Colon anastomotic leakage: improving the mouse model

Purpose

Colon anastomotic leakage remains a serious and common surgical complication. Animal models are valuable to determine the pathophysiological mechanisms and to evaluate possible methods of prevention. The aim of this study was to develop an optimal model of clinical colon anastomotic leakage in a technically insufficient anastomosis in the mouse.

Methods

A total of 110 mice were used in three pilot studies (1–3) and two experiments (A, B). Due to the high complication rates, the analgesic regimen and surgical techniques were changed throughout the pilot studies/experiments. In the final successful experiment (B), eight and four absorbable sutures were used in the control and intervention anastomoses, respectively, and buprenorphine in chocolate spread was used for pain treatment.

Results

In the final model (experiment B), significantly more animals in the intervention group had clinical anastomotic leakage compared with controls (40 vs. 0 %, p = 0.003). The weight loss was greater and the wellness score was also lower in these animals (p < 0.001). The breaking strength of the anastomoses was not significantly different between the control group [0.55 N ± 0.09] and intervention group [0.49 N ± 0.15] (p = 0.091).

Conclusions

This mouse model closely mimics clinical colon anastomotic leakage in humans. The model is of high clinical relevance, since anastomotic leakage has a similar cause, incidence and manifestations in humans.     

Could hyponatremia be a marker of anastomotic leakage after colorectal surgery? A single center analysis of 1,106 patients over 5 years

Purpose

The aim of this study is to define the significance of hyponatremia as a marker of anastomotic leakage after colorectal surgery.

Methods

All anastomoses in colorectal surgery performed at a single institution between July 2007 and July 2012 (n?=?1,106) were retrospectively identified. Serum sodium levels and leukocyte values measured when an anastomotic leak was diagnosed by CT scan and/or surgical reintervention (n?=?81) were compared to the values preferably on postoperative day 5 in the absence of an anastomotic leak (n?=?1,025).

Results

The leak rate in anastomoses of the rectum was 9.0 %, while the leak rate of the other anastomoses was 5.4 %. Mean serum sodium level was 138.8 mmol/l in the group with an anastomotic leak and 140.5 mmol/l in the group without. Hyponatremia (<136 mmol/l) was present in 23 % of patients in the group with an anastomotic leak and in 15 % in the group without (p?<?0.001). In multivariate analysis, leukocytes and serum sodium level remained as significant markers of an anastomotic leak. As a marker of an anastomotic leak, hyponatremia had a specificity of 93 % and a sensitivity of 23 %, while the presence of either leukocytosis or hyponatremia had a sensitivity of 68 %, a specificity of 75 %, a positive predictive value of 18 %, and a negative predictive value of 97 %.

Conclusions

Hyponatremia could be a specific and relevant marker of anastomotic leakage after colorectal surgery. If hyponatremia and leukocytosis are present after colorectal surgery, anastomotic leakage should be suspected and a CT scan with rectal contrast dye is recommended.     

A Prospective Randomized Controlled Trial of Semi-mechanical versus Hand-sewn or Circular Stapled Esophagogastrostomy for Prevention of Anastomotic Stricture

Background

Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture.

Methods

Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter.

Results

The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar.

Conclusions

Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.     

Effectiveness of a Transanal Tube for the Prevention of Anastomotic Leakage after Rectal Cancer Surgery

Aim

We evaluated the effectiveness and safety of a transanal tube placed for the prevention of anastomotic leakage after rectal surgery.

Methods

Between 2007 and 2011, a total of 243 patients underwent anterior resection using the double stapling technique for rectal cancer at our institution. We excluded 67 patients with diverting stoma and divided the remaining patients into two groups: patients who did not receive a transanal tube and diverting stoma (n = 140; control group) and those who received a transanal tube (n = 36). We compared the rate of anastomotic leakage, evaluated the complications associated with the transanal tube, and analyzed the risk factors for anastomotic leakage.

