopic surgery for rectal cancer. Methods A comprehensive and systematic search was performed in the literature database by combining subject and free terms up to 10 October 2023. The overall literature included was integrated and analyzed using Stata 12.0 software and Review Manager version 5.4 software to assess the effect of anastomotic reinforcement sutures on the incidence of AL. Results A total of 2,452 patients from 14 studies were included, and an integrated analysis showed that the use of anastomotic reinforcement sutures significantly reduced the incidence of AL [odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.18-0.37; P < 0.00001; I2 = 0%]. However, the findings confirmed whether or not the anastomosis reinforced with sutures did not affect the incidence of anastomotic stenosis (OR = 0.69; 95% CI, 0.37-1.32; P = 0.27; I2 = 0%). We performed subgroup analyses of the results of the study, the randomized controlled studies (OR = 0.31; 95% CI, 0.15-0.65; P < 0.001) as well as retrospective studies (OR = 0.28; 95% CI, 0.19-0.41; P < 0.001), 3-0 sutures (OR = 0.28; 95% CI, 0.17-0.45; P < 0.001) versus 4-0 sutures (OR = 0.26; 95% CI, 0.13-0.53; P < 0.001), barbed wire sutures (OR = 0.26; 95% CI, 0.14-0.48; P < 0.001) versus non-barbed wire sutures (OR = 0.30; 95% CI, 0.20-0.46; P < 0.001), interrupted (OR = 0.30, 95% CI, 0.20-0.46; P < 0.001) versus continuous sutures (OR = 0.29, 95% CI, 0.16-0.51; P < 0.001) to the anastomosis, full-thickness suture (OR = 0.29; 95% CI, 0.16-0.51; P < 0.001) versus sutured with the seromuscular layer (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001), anastomotic sutured in one (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001) versus non-one circle (OR = 0.30; 95% CI, 0.20-0.44; P < 0.001), and reinforcing sutures to the dog-ear area (OR = 0.26; 95% CI, 0.14-0.50; P < 0.001) versus the non-dog-ear area (OR = 0.30; 95% CI, 0.20-0.45; P < 0.001), which have suggested that there is no significant difference between each other and that all of them reduce the incidence of AL. Conclusions This study provides evidence that performing reinforcement suturing of the anastomosis during laparoscopic rectal surgery significantly lowers the incidence of postoperative AL but has no significant effect on anastomotic stenosis. It is important to note that further randomized controlled studies are required to confirm this conclusion. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022368631.
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Affiliation(s)
- Yumin Yue
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Xiaolong Zhang
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Yaqi Qu
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Xu Zhao
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Fanghui Ding
- General Surgery Department, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jiang Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bobo Zheng
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an, China
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Francesco C, Serafino V. Colorectal eversion technique combined with modified single-stapled double-purse-string low colorectal anastomosis. Colorectal Dis 2024; 26:772-775. [PMID: 38372032 DOI: 10.1111/codi.16907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 02/20/2024]
Abstract
AIM Total mesorectal excision with adequate free margins is the gold standard for rectal surgery. Applying a linear stapler in a narrow pelvis can be challenging and the proper distal margin difficult to assess. In selected cases the colorectal eversion technique combined with single-stapled double-purse-string anastomosis (SSDP) can be a practical solution. METHOD Eleven patients, six men and five women, mean body mass index 27 ± 1.3 kg/m2, underwent total mesorectal excision with the colorectal eversion technique combined with modified SSDP between September 2022 and January 2023. RESULTS The mean operative time was 190 min. The mean hospital stay was 4 days. There were no postoperative complications. The final histology showed complete mesorectal resection, circumferential resection margin negative, free distal resection margin, anastomotic doughnuts negative. At 7 ± 3 months follow-up there was no evidence of local recurrence or distant metastasis. CONCLUSION The colorectal eversion technique combined with modified SSDP is a reproducible and safe technique in selected patients. Prospective randomized trials with large patient series are needed to confirm our preliminary results.
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Affiliation(s)
- Crafa Francesco
- Oncological, General and Robotic Surgery Unit, S. Giuseppe Moscati Hospital, Avellino, Italy
| | - Vanella Serafino
- Oncological, General and Robotic Surgery Unit, S. Giuseppe Moscati Hospital, Avellino, Italy
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Fahmy Y, Trabia MB, Ward B, Gallup L, Froehlich M. Development of an Anisotropic Hyperelastic Material Model for Porcine Colorectal Tissues. Bioengineering (Basel) 2024; 11:64. [PMID: 38247941 PMCID: PMC10813287 DOI: 10.3390/bioengineering11010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/01/2024] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Many colonic surgeries include colorectal anastomoses whose leaks may be life-threatening, affecting thousands of patients annually. Various studies propose that mechanical interaction between the staples and neighboring tissues may play an important role in anastomotic leakage. Therefore, understanding the mechanical behavior of colorectal tissue is essential to characterizing the reasons for this type of failure. So far, experimental data characterizing the mechanical properties of colorectal tissue have been few and inconsistent, which has significantly limited understanding their behavior. This research proposes an approach to developing an anisotropic hyperelastic material model for colorectal tissues based on uniaxial testing of freshly harvested porcine specimens, which were collected from several age- and weight-matched pigs. The specimens were extracted from the same colon tract of each pig along their circumferential and longitudinal orientations. We propose a constitutive model combining Yeoh isotropic hyperelastic material with fibers oriented in two directions to account for the hyperelastic and anisotropic nature of colorectal tissues. Experimental data were used to accurately determine the model's coefficients (circumferential, R2 = 0.9968; longitudinal, R2 = 0.9675). The results show that the proposed model can be incorporated into a finite element model that can simulate procedures such as colorectal anastomoses reliably.
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Affiliation(s)
- Youssef Fahmy
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Mohamed B. Trabia
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Brian Ward
- Department of Surgery, Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV 89154, USA; (B.W.); (M.F.)
| | - Lucas Gallup
- Department of Mechanical Engineering, Howard R. Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA; (Y.F.); (L.G.)
| | - Mary Froehlich
- Department of Surgery, Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas, NV 89154, USA; (B.W.); (M.F.)
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Elsayed MI. Tube Stoma for the Management of Ileocolic Anastomotic Leak in a Patient With Metastatic Colon Cancer. Cureus 2024; 16:e52314. [PMID: 38357040 PMCID: PMC10866551 DOI: 10.7759/cureus.52314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
This case involves a 53-year-old male who was diagnosed with stenotic ascending colon cancer and peritoneal metastatic deposits. He was initially planned for cytoreductive surgery and heated intraperitoneal chemotherapy (CRS and HIPEC), along with resection of the primary tumor in the form of right hemicolectomy. Intraoperatively, the disease was found to be more extensive than anticipated. Consequently, the plan was modified to include debulking right hemicolectomy with hand-sewn ileocolic anastomosis and extensive peritoneal procedures. Postoperatively, he experienced an anastomotic leak, leading to another laparotomy. However, due to anatomical challenges, creating a stoma was considered unsafe. Therefore, innovative interventions were performed, including controlling the anastomotic defect with a 30Fr Foley catheter without disrupting the anastomosis. A collaborative effort from various medical teams facilitated the patient's discharge home after an extended stay in the critical care unit (CCU).
