Management of Anastomotic Leak: Lessons Learned from a Large Colon and Rectal Surgery Training Program

Background

Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions.

Methods

This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997–2008.

Results

Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2–1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks.

Conclusions

Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.     

Sealing of Vessels Larger Than 7 Millimeters Using Enseal in Porcine Aorta

Background:

The Enseal (Ethicon Endo-Surgery, Blue Ash, Ohio) tissue-sealing device has proven efficacy for ligation of vessels <7 mm in diameter, even with significant supraphysiologic bursting pressures. We aimed to evaluate the safety of Enseal in porcine vessels >7 mm.

Materials and Methods:

The lumbar aortas of pigs that were euthanized for unrelated procedures were harvested. A 5- to 6-cm segment of aorta was sealed using the Enseal device. The opposite end was attached to a pressure-testing device to measure pressures at leak or bursting. The bivariate Pearson correlation was used to determine the relationship between diameter and bursting pressure. One-way analysis of variance was used to determine differences between the groups of vessels on the basis of their diameter.

Results:

Ninety samples of 5-cm aorta segments were used to assess bursting pressure. The median diameter was 14 mm (range, 7–18) and bursting pressure was 85 mm Hg (range, 24–650). The Pearson test showed a negative correlation between vessel diameter and bursting pressure (P = .25). One-way analysis of variance did not show any significant difference between vessel diameters grouped by size (P = .517), and neither did the Scheffe post hoc test when comparing diameter with bursting pressure; 31% of specimens failed to seal.

Conclusions:

Bursting pressures are low and inconsistent after tissue sealing with the Enseal device in porcine vessels >7 mm. These vessels also demonstrated a higher rate of failure to seal. The histologic results of the aorta segments (ie, a low collagen-elastin ratio) may be the cause of the low bursting pressures.     

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

Background  

Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision.     

Linkage studies exclude the AT-V gene(s) from the translocation breakpoints in an AT-V patient

An 8-year-old girl with severe microcephaly of prenatal onset, borderline intelligence, defects of skin pigmentation, deficiency of both humoral and cellular immunity, a normal serum α-fetoprotein level and hypersensitivity to ionizing irradiation is described. Spontaneous chromosomal breakage in lymphocytes together with the clinical presentation led to the diagnosis of ataxia telangiectasia variant (AT-V). In addition, the patient carried a constitutional translocation of paternal origin: 46,XX,t(3;7)(q12;q31.3) pat. In subsequent linkage and haplotype studies in 12 AT-V families with microsatellite markers from each of the translocation breakpoint regions, we could clearly exclude the localization of an AT-V gene to these regions.     

Dose-dependent effects of polyphenolic extracts from green tea, blue-berried honeysuckle, and chokeberry on rat caecal fermentation processes

The physiological status of the colon or ceacum is known to be very important for the host organism. Therefore, the aim of this study was to estimate the influence of high doses of polyphenolic extracts from chokeberry (CH), blue-berried honeysuckle (H), and green tea (GT) on fermentation processes in the caecum and caecal parameters of rats fed casein diets. In a 4-week experiment, 35-day-old rats were fed diets containing 0.4, 0.8, and 1.2?% of pure polyphenols. The greatest weight of digesta was recorded in rats fed 1.2?% of GT extract, and these animals were also characterised by having the lowest content of dry matter. Supplementation of diets with the extracts of interest caused a reduction in pH values and ammonia concentrations in caecal digesta in comparison to control animals. The results of a two-way analysis of variance indicated dose-dependent (except for 0.4?% supplementation) inhibition of enzymatic activity compared to control animals. Introduction of CH and H extracts significantly reduced the activity of β-glucuronidase compared to rats fed tea diets. Two-way analysis of variance showed a significant decrease in volatile fatty acids concentration in rats fed diets supplemented with H and CH extracts in comparison to control and tea-fed rats. The obtained results showed that the extracts tested can distinctly influence caecal parameters and metabolism.     