Results

The following perioperative parameters were significantly different between the two groups as follows (control group vs. transanal tube group): diabetes mellitus (8 [22 %] vs. 12 [8.5 %] patients, respectively; p = 0.03), surgical duration (262 ± 54.1 min [171–457] vs. 233 ± 61.7 min [126–430], respectively; p < 0.01). The postoperative anastomosis leakage appeared significantly different between the two groups (1 [2.7 %] vs. 22 [15.7 %] patients, respectively; p = 0.04). Anastomotic leakage was significantly associated with the distance between the anastomosis line and the anal verge (odds ratio [OR] 8.58; 95 % confidence interval [CI] 1.53–48.0; p = 0.01) and non-use of a transanal tube (OR 11.1; 95 % CI 1.04–118; p = 0.04) in both univariate and multivariate analyses.

Conclusions

Placement of a transanal tube is effective in decreasing the rate of anastomotic leakage after anterior resection using the double stapling technique. However, complications associated with a transanal tube should be carefully considered.     

Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

Background

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

Methods

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

Results

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

Conclusions

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.     

Risk factors for anastomotic leakage and favorable antimicrobial treatment as empirical therapy for intra-abdominal infection in patients undergoing colorectal surgery

Purpose

Anastomotic leakage is the most concerning complication that can occur after colorectal surgery. The aim of this study was to determine the incidence of and risk factors for clinical anastomotic leakage following colorectal resection. In addition, we evaluated the efficacy of empirical antimicrobial therapy with respect to the clinical outcomes.

Methods

Between January 2002 and December 2010, we prospectively collected surveillance data for patients, who were undergoing colorectal resection at Mie University Hospital.

Results

A total of 918 patients undergoing elective colorectal surgery were included in our surveillance program, 633 of whom were eligible for the study. Clinical anastomotic leakage was identified in 40 (6.3 %) patients. The use of preoperative irradiation and an NNIS risk index ≧2 were found to be independent predictors of clinical anastomotic leakage after colorectal surgery. Empirical antibiotic treatment strayed from the 2010 IDSA/SIS guidelines, the length of hospital stay was prolonged and the rate of re-intervention was increased.

Conclusions

Anastomotic leakage remains a major complication of colorectal surgery. Surgeons should be aware of such high-risk patients. In patients with anastomotic leakage after surgery, the empirical use of antimicrobial regimens with broad-spectrum activity against both aerobic and anaerobic organisms to treat postoperative intra-abdominal infections following colorectal surgery in accordance with the 2010 IDSA/SIS guidelines is associated with better outcomes.     

Anastomotic leakage after low anterior resection for rectal cancer: comparison of stapled versus compression anastomosis

Purpose

Surgical technique and perioperative management in rectal cancer surgery have been substantially improved and standardized during the last decades. However, anastomotic leakage following low anterior resection still is a significant problem. Based on animal experimental data of improved healing of compression anastomosis, we hypothesized that a compression anastomotic device might improve healing rates of the highest-risk anastomoses.

Methods

All low anterior resections for rectal cancer performed or directly supervised by the senior author between January 2004 and June 2012 were analyzed. Only patients with a stapled or compression anastomosis located within 6 cm from the anal verge were included. Until December 2008, circular staplers were employed, while since January 2009, a novel compression anastomotic device was used for rectal reconstruction exclusively.

Results

Out of 197 patients operated for rectal cancer, a total of 96 (34 females, 35.4 %) fulfilled inclusion criteria. Fifty-eight (60.4 %) were reconstructed with circular staplers and 38 (39.6 %) using a compression anastomotic device. Significantly, more laparoscopic procedures were recorded in the compression anastomosis group, but distribution of gender, age, body mass index, American Society of Anaesthesiologists score, rate of preoperative radiotherapy, tumor staging, or stoma diversion rate were similar. Anastomotic leakage was observed in seven cases (7/58, 12.1 %) in the stapled and twice (2/38, 5.3 %) in the compression anastomosis group (p?=?0.26).