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Chiarello MM, Fico V, Brisinda G. Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes: a prospective non-randomized controlled trial. Updates Surg 2023; 75:2413-2415. [PMID: 37792274 DOI: 10.1007/s13304-023-01662-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/23/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Azienda Sanitaria Provinciale Cosenza, 87100, Cosenza, Italy
| | - Valeria Fico
- Department of Medical and Surgical Sciences, Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Facoltà di Medicina e Chirurgia, Università Cattolica S Cuore, 00168, Rome, Italy.
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Francesco C, Serafino V, Mario B, Antonio L. Colorectal eversion technique combined with modified DST (CET-M-DST) for low colorectal anastomosis after laparoscopic TME for colorectal cancer - Video correspondence. Colorectal Dis 2023; 25:2473-2474. [PMID: 37932880 DOI: 10.1111/codi.16802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/11/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Crafa Francesco
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Vanella Serafino
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Baiamonte Mario
- Oncological, General and Robotic Surgery Unit, S.Giuseppe Moscati Hospital, Avellino, Italy
| | - Longo Antonio
- European Center of Coloproctology and Pelvic Diseases, Multimedica Hospital, Milan, Italy
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12
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Liu H, Xiong M, Zeng Y, Shi Y, Pei Z, Liao C. Comparison of complications and bowel function among different reconstruction techniques after low anterior resection for rectal cancer: a systematic review and network meta-analysis. World J Surg Oncol 2023; 21:87. [PMID: 36899350 PMCID: PMC9999608 DOI: 10.1186/s12957-023-02977-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Anastomosis for gastrointestinal reconstruction has been contentious after low anterior resection of rectal cancer for the past 30 years. Despite the abundance of randomized controlled trials (RCTs) on colon J-pouch (CJP), straight colorectal anastomosis (SCA), transverse coloplast (TCP), and side-to-end anastomosis (SEA), most studies are small and lack reliable clinical evidence. We conducted a systematic review and network meta-analysis to evaluate the effects of the four anastomoses on postoperative complications, bowel function, and quality of life in rectal cancer. METHODS We assessed the safety and efficacy of CJP, SCA, TCP, and SEA in adult patients with rectal cancer after surgery by searching the Cochrane Library, Embase, and PubMed databases to collect RCTs from the date of establishment to May 20, 2022. Anastomotic leakage and defecation frequency were the main outcome indicators. We pooled data through a random effects model in a Bayesian framework and assessed model inconsistency using the deviance information criterion (DIC) and node-splitting method and inter-study heterogeneity using the I-squared statistics (I2). The interventions were ranked according to the surface under the cumulative ranking curve (SUCRA) to compare each outcome indicator. RESULTS Of the 474 studies initially evaluated, 29 were eligible RCTs comprising 2631 patients. Among the four anastomoses, the SEA group had the lowest incidence of anastomotic leakage, ranking first (SUCRASEA = 0.982), followed by the CJP group (SUCRACJP = 0.628). The defecation frequency in the SEA group was comparable to those in the CJP and TCP groups at 3, 6, 12, and 24 months postoperatively. In comparison, the defecation frequency in the SCA group 12 months after surgery all ranked fourth. No statistically significant differences were found among the four anastomoses in terms of anastomotic stricture, reoperation, postoperative mortality within 30 days, fecal urgency, incomplete defecation, use of antidiarrheal medication, or quality of life. CONCLUSIONS This study demonstrated that SEA had the lowest risk of complications, comparable bowel function, and quality of life compared to the CJP and TCP, but further research is required to determine its long-term consequences. Furthermore, we should be aware that SCA is associated with a high defecation frequency.
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Affiliation(s)
- Huabing Liu
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Ming Xiong
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yu Zeng
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yabo Shi
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Zhihui Pei
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Chuanwen Liao
- Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China.
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13
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Lu W, Huang S, Ye H, Xiang S, Zeng X. Application of laparoscopic modified Bacon operation in patients with low rectal cancer and analysis of the changes in anal function: A retrospective single-center study. Front Oncol 2023; 13:1087642. [PMID: 36798824 PMCID: PMC9928179 DOI: 10.3389/fonc.2023.1087642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/16/2023] [Indexed: 02/03/2023] Open
Abstract
Purpose To investigate the value of modified Bacon operation in patients with low rectal cancer. Methods Retrospective analysis of 60 patients treated with laparoscopic surgery for low rectal cancer in the Department of Colorectal and Anal Surgery, Jingzhou Hospital affiliated to Yangtze University, from 2019 to 2022, divided into observation and control groups based on the method of the operation (laparoscopic modified Bacon operation group and laparoscopic Dixon operation with prophylactic ileostomy group). We compared the variations between the two groups. Results The length of the abdominal surgical incision was shorter in the observation group than in the control group(P<0.05). In the observation group, the length of hospital stay after the first operation was shorter(P<0.05), the both operations time and the second intraoperative bleeding were less(P<0.05), the DET score at one week after the first operation and the VAS after both operations were fewer than in the control group(P<0.05), the postoperative rate of ischemic necrosis of the exposed bowel was higher(P<0.05), and the anal function was poorer in the short term after the second operation compared with the control group(P<0.05), but there was no significant difference between the anal function at 6 months after the second operation compared with the control group(P>0.05).12 months after the second operation, the anal function has recovered to the preoperative level in the observation group(P>0.05). Conclusion The laparoscopic modified Bacon operation has smaller abdominal wounds, which reduces postoperative pain; it does not require the use of staplers, which reduces the patient's financial burden; no postoperative anastomotic leakage occurs, and a more satisfactory anal function can be obtained.
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Affiliation(s)
- Wei Lu
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Shujuan Huang
- Department of Respiratory and Critical Care Medicine, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Hui Ye
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China,*Correspondence: Hui Ye,
| | - Shang Xiang
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Xiangsheng Zeng
- Department of Colorectal and Anal Surgery, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
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14
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Johnston WF. Coloanal Anastomosis. Clin Colon Rectal Surg 2023; 36:29-36. [PMID: 36619278 PMCID: PMC9815906 DOI: 10.1055/s-0042-1757563] [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: 01/11/2023]
Abstract
The furthest extent of restorative proctectomy involves a colon to anal anastomosis in the deep pelvis. While the anastomosis can be challenging, it can allow the patient to avoid a permanent ostomy. Patient and surgeon preparation can improve patient outcomes. This article will describe the options, technical challenges, and anecdotal tips for coloanal anastomosis.
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15
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Brisinda G, Chiarello MM, Pepe G, Cariati M, Fico V, Mirco P, Bianchi V. Anastomotic leakage in rectal cancer surgery: Retrospective analysis of risk factors. World J Clin Cases 2022; 10:13321-13336. [PMID: 36683625 PMCID: PMC9850997 DOI: 10.12998/wjcc.v10.i36.13321] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after restorative surgery for rectal cancer (RC) is associated with significant morbidity and mortality.
AIM To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.
METHODS To identify risk factors for AL, a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed. Clinical, demographic and operative features, intraoperative outcomes and oncological characteristics were evaluated.
