CT scan for early diagnosis of anastomotic leak after colorectal surgery: is rectal contrast useful?

Techniques in Coloproctology - Computed tomography (CT) scan with rectal contrast enema (RCE-CT) could increase the detection rate of anastomotic leaks (AL) in the early postoperative period...     

Colorectal anastomotic stricture: Is it associated with inadequate colonic mobilization?

Background

Anastomotic stricture or stenosis is a well-described complication of intestinal anastomosis. The incidence of stricture after colorectal anastomosis ranges from 0 to 30 %. The aim of this study was to identify possible factors related to postoperative colorectal anastomotic stricture and to indicate reoperative surgery outcomes.

Methods

After institutional review board approval, medical records were reviewed for patients who underwent surgery for colorectal anastomotic stricture at Cleveland Clinic Florida between January 2001 and December 2010. The main outcome measures were demographics, indications for initial surgery, body mass index, comorbidities, previous treatment, level of anastomosis, history of radiotherapy, and operative data for the reoperative surgery.

Results

Nineteen patients (15 males) were eligible for the study. Nine patients had a diagnosis of cancer, 7 of whom received radiotherapy. The initial surgeries were low anterior resection (n = 9; 47.4 %), high anterior resection (n = 9; 47.4 %), and sigmoidectomy (n = 1; 5.2 %). Six patients (31.6 %) had anastomotic leak after initial surgery. The majority of the patients (n = 17; 89.5 %) had an intact splenic flexure, inferior mesenteric artery, and inferior mesenteric vein. In all patients, full mobilization of the splenic flexure and high ligation of the mesenteric vessels was performed. Seven patients (36 %) developed postoperative complications. Over a mean follow-up of 24.3 months, there was no recurrence of anastomotic stricture.

Conclusions

An intact splenic flexure and mesenteric vessels were the most prevalent in patients who underwent reoperation at our institution. Full mobilization of the splenic flexure, high ligation of the mesenteric vessels, anastomotic stricture resection, and re-anastomosis can be successfully performed with satisfactory outcomes.     

Using CRP to predict anastomotic leakage after open and laparoscopic colorectal surgery: is there a difference?

Aim

C-reactive protein (CRP) has proven to be a useful adjunct in early diagnosis of anastomotic leak (AL) after colorectal surgery. It would be of considerable value to examine whether modality of surgery has influence upon postoperative CRP serum levels and their predictive value in the diagnosis of AL.

Methods

All patients undergoing elective colorectal surgery with anastomosis were enrolled into a prospective database between 2011 and 2014. AL was defined with strict operative and radiological criteria. Outcomes between open and laparoscopic resections were assessed statistically and Receiver Operating Characteristic (ROC) curve analysis performed.

Results

Seven hundred twenty-seven patients with an intestinal anastomosis were identified including 468 laparoscopic procedures (468/727; 64 %). There were 58 anastomotic leaks (58/727; 7.9 %) of which 29 (6.2 %) were laparoscopic and 29 (11.2 %) were open.Mean CRP levels were significantly higher in patients after open surgery compared with laparoscopic both with AL (p?=?0.013), and without (p?=?0.02).ROC curve analysis revealed postoperative day 3 (cut-off CRP 209) and day 4 (cut-off CRP 123.5) to be most predictive of leak in the open group with an area under the curve (AUC) 0.794 (sensitivity 80 %, specificity 80 %) and AUC 0.806 (sensitivity 94 %, specificity 60 %), respectively. In the laparoscopic group, day 2 proved to be the most accurate day for detection of leak with a cut-off CRP of 146.5 showing 75 % sensitivity and a 70 % specificity (AUC 0.766).

Conclusion

CRP levels are higher after open surgery compared with laparoscopic surgery, both with and without AL. AL generates a significant detectable increase in CRP within 2–4 days after surgery.

     

Transsphenoidal pituitary surgery in Cushing's disease: can we predict outcome?