Conclusions

In this series, rectal reconstruction following low anterior resection using a novel compression anastomotic device was safe and (at least) equally effective compared to traditional circular staplers concerning leak rate.     

Compromised visceral circulation does not affect the outcome of colorectal surgery

Purpose

Anastomotic leakage is a serious complication after colorectal surgery, and many risk factors for this problem have so far been identified. The aim of this study was to assess the association between visceral arterial occlusive disease and anastomotic leakage.

Methods

The preoperative abdominal computed tomography scans from all consecutive patients who underwent colorectal surgery with anastomosis in 2010 were retrospectively analyzed.

Results

A total of 242 patients were included, with a median age of 65 years (interquartile range 55–74). Anastomotic leakage occurred in 14 % of cases (n = 34). The mortality rate was 3 % (n = 8). There was no association between atherosclerosis of the visceral or iliac arteries and anastomotic leakage. There was also no association between right-sided or left-sided resections and total occlusion of the superior or inferior mesenteric artery, respectively.

Conclusion

Asymptomatic visceral artery occlusive disease is not a risk factor for anastomotic leakage after colorectal surgery, and additional radiological imaging or percutaneous transluminal angioplasty for occluded visceral vessels is not indicated prior to colorectal surgery.     

End-to-End Cervical Esophagogastric Anastomoses Are Associated with a Higher Number of Strictures Compared with End-to-Side Anastomoses

Background

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

Methods

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

Results

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p?=?0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p?=?0.04). Moreover, a median of 11 (7–17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2–8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p?<?0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p?=?0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p?=?0.03 and p?=?0.01, respectively).

Conclusion

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.     

High 1-Year Complication Rate after Anterior Resection for Rectal Cancer

Background

Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies.

Methods

Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality.

Results

Nineteen percent of 388 included patients received a primary anastomosis, 55 % an anastomosis with defunctioning stoma, and 27 % an end colostomy. Short-term anastomotic leakage was 10 % in patients with a primary anastomosis vs. 7 % with a defunctioning stoma (P?=?0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18 %) readmissions and re-intervention (12 %) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30 % increase in patients with an end colostomy.

Conclusions

This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.     

Clinical outcomes of endoscopic and surgical management for postoperative upper gastrointestinal leakage

Background

The purpose of this study was to evaluate the safety and efficacy of endoscopic therapy, an alternative and less invasive modality for the management of leakage after gastrectomy.

Methods

An electronic database of 35 patients with anastomotic leaks after surgery for stomach cancer that were treated with either an endoscopic procedure or surgery between January 2004 and March 2012 was reviewed. The success rates and safety of both modalities were evaluated.

Results

Endoscopic treatment was performed in 20 patients and surgical treatment in 15 patients. The median time interval between the primary surgery and diagnosis of leakage was 8.0 days (interquartile range, 5.0–14.0 days). Of the 20 patients with endoscopic treatment, technical success was achieved in 19 patients (95 %) with resulting clinical success achieved in all of these 19 patients (100 %). One patient with failed endoscopic management went on to receive surgery. There were no cases of leakage-related deaths after endoscopic treatment. Of the 15 patients with surgical treatment, 5 died due to sepsis, bleeding, or hospital-acquired pneumonia. For diagnosis of leakage, 17 patients from the endoscopy group underwent computed tomography (CT) scanning, which revealed leakages in 3 patients (17.6 %) and occult leakages were subsequently defined at fluoroscopy in all 20 patients. Seven of twelve patients (58.3 %) from the surgical group had leakages diagnosed by CT scan.

Conclusions

Endoscopic treatment can be considered a valuable option for the management of postoperative anastomotic leakage with a high degree of technical feasibility and safety, particularly for leakages that are not excessively large.     

Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses

Background

Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.

Methods

From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.

Results

In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1–78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤10 versus >10 mm (68 vs. 64 %; p = 0.479).

Conclusion

CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.     