RESULTS The incidence of AL was 10.4%, with a mean time interval of 6.2 ± 2.1 d. Overall mortality was 0.8%. Mortality was higher in patients with AL (4.9%) than in patients without leak (0.4%, P = 0.009). Poor bowel preparation, blood transfusion, median age, prognostic nutritional index < 40 points, tumor diameter and intraoperative blood loss were identified as risk factors for AL. Location of anastomosis, number of stapler cartridges used to divide the rectum, diameter of circular stapler, level of vascular section, T and N status and stage of disease were also correlated to AL in our patients. The diverting ileostomy did not reduce the leak rate, while the use of the transanastomic tube significantly did.
CONCLUSION Clinical, surgical and pathological factors are associated with an increased risk of AL. It adversely affects the morbidity and mortality of RC patients.
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Affiliation(s)
- Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica S Cuore, Rome 00168, Italy
| | | | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Paolo Mirco
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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16
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Machowicz J, Wołkowski M, Jabłońska B, Mrowiec S. Ileocolonic anastomosis-comparison of different surgical techniques: A single-center study. Medicine (Baltimore) 2022; 101:e31582. [PMID: 36595875 PMCID: PMC9794342 DOI: 10.1097/md.0000000000031582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 10/07/2022] [Indexed: 12/29/2022] Open
Abstract
Right hemicolectomy (RH) is a common procedure for both benign and malignant colic disease. Different anastomotic types are performed during this procedure. To assess the association between anastomotic type and postoperative complications (PC) in patients undergoing RH. Retrospective analysis of medical records of 72 patients (39 female and 33 male), aged 24 to 93, undergoing open RH in the Department of Gastrointestinal Surgery. Data regarding anastomotic type [end-to-end anastomosis, side-to-side (SSA), end-to-side anastomosis, and side-to-end anastomosis (SEA)], and different clinical factors were collected. There were 21 (29%) end-to-end anastomosis, 25 (35%) SSA, 15 (21%) end-to-side anastomosis, and 11 (15%) SEA in the analyzed group. Adenocarcinoma G2 was the most frequent indication for RH - 30 (42%). Total duration of hospitalization (in days) was the longest (14, 26) after SEA and the shortest (12, 68) after SSA. PC were noted in 17(24%) patients. Wound infection was the most common complication noted in 15(21%) patients. The overall anastomotic leak rate was 7% (5/72). PC were the most frequent after SEA noted in 64% (7/11) including abdominal bleeding and bowel perforation. The overall reoperations rate was 6% (4/72). The overall mortality rate was 4% (3/72). SEA was associated with the highest incidence of postoperative complication however based on this and other studies there are no satisfying conclusions regarding the best choice of anastomosis.
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Affiliation(s)
- Joanna Machowicz
- Student Scientific Society, Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Maciej Wołkowski
- Student Scientific Society, Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Beata Jabłońska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
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Gaidarski III AA, Ferrara M. The Colorectal Anastomosis: A Timeless Challenge. Clin Colon Rectal Surg 2022; 36:11-28. [PMID: 36619283 PMCID: PMC9815911 DOI: 10.1055/s-0042-1756510] [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: 12/14/2022]
Abstract
Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.
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Affiliation(s)
| | - Marco Ferrara
- Colon and Rectal Clinic of Orlando, Orlando, Florida,Address for correspondence Marco Ferrara, MD Colon and Rectal Clinic of Orlando110 West Underwood ST, Suite A, Orlando, FL 32806
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18
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Pontrelli G, Huscher C, Scioscia M, Brusca F, Tedeschi U, Greco P, Mancarella M, Biglia N, Novara L. End-to-end versus side-to-end anastomosis after bowel resection for deep infiltrating endometriosis: A retrospective study. J Gynecol Obstet Hum Reprod 2022; 51:102472. [DOI: 10.1016/j.jogoh.2022.102472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022]
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19
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Vanella S, Bottazzi EC, Farese G, Murano R, Noviello A, Palma T, Godas M, Crafa F. Minimally invasive colorectal surgery learning curve. World J Gastrointest Endosc 2022; 14:731-736. [PMID: 36438877 PMCID: PMC9693684 DOI: 10.4253/wjge.v14.i11.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2022] Open
Abstract
The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.
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Affiliation(s)
- Serafino Vanella
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Enrico Coppola Bottazzi
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Giancarlo Farese
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Rosa Murano
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Adele Noviello
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Tommaso Palma
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Maria Godas
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
| | - Francesco Crafa
- Department of General and Oncology Surgery, A.O.R.N. San Giuseppe Moscati, Avellino 83100, Italy
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20
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Chen ZZ, Huang W, Chai NH, Qiu YH, Wei ZQ. A novel colorectal anastomotic method in natural orifice specimen extraction surgery for colorectal cancer. Surg Today 2022; 52:1202-1211. [PMID: 35546641 DOI: 10.1007/s00595-022-02519-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
PURPOSE We introduced a novel colorectal anastomotic technique, double-angle anastomosis combined with the double stapling technique (DAA-DST), to simplify the anastomosis step during natural orifice specimen extraction surgery (NOSES) and compared its safety and effectiveness with purse string anastomosis combined with the double stapling technique (PSA-DST). METHODS Between January 2018 and March 2021, 63 patients with colorectal cancer underwent NOSES with DAA-DST or PSA-DST. We compared the perioperative and oncological outcomes between the groups. RESULTS There were no significant differences in the operation time, blood loss, time to first passage of flatus and excrement or hospital stay duration between PSA-DST and DAA-DST groups. The overall postoperative complication rates were similar (DAA-DST vs PSA-DST, 21.2% vs 26.7%, p = 0.78), including the rate of anastomotic leakage (6.1% vs 10%, p = 0.91). The rate of successful DAA-DST was higher than that of PSA-DST (100% vs 93.3%). The DAA-DST group had a lower rate of positive drain fluid culture than the PSA-DST group (18.2% vs 26.7% p = 0.61). Recurrence (3.01% vs 6.67%, p = 0.93) and metastasis rates (6.06% vs 6.67%, p = 0.98) were similar between the groups. CONCLUSION DAA-DST is a safe and effective procedure and can simplify the procedure of NOSES.
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Affiliation(s)
- Zhen-Zhou Chen
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, No.1 You-yi Road, Yu-zhong District, Chongqing, 400000, China
| | - Wang Huang
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Ning-Hui Chai
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, No.1 You-yi Road, Yu-zhong District, Chongqing, 400000, China
| | - Yu-Hao Qiu
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, No.1 You-yi Road, Yu-zhong District, Chongqing, 400000, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, No.1 You-yi Road, Yu-zhong District, Chongqing, 400000, China.
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21
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Chiarello MM, Bianchi V, Fransvea P, Brisinda G. Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery. World J Gastroenterol 2022; 28:3747-3752. [PMID: 36161042 PMCID: PMC9372806 DOI: 10.3748/wjg.v28.i28.3747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/13/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage (AL) has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure. An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication. Despite AL continues to be a dreadful compli-cation after colorectal surgery, there has been no consensus on its management. However, based on patient’s presentation and timing of the AL, there has been a gradual shift to a more conservative management, keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak. A nonoperative management is usually preferred in these patients. There are several treatment options, also for patients without a stoma who do not require a reoperation for a contained pelvic leak, including recently developed endoscopic procedures, such as clip placement or endoluminal vacuum-assisted therapy. More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.