OBJECTIVE: To assess the results of transsphenoidal pituitary surgery in patients with Cushing's disease over a period of 18 years, and to determine if there are factors which will predict the outcome. PATIENTS: Sixty-nine sequential patients treated surgically by a single surgeon in Newcastle upon Tyne between 1980 and 1997 were identified and data from 61 of these have been analysed. DESIGN: Retrospective analysis of outcome measures. MAIN OUTCOME MEASURES: Patients were divided into three groups (remission, failure and relapse) depending on the late outcome of their treatment as determined at the time of analysis, i.e. 88 months (median) years after surgery. Remission is defined as biochemical reversal of hypercortisolism with re-emergence of diurnal circadian rhythm, resolution of clinical features and adequate suppression on low-dose dexamethasone testing. Failure is defined as the absence of any of these features. Relapse is defined as the re-emergence of Cushing's disease more than one year after operation. Clinical features such as weight, sex, hypertension, associated endocrine disorders and smoking, biochemical studies including preoperative and postoperative serum cortisol, urine free cortisol, serum ACTH, radiological, histological and surgical findings were assessed in relation to these three groups to determine whether any factors could reliably predict failure or relapse after treatment. RESULTS: Of the 61 patients included in this study, 48 (78.7%) achieved initial remission and 13 (21.3%) failed treatment. Seven patients suffered subsequent relapse (range 22-158 months) in their condition after apparent remission, leaving a final group of 41 patients (67.2%) in the remission group. Tumour was identified at surgery in 52 patients, of whom 38 achieved remission. In comparison, only 3 of 9 patients in whom no tumour was identified achieved remission. This difference was significant (P = 0.048). When both radiological and histological findings were positive, the likelihood of achieving remission was significantly higher than if both modalities were negative (P = 0.038). There were significant differences between remission and failure groups when 2- and 6-week postoperative serum cortisol levels (P = 0.002 and 0.001, respectively) and 6-week postoperative urine free cortisol levels (P = 0.026) were compared. This allowed identification of patients who failed surgical treatment in the early postoperative period. Complications of surgery included transitory DI in 13, transitory CSF leak in 8 and transitory nasal discharge and cacosmia in 3. Twelve of 41 patients required some form of hormonal replacement therapy despite achieving long-term remission. Thirteen patients underwent a second operation, of whom 5 achieved remission. CONCLUSIONS: Transsphenoidal pituitary surgery is a safe method of treatment in patients with Cushing's disease. Operative findings, radiological and histological findings, together with early postoperative serum cortisol and urine free cortisol estimates may identify failures in treatment. Alternative treatment might then be required for these patients. Because of the risk of late relapse, patients require life-long follow-up.     

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Background  

Millions of people suffer from anal incontinence not currently treated due to the complexity and cost of the surgical techniques in use. The purpose of this report is to evaluate the results of anal encirclement with a simple device in a group of patients with faecal incontinence of multiple causes.     

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.     

Does stenting of left-sided colorectal cancer as a “bridge to surgery” adversely affect oncological outcomes? A comparison with non-obstructing elective left-sided colonic resections

Purpose

With a theoretical link between stent insertion and increased risk of tumour seeding, there is concern about long-term survival after the use of self-expanding metallic stents (SEMS) as a “bridge to surgery” in the treatment of left-sided obstructing colorectal cancer. This cohort study aims to determine if preoperative stenting adversely affects long-term survival by comparing a group of patients having preoperative stenting (group A) with a group of patients having elective surgery (group B) in a single centre.

Methods

The study is retrospective. Survival was calculated with Kaplan–Meier analysis and compared using the log-rank test. Other group characteristics were compared with Fisher's exact test.

Results

From November 1998 to November 2008, 15 patients had preoperative SEMS and were entered in group A. This represented 11.5?% of a total of 130 patients undergoing SEMS insertion in the same period. Group B included 88 consecutive patients undergoing elective left-sided colonic resection for Dukes' B and C cancer excluding mid and low rectal tumours between January 2003 and December 2007. The 30-day mortality rate for groups A and B was 6.7?% (one patient) and 5.7?% (five patients), respectively. The 5-year survival rate was 60?% and 58?%, respectively, with a p value of 0.96.