Intrathoracic Anastomotic Leakage after Gastroesophageal Cancer Resection Is Associated with Reduced Long-term Survival

Background

Most likely because of low statistical power, no previous studies have shown any significant association between long-term survival and anastomotic leakage in patients who have undergone gastroesophageal cancer resection.

Material and methods

The present study included, prospectively and consecutively, nationwide collected patients who underwent gastroesophageal cancer resection between 2003 and 2011 in Denmark. The operation was carried out as an Ivor Lewis procedure. Only patients with intrathoracic anastomosis were included in the analysis.

Results

From 2003 to 2011, 1,296 patients underwent gastroesophageal resection, and 128 (9.9 %) of these experienced anastomotic leakage. The overall 5-year survival rates in patients with and without anastomotic leakage were 20 and 35 % (P < 0.0001), respectively. After exclusion of 4 weeks mortality, the 5-year survival rate in patients with leakage was 22 % compared to 36 % in patients without anastomotic leakage (P < 0.001). After exclusion of 8 weeks mortality, the 5-year survival rate was 23 % in patients with leakage and 36 % in those without (P = 0.009). The corresponding median time of survival was 74 versus 128, 87 versus 138, and 95 versus 138 weeks, respectively. The overall hazard ratios of death after anastomotic leakage, unadjusted, and after adjusting for potentially confounding factors, were 1.59 (1.27–1.99) and 1.45 (1.14–1.84). The unadjusted and adjusted odds ratios after exclusion of 4 weeks mortality were 1.51 (1.19–1.90) and 1.41 (1.10–1.81). After exclusion of 8 weeks mortality the odds ratios were 1.38 (1.08–1.77) and 1.32 (1.02–1.71).

Conclusions

This nationwide study confirms that patients experiencing anastomotic leakage after gastroesophageal cancer resection have a significantly lower long-term survival, even following full recovery after the leakage.     

Anastomoseninsuffizienzen nach Kolonkarzinomresektionen

Background

The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage after colon cancer surgery using data compiled in the nationwide German qualitative multi-center study ?Colon/Rectum Cancer“ (WGCRC).

Methods

From 01/01/2000 to 12/31/2004 data recorded from patients with anastomotic leakages were evaluated to determine independent predictors of leakage using logistic regression analysis.

Results

A total of 28,271 patients underwent colon resection with anastomoses and anastomotic leaks occurred in 3.0% (n=844). Multivariate analysis identified long duration of surgery, a high ASA score, male gender, obstruction, left-sided tumor, cardiovascular hepatic comorbidity, single-layer hand suture, anastomoses using the biofragmentable Valtrac® ring, intraoperative complications and BMI>30 kg/m² as risk factors for postoperative occurrence of anastomotic leakage.

Conclusions

Even though the rate of anastomotic leaks in patients with anastomoses after resection for colon cancer is low, it remains a significant complication, associated with significant morbidity and mortality. The knowledge of risk factors should be considered in perioperative decision-making regarding anastomotic technique and indications for Hartmann’s procedure.     

Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality,morbidity, and functional results

Purpose

To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route.

Methods

We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011.

Results

The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory.

Conclusion

Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.     

Diagnostic markers of postoperative morbidity after laparoscopic Roux-en-Y gastric bypass for obesity

Purpose

The main objective of this study was to detect subacute complications that can arise from laparoscopic Roux-en-Y gastric bypass and take a rational approach to manage these complications.

Methods

A prospective observational study was performed from November 2010 to December 2012. All patients undergoing gastric bypass surgery for morbid obesity were included in this study. Patients with complications before day 5 were excluded from the study. Clinical and laboratory data (C-reactive protein, leukocyte count) at postoperative day 5, 30-day morbidity, were recorded. The diagnostic value of C-reactive protein (CRP) and leukocytes were determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

Results

One hundred and twenty-six patients were included. The overall incidence of 30-day morbidity was 8.7 %, and anastomotic leakage rate was 3.2 %. C-reactive protein at postoperative day 5 was a good predictor of complications (AUC was 0.862 (95 % CI [0.76; 0.96]; p?<?0.001) and anastomotic leakage (AUC was 0.863 (95 % CI [0.66; 1]; p?=?0.014). A CRP cutoff level of 136 mg/l at postoperative day 5 yielded a specificity of 95.5 % and a sensitivity of 57.1 % for the detection of postoperative complications. The negative predictive value was 94.6 %. A CRP level of 136 mg/l at day 5 was significantly associated with postoperative morbidity.