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Affiliation(s)
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, taly
| | - Giuseppe Brisinda
- Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
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22
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Mazaki J, Katsumata K, Udo R, Tago T, Kasahara K, Kuwabara H, Enomoto M, Ishizaki T, Nagakawa Y, Tsuchida A. Comparison of pressure resistance of double-rows and triple-rows circular stapler in rectal double stapling technique: In vitro study. Medicine (Baltimore) 2022; 101:e29600. [PMID: 35839009 PMCID: PMC11132375 DOI: 10.1097/md.0000000000029600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 05/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Anastomotic leak after gastrointestinal anastomosis is a serious complication. Anastomotic failure depends on various parameters. The aim of our study was to evaluate the pressure resistance of a new device, EEA™ circular stapler with Tri-Staple™ technology 28 mm Medium/Thick (Triple-rows circular stapler; TCS) compared with EEA™ circular stapler with DST series™ technology 28 mm, 4.8 mm staples (double-rows circular stapler; DCS). PATIENTS AND METHODS We performed 30 anastomoses (DSC: 15, TCS: 15) of DST with porcine colon model in vitro. We performed following 3 comparative experiences; Experiment 1: observation of staple shape with a colonoscopy, Experiment 2: comparison of the pressure resistance, Experiment 3: comparison of leakage points. RESULTS There was no hypoplasia of staples and the shapes were well-formed by colonoscopy. The leakage pressure of DCS was 19.6 ± 4.4 mm Hg (mean ± standard deviation) and that of TCS was 38.6 ± 10.2 mm Hg (mean ± standard deviation). There was a significantly difference between 2 groups (P < .001). 12 cases of DCS (80%) and 10 cases of TCS (66.7%) had leakages from Circular stapler point. 2 cases of DCS (13.3%) and 5 cases of TCS (33.3%) had leakages from Crossing points. Only 1 case of DCS had leakages from Dog ear point (6.7%). There was no significantly difference in leakage site between 2 groups (P = .195). CONCLUSIONS TSC showed high pressure resistance during DST compared with that of DCS. It was suggested that TCS may contribute to the reduction of anastomotic leakage rate.
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Affiliation(s)
- Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Kuwabara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masanobu Enomoto
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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23
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Habeeb TAAM, Mohammad H, Wasefy T, Mansour MI. Outcomes of side-to-end versus end-to-end colorectal anastomosis in non-emergent sigmoid and rectal cancers: randomized controlled clinical trial. Ann Coloproctol 2022:ac.2021.00906.0129. [PMID: 35272448 DOI: 10.3393/ac.2021.00906.0129] [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: 10/14/2021] [Accepted: 12/17/2021] [Indexed: 10/18/2022] Open
Abstract
Purpose The outcomes of open colorectal anastomosis of side-to-end vs. end-to-end in non-emergent sigmoid and rectal cancer surgery in adults were compared. Methods A randomized controlled trial on individuals with sigmoid and rectal cancers was conducted between September 2016 and September 2018. Results The mean age was 62.58±12.3 years in the side-to-end anastomotic (SEA) group and 61.03±13.98 years in the end-to-end anastomotic (EEA) group. Except for the operative time, intraoperative data revealed no significant differences between the studied groups, and the SEA group revealed that the mean anastomotic time was significantly shorter. Perioperative blood loss, length of stay, reoperation, inpatient death, infection, and bleeding were significantly associated with leakage. There is a statistically significant change regarding the range of bowel frequency in the EEA group only (P=0.04). There is a statistically significant difference regarding incontinence for flatus in the SEA group only (P≤0.001). A statistically significant change in both groups regards incontinence for liquid stools (P≤0.001) and clustering of stools (P≤0.001 and P=0.043). The quality of life in the SEA group significantly dropped at 6 months and then returned to baseline as regards to physical well-being (PWB), functional well-being (FWB), and colorectal cancer symptoms (CCS) with no difference as regards SWB and EWB, while in the EEA group, the exact change happened only as regard PWB and FWB, but SWB and CCS percentage did not return to baseline. Conclusion The SEA group offers a safe alternative approach to the EEA group.
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Affiliation(s)
- Tamer A A M Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hatem Mohammad
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Tamer Wasefy
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Chiarello MM, Fransvea P, Cariati M, Adams NJ, Bianchi V, Brisinda G. Anastomotic leakage in colorectal cancer surgery. Surg Oncol 2022; 40:101708. [PMID: 35092916 DOI: 10.1016/j.suronc.2022.101708] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/05/2023]
Abstract
The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.
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Affiliation(s)
| | - Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Maria Cariati
- Department of Surgery, General Surgery Unit, "San Giovanni di Dio" Hospital, Crotone, Italy
| | - Neill James Adams
- Department of Health Sciences, Clinical Microbiology Unit, "Magna Grecia" University, Catanzaro, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giuseppe Brisinda
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
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Anastomosis-Related Complications After Stapled Anastomosis With Reinforced Sutures in Transanal Total Mesorectal Excision for Low Rectal Cancer: A Retrospective Single-Center Study. Dis Colon Rectum 2022; 65:246-253. [PMID: 34657080 DOI: 10.1097/dcr.0000000000002016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The International Transanal Total Mesorectal Excision Registry group showed that transanal total mesorectal excision included clinical issues regarding anastomosis-related complications. OBJECTIVE This study evaluated anastomotic complications in patients whose anastomoses were created with the stapler plus reinforced sutures procedure after transanal total mesorectal excision for low rectal cancer. DESIGN This was a retrospective single-center study. SETTING The study was conducted at the National Cancer Center Hospital East, Japan. PATIENTS Between June 2016 and December 2019, 150 patients underwent transanal total mesorectal excision for low rectal cancer. Stapled anastomosis was performed for 55 patients, and coloanal handsewn anastomosis was performed for 95 patients. Blood perfusion of the colon was routinely evaluated with intraoperative indocyanine green fluorescence angiography. All patients who underwent stapled anastomosis received additional handsewn sutures on all rounds of the stapled line. Patients who underwent intersphincteric resection were excluded. MAIN OUTCOME MEASURES The anastomosis-related complications were compared between the groups. RESULTS Early anastomotic leakage was found in one (1.8%) and eight (8.4%) patients in the stapled group and handsewn group. Overall anastomosis-related complications, pelvic abscess, and anastomotic stenosis were significantly less frequent in the stapled group (p < 0.001, p < 0.048, and p < 0.032). Incomplete donuts after the stapled anastomosis were observed in 9 patients (16.4%); however, we reinforced all around the stapled line in these patients, and this reduced the subsequent occurrence of anastomotic leakage. LIMITATIONS First, this was a retrospective single-center study that was not randomized or controlled. Second, there were chronological differences regarding the anastomotic method between the two groups. Third, our study included a relatively small number of patients who received preoperative chemoradiotherapy. CONCLUSIONS Stapled anastomosis with reinforced handsewn sutures resulted in fewer anastomosis-related complications than did coloanal handsewn anastomosis after transanal total