Conclusions

In our own practice, patients undergoing SEMS as a “bridge to surgery” have the same long-term survival with those undergoing elective surgery. This finding needs to be confirmed in larger scale studies.     

Follow-up loss in smoking cessation consultation: can we predict and prevent it?

BackgroundCigarette smoking has a considerable health and economic burden in modern society, with increased risk of morbidity and mortality. Therefore, smoking cessation policies and medical treatments are essential. However, cessation rates are low and the abandonment of the consultation is common. The identification of characteristics that may predict adherence will help defining the best treatment strategy. This study aimed to identify predictors of follow-up loss in smoking cessation consultation.MethodsWe made a retrospective observational study, including a cohort of patients who started smoking cessation consultation (April-December 2018). Clinical data from consultations was collected and analyzed with IBM SPSS Statistics (SPSS, RRID:SCR_002865).ResultsA total of 175 patients was selected (41.1% female), with a mean age of 53±12 years. Eighty-five patients (48.6%) were discharged for abandonment. They had a median pack-year unit 38±36 (P=0.011), Fagerström and Richmond scores of 5±2 and 7±2, respectively. There was an association between women (P<0.001), younger age (P<0.001), depression/anxiety (P=0.023), lower smoking load (P=0.019), starting the treatment in the first appointment (P=0.004) and the abandonment of the consultation. In binary logistic regression, younger age (less than 50 years) (OR =4.39; 95% CI: 1.99–9.70), starting the treatment in the first appointment (OR =3.04; 95% CI: 1.44–6.42) and depression/anxiety (OR =2.30; 95% CI: 1.08–4.88) remained independent predictors of loss in follow-up.ConclusionsWomen, younger age, depression/anxiety, lower smoking load and starting treatment in the first appointment are predictors of follow-up loss, so, these patients may benefit from more frequent evaluations and intensive cognitive approach. This study also raises awareness about the adequate timing to start pharmacological support for smoking cessation.     

Mechanical bowel preparation before elective colorectal surgery: is it necessary?

Aim

To present the worldwide accepted guidelines concerning the use of mechanical bowel preparation (MBP) before elective colorectal surgery (ECS).

Patients and methods

We conducted a retrospective review of the Pubmed Databases for randomized controlled trials (RCTs) and meta-analyses, which included adult patients who underwent elective colorectal surgery. We compared the patients who had a preoperative MBP with those who did not. Significant factors that were taken into account were postoperative septic complications and anastomotic dehiscence.

Results

Our search revealed 5 RCTs and 2 meta-analyses that met our criteria. Patients who underwent emergency colorectal surgery were excluded from the study. We identified the recommendations for 6 different types of elective colorectal surgery.

Conclusion

MBP has been for many years a standard clinical procedure for patients undergoing elective colorectal surgery. However, many recent researches suggest the omission of MBP, since there are no significant differences regarding postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. Furthermore, MBP is a time-consuming, expensive procedure and causes severe discomfort to the patient. More importantly, the application of MBP has been associated with serious complications in both healthy patients and patients with existing cardiac or renal disease, such as electrolyte and volume disturbances.

     

Is the intraoperative air leak test effective in the prevention of colorectal anastomotic leakage? A systematic review and meta-analysis

Objective

The intra-operative air leak test (ALT) is a common intraoperative test used to identify mechanically insufficient anastomosis. This meta-analysis aims to determine whether ALT aids to the reduction of postoperative colorectal anastomotic leakage (CAL).

Methods

A literature search was performed to select studies in acknowledged databases. Full text articles targeting ALT during colorectal surgery were included. Quality assessment, risk of bias, and the level-of-evidence of the inclusions were evaluated. ALT methodology, ALT(+) (i.e., leak observed during the test) rate, and postoperative CAL rate of the included studies were subsequently analyzed.