Conclusions

C-reactive protein dosage at postoperative day 5 is a relevant predictor of postoperative complications permitting to select patients at risk. Radiological examination and close monitoring could be restricted to patients with CRP level exceeding 136 mg/l.     

Feasibility and Impact on Surgical Outcomes of Modified Double-Stapling Technique for Patients Undergoing Laparoscopic Anterior Resection

Background

Anastomotic leakage is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate the modified double-stapling technique (MDST), as an alternative for conventional double-stapling technique (DST), and whether it could reduce the anastomotic leakage rate in laparoscopic anterior resection (Lapa-AR).

Study Design

Between March 2009 and October 2010, a total of 189 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectosigmoid colon were divided into the MDST group (n?=?95) and the DST group (n?=?94) according to the anastomotic technique. Data were analyzed retrospectively. Morbidity and anastomotic leakage rate were compared between the two groups.

Results

Patient demographics, preoperative comorbidity, tumor size, stage, and operative details were comparable between the two groups. There was no difference in operation time between the two groups. The overall complication rate was significantly lower in the MDST group than in the DST group (3.2 vs. 10.6 %, p?=?0.042), including anastomotic leakage rate (0 vs.4.6 %, p?=?0.029). The anastomotic technique was the only factor associated with anastomotic leakage in univariate analysis.

Conclusions

Our comparative study demonstrates MDST to have better short-term outcome in reducing anastomotic leakage compared with DST. This technique could be an alternative approach to maximize the patients' benefit in laparoscopic anterior resection.     

Prevention of Anastomotic Leakage after Total Gastrectomy with Perioperative Supplemental Oxygen Administration: A Prospective Randomized, Double-blind, Controlled, Single-center Trial

Background

The role of supplemental oxygen therapy in the healing of esophagojejunal anastomosis is still very much in an experimental stage. The aim of the present prospective, randomized study was to assess the effect of administration of perioperative supplemental oxygen therapy on esophagojejunal anastomosis, where the risk of leakage is high.

Methods

We enrolled 171 patients between January 2009 and April 2012 who underwent elective open esophagojejunal anastomosis for gastric cancer. Patients were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO₂) of 30 % (n = 85) or 80 % (n = 86). Administration commenced after induction of anesthesia and was maintained for 6 h after surgery.

Results

The overall anastomotic leak rate was 14.6 % (25 of 171): 17 patients (20 %) had an anastomotic dehiscence in the 30 % FiO₂ group and 8 (9.3 %) in the 80 % FiO₂ group (P < 0.05). The risk of anastomotic leak was 49 % lower in the 80 % FiO₂ group (relative risk 0.61; 95 % confidence interval 0.40–0.95) versus 30 % FiO₂.

Conclusions

Supplemental 80 % FiO₂ provided during and for 6 h after major gastric cancer surgery to reduce postoperative anastomotic dehiscence should be considered part of ongoing quality improvement activities related to surgical care, with few risks to the patient and little associated cost.     

Emergency Management in Patients with Late Hemorrhage after Pancreatoduodenectomy for a Periampullary Tumor

Background

The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported.

Methods

From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients.

Results

Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention.

Conclusion

The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.     

Embedded Cervical Esophagogastrostomy: A Simple and Convenient Method Using a Circular Stapler After Esophagectomy for Esophageal Carcinomas

Background

Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.

Methods

In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.

Results

A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.

Conclusions

Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.