mesorectal excision for low rectal cancer; thus, the former may be superior and should be the preferred method, when technically possible. See Video Abstract at http://links.lww.com/DCR/B749.COMPLICACIONES RELACIONADAS CON LAS ANASTOMOSIS ENGRAMPADAS Y REFORZADAS CON SUTURAS EN LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER DE RECTO BAJO: ESTUDIO RETROSPECTIVO UNICÉNTRICO. ANTECEDENTES El grupo del Registro Internacional de Excisión Total del Mesorrecto por vía Transanal mostró que la excisión total mesorrectal transanal incluía problemas clínicos relacionados a las complicaciones involucradas con la anastomosis. OBJETIVO Se evaluaron las complicaciones anastomóticas en pacientes cuyas anastomosis se realizaron con engrampadora reforzada de suturas después de la excisión total de l mesorrecto por vía transanal en casos de cáncer de recto bajo. DISEO Estudio retrospectivo unicéntrico. AJUSTE El Hospital del Centro Nacional del Cáncer del Este, Japón. PACIENTES Entre junio de 2016 y diciembre de 2019, 150 pacientes se sometieron a excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo. Se realizó anastomosis con engrampadora en 55 y anastomosis coloanal suturada a mano en 95 pacientes. La perfusión tisular sanguínea del colon operado se evaluó de forma rutinaria con angiografía de fluorescencia con verde de indocianina intraoperatoria. Todos los pacientes que se sometieron a anastomosis con grapas recibieron suturas realizadas a mano adicionales sobre la totalidad de la línea de grapas. Se excluyeron los pacientes sometidos a resección interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO Las complicaciones relacionadas con la anastomosis se compararon entre los grupos. RESULTADOS Se encontró fuga anastomótica temprana en 1 (1.8%) y 8 (8.4%) pacientes en el grupo de engrampado y en el grupo suturado a mano, respectivamente. En general, las complicaciones relacionadas con la anastomosis, el absceso pélvico y la estenosis anastomótica fueron significativamente menos frecuentes en el grupo con grapas (p < 0.001, p < 0.048, p < 0.032, respectivamente). Se observaron donas incompletas después de la anastomosis grapada en 9 pacientes (16,4%); sin embargo, reforzamos todo alrededor de la línea de grapas en estos pacientes, y esto redujo la aparición posterior de fugas anastomóticas. LIMITACIONES Inicialmente, este fue un estudio retrospectivo de un solo centro que no fue aleatorizado ni controlado. En segundo lugar, hubo diferencias cronológicas con respecto al método anastomótico entre los dos grupos. En tercer lugar, nuestro estudio incluyó un número relativamente pequeño de pacientes que recibieron quimiorradioterapia preoperatoria. CONCLUSIONES La anastomosis engrapada reforzada con suturas realizadas a mano dio como resultado menos complicaciones relacionadas con la anastomosis que la anastomosis coloanal suturada a mano después de la excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo; por tanto, el primero puede ser superior y debería ser el método preferido, cuando sea técnicamente posible. Consulte Video Resumen en http://links.lww.com/DCR/B749. (Traducción-Dr. Xavier Delgadillo).
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Gray M, Marland JRK, Murray AF, Argyle DJ, Potter MA. Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients. J Pers Med 2021; 11:471. [PMID: 34070593 PMCID: PMC8229046 DOI: 10.3390/jpm11060471] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.
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Affiliation(s)
- Mark Gray
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Jamie R. K. Marland
- School of Engineering, Institute for Integrated Micro and Nano Systems, University of Edinburgh, Scottish Microelectronics Centre, King’s Buildings, Edinburgh EH9 3FF, UK;
| | - Alan F. Murray
- School of Engineering, Institute for Bioengineering, University of Edinburgh, Faraday Building, The King’s Buildings, Edinburgh EH9 3DW, UK;
| | - David J. Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Roslin, Midlothian, Edinburgh EH25 9RG, UK;
| | - Mark A. Potter
- Department of Surgery, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;
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Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes. Updates Surg 2021; 73:2137-2143. [PMID: 33993462 DOI: 10.1007/s13304-021-01061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).
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Colorectal resection in emergency general surgery: An EAST multicenter trial. J Trauma Acute Care Surg 2021; 89:1023-1031. [PMID: 32890337 DOI: 10.1097/ta.0000000000002894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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McKechnie T, Sharma S, Daniel R, Eskicioglu C. End-to-end versus end-to-side anastomosis for low anterior resection: A systematic review and meta-analysis of randomized controlled trials. Surgery 2021; 170:397-404. [PMID: 33541747 DOI: 10.1016/j.surg.2020.12.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Numerous randomized controlled trials comparing end-to-end and end-to-side anastomoses after low anterior resection have been performed. Rates of anastomotic leakage and overall postoperative morbidity, as well as reported quality of postoperative bowel function, vary across individual studies. As such, this study meta-analyzes pooled data comparing end-to-end and end-to-side anastomosis after low anterior resection in terms of anastomotic leak rate and postoperative bowel function. METHODS A search of Medline, EMBASE, and Cochrane Central Register of Controlled Trials was performed. Articles were included if they were randomized controlled trials that compared end-to-end and end-to-side anastomosis after low anterior resection for benign or malignant disease. The primary outcome was anastomotic leak rate. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS From 1,452 citations, 6 randomized controlled trials with 270 patients undergoing end-to-end anastomosis (45.9% female, mean age: 63.5 years) and 268 patients undergoing end-to-side anastomosis (52.4% female, mean age: 64.0 years) met inclusion criteria. Patients undergoing end-to-side anastomosis had a significantly lower rate of anastomotic leak (RR 0.37, 95% CI 0.15-0.93, P = .04, I2=0%). There were no differences in rate of anastomotic stenosis (RR 1.03, 95% CI 0.21-5.19, P = .97) or overall postoperative morbidity (RR 0.60, 95% CI 0.33-1.07, P = .08). Narrative review of postoperative bowel function demonstrated evidence of improved Wexner scores for 6 months postoperatively in patients undergoing end-to-side anastomosis. CONCLUSION End-to-side anastomosis significantly reduces the risk of anastomotic leak after low anterior resection. Additional prospective trials are warranted to confirm the findings of this review and to contribute to the growing evidence-base aimed at optimization of bowel function after low anterior resection.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. https://twitter.com/tylermckechnie
| | - Sahil Sharma
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada. https://twitter.com/SharmaS_14
| | - Ryan Daniel
- University of Toronto, Temerty Faculty of Medicine, Toronto, ON, Canada. https://twitter.com/ryandaniel82
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, ON, Canada.
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Colorectal anastomosis during cytoreductive radical surgery in patients with peritoneal surface malignancies. Validation of a new technique (without stoma) to prevent anastomosis leakage in more than 1000 procedures. Clin Transl Oncol 2021; 23:1201-1209. [PMID: 33393053 DOI: 10.1007/s12094-020-02511-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/03/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To describe a novel end-to-end "true" reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer. METHODS Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were: (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) "cleaning" the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed. RESULTS According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis. Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%. CONCLUSIONS A technical modification to create a "true" end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.