Results

Twenty studies were included for analysis, in which we found substantial risks of bias. A lower CAL rate was observed in patients who underwent ALT than those did not; however, the difference was not significant (p = 0.15). The intraoperative ALT(+) rate greatly varied among the included studies from 1.5 to 24.7 %. ALT(+) patients possessed a significantly higher CAL rate than the ALT(?) patients (11.4 vs. 4.2 %, p < 0.001).

Conclusions

Based on the available evidence, performing an ALT with the reported methodology has not significantly reduced the clinical CAL rate but remains necessary due to a higher risk of CAL in ALT(+) cases. Unfortunately, additional repairs under current methods may not effectively decrease this risk. Results of this review urge a standardization of ALT methodology and effective methods to repair ALT(+) anastomoses.

     

“Fast-track” rehabilitation after colonic surgery in elderly patients—is it feasible?

Background and aims The aim of the “fast-track” rehabilitation after elective colonic surgery is to lower the extent of general complications. Elderly patients may especially profit from this multi-modal peri-operative treatment including enforced early mobilisation and oral nutrition. Materials and methods In this prospective study using a well-defined post-operative multi-modal treatment programme, we examined the feasibility of this so-called fast-track rehabilitation in elderly patients. The programme employed combined thoracic peri-dural analgesia, early enforced mobilisation and rapid oral nutrition. Results Seventy-four consecutive patients older than 70 years with benign or malignant disease of the large intestine were operated on. All patients were treated peri-operatively using the “fast-track” rehabilitation programme. Of the patients, 84% were able to have liquids orally on the day of surgery and 86% had solid food on the 1st post-operative day. The median time until the first bowel movement was 2 days. Only 12 (16%) patients had a total of 16 local complications, including 2 (3%) patients with anastomotic leakages. Nine patients (12%) had a total of 14 general complications; mortality rate was 1% (n = 1). Patients were discharged from the hospital 5 (5th–95th percentile = 4–6 days) days after surgery. Conclusion Using the “fast-track” rehabilitation programme on elderly patient is not only feasible but may also lower the number of general complications and the duration of the hospital stay.     

Venous thromboembolism in colorectal surgery: skip SCIP or comply?

Background

The Surgical Care Improvement Project (SCIP) includes recommendations for mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis after colorectal surgery. Compliance with these recommendations is publicly reported and included in current pay for performance plans. Presently, there is limited evidence to support compliance with these recommendations.

Aim

To determine the incidence of venous thromboembolic events in colorectal surgery patients who did or did not receive the recommended pharmacologic prophylaxis.

Methods

We performed a retrospective analysis of prospectively accrued data from a single-center, tertiary care, colorectal surgery department. The main outcome measure was the occurrence of venous thromboembolic events and the need for blood transfusion after surgery.

Results

Of 674 patients, 613(91 %) received the recommended pharmacologic VTE prophylaxis and 61 (9 %) did not. Diagnosis, patient variables, and type of surgery performed were similar in each group while operative time was increased in the compliant group (251 vs. 194 min, p < 0.05). In the compliant and noncompliant groups, the incidence of extremity deep venous thrombosis was 2.8 and 8.2 % (p = 0.04), the incidence of pulmonary embolus 1.1 and 3.3 % (p = 0.19), the incidence of portomesenteric venous thrombosis 2.6 and 4.9 % (p = 0.38), and the incidence of any VTE 5.4 and 13.1 % (p = 0.02), respectively. The use of perioperative red blood cell transfusions in the two groups was 9.1 and 14.8 %, p = 0.17. In the subgroup analysis of open cases, there were no statistical differences in the occurrence of any type or combination of VTE.

Conclusions

Compliance with SCIP recommendations for pharmacologic VTE prophylaxis decreased the incidence of VTE after colorectal surgery with no increase in the use of perioperative transfusion. Colorectal surgeons who elect to skip these recommendations may jeopardize both the reputational score and financial reimbursement of their hospital and may put their patients at unnecessary risk for a preventable postoperative complication.