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Planellas P, Farrés R, Cornejo L, Rodríguez-Hermosa JI, Pigem A, Timoteo A, Ortega N, Codina-Cazador A. Randomized clinical trial comparing side to end vs end to end techniques for colorectal anastomosis. Int J Surg 2020; 83:220-229. [PMID: 33038521 DOI: 10.1016/j.ijsu.2020.09.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Low anterior resection syndrome affects 60%-90% of patients with anastomoses after colorectal resection. Consensus regarding the best anastomosis is lacking. OBJECTIVE To compare outcomes after end-to-end versus side-to-end anastomoses. DESIGN Randomized clinical trial. SETTINGS University hospital (April 2016-October 2017). PATIENTS Patients aged ≥18 years with rectal or sigmoid adenocarcinoma. INTERVENTIONS Patients were randomized to undergo mechanical end-to-end or side-to-end (n = 33) anastomosis after laparoscopic resection. MAIN OUTCOME MEASURES Primary outcome was to assess intestinal function (COREFO and LARS questionnaires) 12 months after surgery or ileostomy closure. Secondary outcomes were postoperative complications and intestinal function and quality of life (SF-36® questionnaire) at different time points after surgery or ileostomy closure. RESULTS No significant differences in intestinal function were observed between the two groups 12 months after surgery. Subanalysis of low-mid rectum tumors with end-to-end anastomosis yielded better function at 12 months. Postoperative complications did not differ between the two groups (p = 0.070), but reinterventions were more common in the side-to-end group (p = 0.040). Multivariate analysis found neoadjuvant treatment was independently associated with intestinal dysfunction at 12 months (β = 0.41, p = 0.033, COREFO; β = 0.41, p = 0.024, LARS). CONCLUSIONS End-to-end anastomosis yielded low rates of severe complications and reintervention, as well as better intestinal function at 12 months in the subgroup with tumors in the low-mid rectum. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02746224.
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Affiliation(s)
- Pere Planellas
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain.
| | - Ramon Farrés
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Lídia Cornejo
- Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Jose Ignacio Rodríguez-Hermosa
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Anna Pigem
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Ander Timoteo
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Núria Ortega
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Antoni Codina-Cazador
- Department of Surgery, Dr Josep Trueta University Hospital, Girona, Spain; Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI), Girona, Spain
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Li XK, Xu Y, Cong ZZ, Luo J, Zhou H, Ji SG, Diao YF, Wu WJ, Qiang Y, Qian JJ, Shen Y. Modified Collard versus end-to-side hand-sewn anastomosis for cervical anastomosis after McKeown esophagectomy. Thorac Cancer 2020; 11:2909-2915. [PMID: 32833352 PMCID: PMC7529547 DOI: 10.1111/1759-7714.13630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background According to previously published studies, esophagectomy with modified Collard anastomosis has been reported to have low incidences of anastomotic leak and stricture. However, the optional anastomotic method after esophagectomy is still controversial. We conducted this study to compare the incidence of postoperative anastomotic stricture formation and dysphagia over three years after an esophagectomy with modified Collard anastomosis (MC) or end‐to‐side (ETS) hand‐sewn anastomosis. Meanwhile, the early postoperative anastomotic leakage and other complications, hospital stay and 30‐ and 90‐day mortality were also evaluated. Methods The clinical data of 905 patients undergoing McKeown esophagectomy were retrospectively reviewed. The rate of postoperative stricture formation after three years was demonstrated by stricture‐free survival which is the primary end‐point of this study. The incidence of dysphagia, first time of onset of stricture and number of dilatations were also recorded during follow‐up. Results The incidence of anastomotic leak tended to be higher in the MC group compared with that in the ETS group (13.0% vs. 8.7%, P = 0.064). The rates of anastomotic stricture in the MC group were significantly less than in the ETS group (P = 0.004). The number of dilatations in the MC group were significantly greater than those in the ETS group (2.34 vs. 2.46, P = 0.011). Conclusions A modified Collard cervical esophagogastric anastomosis was associated with lower rates of anastomotic stricture and dysphagia, compared with ETS hand‐sewn anastomosis. However, the modified Collard anastomosis is accompanied by an increased anastomotic leakage rate.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Hai Zhou
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Sai-Guang Ji
- Department of Thoracic Surgery, Nanjing Second Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jian-Jun Qian
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
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Pirhan Y, Gök K, Gök A. Comparison of two different bowel anastomosis types using finite volume method. Comput Methods Biomech Biomed Engin 2020; 23:323-331. [PMID: 32009459 DOI: 10.1080/10255842.2020.1722809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The purpose of this study was to compare side-to-side and functional end-to-end anastomosis techniques that are commonly used in bowel surgery. Considering the dimensions of these two different anastomosis models, SolidWorks program was used for 3 D studies. Intra-intestinal flow analyzes were performed based on the finite volume method using Ansys Fluent, a computational fluid Dynamics (CFD) program. The flow velocity, pressure, turbulent knetic energy, turbulence vortex distribution, vortex viscosity and wall shear stresses for each model were calculated in results of the analysis for the side-to-side and functional end-to-end anastomosis technique. Due to the geometrical structure of the functional end - to - end anastomosis model, turbulence and hence the vortex formation is less than the side - to - side anastomosis technique. Because intersect area of bowels has wider in functional end - to - end anastomosis model, flow become easier than other. In surgical practice, functional end-to-end anastomosis is preferred over side-to-side anastomosis because of the low probability of leakage. It can be noted that the functional end - to - end anastomosis technique will be safer because of less turbulence, based on the data of fluid flow velocities, pressure, turbulent knetic energy, turbulence vortex distribution, vortex viscosity and wall shear stresses in the anastomosis.
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Affiliation(s)
- Yavuz Pirhan
- Department of General Surgery, Sabuncuoğlu Şerefeddin Research and Training Hospital, Amasya University, Amasya, Turkey
| | - Kadir Gök
- Department of Biomedical Engineering, Engineering and Architecture Faculty, Izmir Bakircay University, Izmir, Turkey
| | - Arif Gök
- Department of Mechanical Engineering, Technology Faculty, Amasya University, Amasya, Turkey
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Better Function With a Colonic J-Pouch or a Side-to-end Anastomosis?: A Randomized Controlled Trial to Compare the Complications, Functional Outcome, and Quality of Life in Patients With Low Rectal Cancer After a J-Pouch or a Side-to-end Anastomosis. Ann Surg 2020; 269:815-826. [PMID: 30921049 DOI: 10.1097/sla.0000000000003249] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND INFORMATION We aimed to compare prospectively the complications and functional outcome of patients undergoing a J-Pouch (JP) or a side-to-end anastomosis (SE) for treatment of low rectal cancer at a 2-year time point after resection for rectal cancer. METHODS A multicenter study was conducted on patients with low rectal cancer who were randomized to receive either a JP or SE and were followed for 24 months utilizing SF-12 and FACT-C surveys to evaluate the quality of life (QOL). Fecal incontinence was evaluated using the Fecal Incontinence Severity Index (FISI). Bowel function, complications, and their treatments were recorded. RESULTS Two hundred thirty-eight patients (165 males) were randomized with 167 final eligible patients, 80 in the JP group and 87 in the SE group for evaluation. The mean age at surgery was 61 (range 29 to 82) years. The overall mean recurrence rate was 12 of 238, 5% and similar in both groups. COMPLICATIONS Overall, 37 of 190 (19%) patients reported complications, 14 of these were Clavien Dindo Grade 3b and 2 were 3a: leak 3 (2 JP,1 SE), fistula 4 (1 JP, 3 SE), small bowel obstruction 4 (3JP, 1 SE), stricture 4 (3 SE, 1 SA), pouch necrosis 2 (JP), and wound infection 5 (2 JP, 3 SE). QOL scores using either instrument between the 2 groups at 12 and 24 months were similar (P > 0.05). Bowel movements, clustering, and FISI scores were similar. CONCLUSION At time points of 1 and 2 years after a JP or a SE for low rectal cancer, QOL, functional outcome, and complications are comparable between the groups. Although choosing a particular procedure may depend on surgeon/patient choice or anatomical considerations at the time of surgery, SE functions similar to JP and may be chosen due to the ease of construction.
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Foo CC, Hung HT, Ho YC, Lam WWM, Law WL. Predicting the level of difficulty of the double-stapling technique in laparoscopic total mesorectal excision. Surg Endosc 2019; 34:3382-3387. [PMID: 31506793 DOI: 10.1007/s00464-019-07112-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The transection of rectum and fashioning of anastomosis is a crucial step in laparoscopic total mesorectal excision (TME) and the double-stapling technique (DST) is often employed. This study aimed to evaluate the factors that were associated with difficult DST. METHOD Cases of laparoscopic TME were retrospectively reviewed. The clinico-anatomical parameters were retrieved from a prospectively maintained database. In addition, pelvic dimensions were taken by reviewing the magnetic resonance imaging scan. The number of stapler cartridges used for intracorporeal transection of rectum was used as a surrogate for the level of difficulty of DST and its relationship with various parameters were evaluated. RESULTS There were a total of 121 consecutive cases analyzed. The mean number of stapler cartridges used was 2.1 ± 0.7. Pelvic inlet (p = 0.002) and tumor height (p = 0.015) were predictors of the number of cartridges used, R2 = 0.366. A model was developed to predict the likelihood of transecting the rectum with two or less stapler cartridges, which included the following parameters: gender, pelvic inlet, interspinous distance, intertuberous distance, and tumor height. The predicted probability also correlated with overall operation time (p = 0.009) and anastomotic leakage (p = 0.023). CONCLUSION The difficulty of DST was associated with patient's clinico-anatomical factors. Surgeons can consider other feasible alternatives, like transanal anastomosis, when a technically challenging DST is anticipated.
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Affiliation(s)
- Chi Chung Foo
- Department of Surgery, The University of Hong Kong, Hong Kong, China. .,Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
| | - Hing Tsun Hung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Yuen Chi Ho
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | | | - Wai Lun Law
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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Muralee M, Acharya NR, Sudham WM, Mathew AP, Cherian K, Chandramohan K, Augustine P, Ahamed MI. Triple Test-a Predictor of Anastomotic Integrity in Patients Undergoing Low Anterior Resection After Neoadjuvant Chemoradiotherapy. Indian J Surg Oncol 2017; 8:506-510. [PMID: 29203981 PMCID: PMC5705510 DOI: 10.1007/s13193-017-0676-8] [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: 08/04/2016] [Accepted: 06/27/2017] [Indexed: 11/24/2022] Open
Abstract
Anastomotic leak after low anterior resection for rectal cancer is a dreaded complication. Diversion stoma helps tiding over this crisis and it is routinely practised in most centres, especially in post chemoradiotherapy setting. But a diversion stoma has got its own problems. In this study, we attempt to use the triple test as a predictor of anastomotic integrity and thereby avoid a diverting stoma, and patients undergoing low anterior resection after neoadjuvant chemoradiotherapy were spared the trouble of a diverting stoma if the on table triple test was negative. Two hundred such consecutive patients were prospectively followed up in the postoperative period. The incidence of anastomotic leak and the factors predicting the same were analysed in this group of patients. The incidence of anastomotic leak in our study was 7%, which is much less when compared to published literature. The triple test was a reliable predictor of the integrity of anastomosis and if the test is negative, a diverting stoma can be avoided. Age more than 60 years and end-to-end anastomosis were found to be associated with increased incidence of leak, and patients with a negative triple test need not routinely undergo diversion stoma after a low anterior resection even in post chemoradiotherapy setting.
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Affiliation(s)
- Madhu Muralee
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Nithish R. Acharya
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Wagh Mira Sudham
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Arun Peter Mathew
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Kurian Cherian
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - K. Chandramohan
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - Paul Augustine
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
| | - M. Iqbal Ahamed
- Division of Surgical Oncology, Regional Cancer Centre, Trivandrum-11, Kerala India
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García-Granero E, Navarro F, Cerdán Santacruz C, Frasson M, García-Granero A, Marinello F, Flor-Lorente B, Espí A. Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients. Surgery 2017; 162:1006-1016. [PMID: 28739093 DOI: 10.1016/j.surg.2017.05.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 05/14/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection. METHODS This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak. RESULTS Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale. CONCLUSION The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.
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Affiliation(s)
- Eduardo García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Francisco Navarro
- Department of General Surgery, Colorectal Surgery Unit. Hospital de Manises, Manises, Valencia, Spain
| | - Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alvaro García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Franco Marinello
- Department of General Surgery, Colorectal Surgery Unit, Hospital Vall D´Hebrón, Barcelona, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alejandro Espí
- Department of General Surgery, Hospital Clínico Universitario, Valencia, Spain
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Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2017; 23:1195-1201. [PMID: 28410344 DOI: 10.1097/mib.0000000000001122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications. METHODS A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups. RESULTS Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNFα (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001). CONCLUSIONS Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.
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Bruns BR, Morris DS, Zielinski M, Mowery NT, Miller PR, Arnold K, Phelan HA, Murry J, Turay D, Fam J, Oh JS, Gunter OL, Enniss T, Love JD, Skarupa D, Benns M, Fathalizadeh A, Leung PS, Carrick MM, Jewett B, Sakran J, O’Meara L, Herrera AV, Chen H, Scalea TM, Diaz JJ. Stapled versus hand-sewn. J Trauma Acute Care Surg 2017; 82:435-443. [DOI: 10.1097/ta.0000000000001354] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Laparoscopy following peritoneal entry during transanal endoscopic microsurgery may increase the safety and maximize the benefits of the transanal excision. Tech Coloproctol 2016; 20:221-6. [DOI: 10.1007/s10151-016-1436-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 01/15/2016] [Indexed: 12/15/2022]
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Takeyama H, Yamamoto H, Hata T, Takahashi Y, Ohtsuka M, Nonaka R, Inoue A, Naito A, Matsumura T, Uemura M, Nishimura J, Takemasa I, Mizushima T, Doki Y, Mori M. A novel single-stapling technique for colorectal anastomosis: a pre-ligation single-stapling technique (L-SST) in a porcine model. Surg Endosc 2014; 29:2371-6. [DOI: 10.1007/s00464-014-3960-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 10/25/2014] [Indexed: 01/17/2023]
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Rubin FO, Douard R, Wind P. The Functional Outcomes of Coloanal and Low Colorectal Anastomoses with Reservoirs after Low Rectal Cancer Resections. Am Surg 2014. [DOI: 10.1177/000313481408001224] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.
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Affiliation(s)
- FranÇ Ois Rubin
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
| | - Richard Douard
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
- UFR SMBH, Paris-Nord University, Bobigny, France
| | - Philippe Wind
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
- UFR SMBH, Paris-Nord University, Bobigny, France
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Radovanovic Z, Petrovic T, Radovanovic D, Breberina M, Golubovic A, Lukic D. Single versus double stapling anastomotic technique in rectal cancer surgery. Surg Today 2013; 44:1026-31. [PMID: 23801054 DOI: 10.1007/s00595-013-0646-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/30/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE The present study was designed to investigate whether there is a difference in the anastomotic leakage rate (AL) between the single stapling (CSA) and double stapling (DSA) anastomosis techniques. METHODS One hundred consecutive rectal cancer patients who underwent rectal resection with primary anastomosis were enrolled in this study. RESULTS The overall rate of clinical anastomotic leakage in both groups was 7 % (7/100); 6 % (3/50) in the CSA group and 8 % (4/50) in the DSA group. The anastomotic technique did not have any significant influence on the rate of AL. All AL were seen in low anastomoses (7 cm and below). The rate of AL in patients with a diverting stoma (13 %, 3/23) was not significantly different from that of the patients without (5.2 %, 4/77) (p = 0.195). The mean length of the operation was significantly shorter in the DSA group compared to the CSA group, at 127 and 141 min, respectively (p = 0.005). There were significantly higher rates of AL in patients receiving preoperative long course radiotherapy (15.4 %, 6/39) compared with those who did not receive radiotherapy (1.63 %, 1/61) (p = 0.014). CONCLUSIONS The CSA and DSA techniques are equally safe for the creation of a rectal anastomosis, without any significant difference in the AL rate. However, we recommend using the DSA technique because it has other definite advantages. In cases of neoadjuvant treatment and a low anastomosis, proximal diversion is recommended.
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Affiliation(s)
- Z Radovanovic
- Department of Surgical Oncology, Oncology Institute of Vojvodina, Put dr Goldmana 4, 21204, Sremska Kamenica, Serbia,
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Tarchi P, Moretti E, de Manzini N. Reconstruction. Updates Surg 2013. [DOI: 10.1007/978-88-470-2670-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brisinda G, Vanella S, Maria G, Crocco A, Lombardi CP. Anastomotic leak and local recurrence in colorectal cancer. Ann Surg 2012; 256:e32-3; author reply e34. [PMID: 23108131 DOI: 10.1097/sla.0b013e31827693db] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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End-to-end versus end-to-side esophagogastrostomy after esophageal cancer resection: a prospective randomized study. Ann Surg 2011; 254:226-33. [PMID: 21725230 DOI: 10.1097/sla.0b013e31822676a9] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare single-layered hand-sewn cervical end-to-side (ETS) anastomosis with end-to-end (ETE) anastomosis in a prospective randomized fashion. BACKGROUND The preferred organ used for reconstruction after esophagectomy for cancer is the stomach. Previous studies attempted to define the optimal site of anastomosis and anastomotic techniques. However, anastomotic stricture formation and leakage still remain an important clinical problem. METHODS From May 2005 to September 2007, 128 patients (64 in each group) were randomized between ETE and ETS anastomosis after esophagectomy for cancer with gastric tube reconstruction. Routine contrast swallow studies and endoscopy were performed. Anastomotic stricture within 1 year, requiring dilatation, was the primary endpoint. Secondary endpoints were anastomotic leak rate and mortality. RESULTS Ninety-nine men and 29 women underwent esophagectomy and gastric tube reconstruction. Benign stenosis of the anastomosis, for which dilatation was required, occurred more often in the ETE group (40% vs. ETS 18%, P < 0.01) after 1 year of follow-up. The overall (clinical and radiological) anastomotic leak rate was lower in the ETE group (22% vs. ETS 41%, P = 0.04). Patients with an ETE anastomosis suffered less often from pneumonia; 17% versus ETS 44%, P = 0.002 and had subsequently significantly shorter in-hospital stay (15 days vs. 22 days, P = 0.02). In-hospital mortality did not differ between both groups. CONCLUSION ETS anastomosis is associated with a lower anastomotic stricture rate, compared to ETE anastomosis. However, prevention of stricture formation was at high costs with increased anastomotic leakage and longer in-hospital stay. This study is registered with the Dutch Trial Registry and carries the ID number OND1317772.
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Boccola MA, Buettner PG, Rozen WM, Siu SK, Stevenson ARL, Stitz R, Ho YH. Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients. World J Surg 2011; 35:186-95. [PMID: 20972678 DOI: 10.1007/s00268-010-0831-7] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking. METHODS Data of 1576 patients who underwent primary resection and anastomosis for colorectal adenocarcinoma at a single institution from 1984 to 2004 were prospectively collected. Anastomotic leaks (LEK) were classified as radiological (RAD), local (LOC), or generalised (GEN). Logistic regression analysis of 21 variables was undertaken. Overall survival, cancer-related survival, and disease-free survival were analysed using the Kaplan-Meier method. RESULTS Mean age of the patients was 67 years (SD = 12.5) and 834 (52.9%) were male. An LEK was more likely when relatively major gynaecological (tubo-oophorectomy, P = 0.004; hysterectomy, P = 0.006) or urological (total cystectomy, P = 0.014) procedures were performed during the same operative session. Other significant factors were anterior resection (P < 0.001), anastomosis using an intraluminal stapling device (P = 0.005), abdominal drain via laparoscopic port (P = 0.024), postoperative blood transfusion (P < 0.001), primary cancer site at the rectum (P = 0.016), and TNM stage of T2 or higher (P = 0.026). Having an LEK showed significant impact on overall (P = 0.021), cancer-related (P = 0.006), and disease-free (P = 0.001) survival. CONCLUSION In this prospective study, advanced tumour stage, distal site, and need for postoperative blood transfusion were associated with increased rates of anastomotic leakage. In addition to their high risk of immediate postoperative morbidity and mortality, both localized and generalized leaks had similarly negative impacts on overall, cancer-related, and disease-free survival.
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Affiliation(s)
- Mark A Boccola
- Discipline of Surgery, School of Medicine, James Cook University, Townsville, QLD, 4814, Australia
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Abstract
There is still controversy about the necessity of a diverting stoma after deep anterior resection with total mesorectal excision for rectal cancer. Recent results of randomized controlled trials and from systematic reviews have improved the currently available data. A significant benefit was shown for patients with diverting stoma in terms of clinically relevant anastomotic leakage and re-operation rates. The influence on mortality is not as clear. However, analysis of the data of 19 prospective studies within a systematic review including more than 9,000 patients, revealed a significant benefit for stoma creation. Furthermore, the rate of patients with stoma 5 years after primary resection was lower in the group of patients with diverting stoma. The purpose of this manuscript is to show the necessity of a diverting stoma based on the currently available data.
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Brisinda G, Vanella S, Crocco A, Maria G. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg 2010; 252:574-5; author reply 575-6. [PMID: 20739867 DOI: 10.1097/sla.0b013e3181f08099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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50
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