Serum Soluble Glycoprotein 130 Concentration Is Inversely Related to Insulin Sensitivity in Women With Polycystic Ovary Syndrome

OBJECTIVE

Insulin resistance might play a role in the pathogenesis of polycystic ovarian syndrome (PCOS). The family of glycoprotein 130 (gp130) cytokines could influence insulin action. One of these cytokines is interleukin (IL)-6, which exerts a short-term insulin-sensitizing effect, whereas in a long-term period, it might induce insulin resistance. Some other gp130 activators are supposed to have beneficial metabolic effects. Gp130 is present in the circulation in the soluble form (sgp130), which inhibits intracellular gp130 signaling. The aim of the present study was to estimate the relation between sgp130 and insulin sensitivity in women with PCOS.

RESEARCH DESIGN AND METHODS

We studied 78 women with PCOS (35 lean and 43 obese) and 34 healthy women (18 lean and 16 obese). The euglycemic-hyperinsulinemic clamp and the measurements of serum sgp130, IL-6, soluble IL-6 receptor (sIL-6R), and sex hormones were performed.

RESULTS

Both obesity and PCOS were characterized by an increased sgp130 (P < 0.0001 and P = 0.0002, respectively). sIL-6R concentration was lower (P = 0.0036) in women with PCOS independently of obesity. Serum sgp130 was negatively correlated with insulin sensitivity when control and PCOS women were analyzed together (r = −0.36, P < 0.0001) and in the PCOS subjects separately (r = −0.34, P = 0.002). In multiple regression analysis, this correlation was significant after adjustment for BMI, waist, percent of body fat, postload glucose and insulin, triglycerides, and high-sensitive C-reactive protein.

CONCLUSIONS

Serum sgp130 is inversely and independently associated with insulin sensitivity in women with PCOS. An increased serum sgp130 in obesity and PCOS suggests an inhibition of intracellular gp130 signaling in insulin-resistant conditions.Polycystic ovarian syndrome (PCOS) is a common endocrine disorder with a diverse and heterogeneous nature that is present in 5–10% of reproductive-age women. PCOS is characterized by hyperandrogenism and chronic anovulation (1,2). Insulin resistance is a common feature of PCOS and might be the cause of significant metabolic and cardiovascular complications observed in this condition (3).The family of glycoprotein 130 (gp130) cytokines might influence insulin action (4). This family includes interleukin (IL)-6, IL-11, leukemia inhibitory factor, ciliary neurotrophic factor, oncostatin, and cardiotrophin-1 (5). Gp130 cytokines play a pivotal role in the regulation of the immune, hematopoietic, nervous, cardiovascular, and endocrine systems (5). These cytokines exert their actions through a heterodimeric or homodimeric receptor consisting of two membrane-bound glycoproteins: a cytokine binding subunit and a glycoprotein termed IL-6 transducer, or IL6ST, also known as gp130, which is responsible for signal transduction (6).IL-6 was thought to be an insulin-desensitizing factor (7). However, it might have some beneficial metabolic actions, and it was hypothesized that it exerts a short-term insulin-sensitizing effect, whereas in the long-term period, IL-6 might induce insulin resistance (8). IL-6 increased glycogen synthesis and enhanced lipid oxidation via an AMP-activated protein kinase (AMPK)-dependent mechanism in skeletal muscle (9). Another gp130 cytokine, ciliary neurotrophic factor, prevented weight gain and stimulated AMPK in skeletal muscle (10). Therefore, it is supposed that gp130 activators might be useful in the treatment of obesity and insulin resistance (4). Gp130 is expressed in most cells of the body (6) and is present in the circulation in soluble form (sgp130), which inhibits intracellular gp130 signaling (11). The role of sgp130 in the pathogenesis of human insulin resistance has not been studied so far.Soluble form of the IL-6R (sIL-6R) occurs in various body fluids and might induce gp130 dimerization and signaling when complexed with IL-6. The presence of sIL-6R leads to sensitization of IL-6–responsive cells toward the ligand (12). The IL-6/sIL-6R complex stimulates several types of cells that only express gp130 and are unresponsive to IL-6 alone. This process is called trans-signaling (13). Sgp130 exerts also inhibitory effects toward the IL-6/sIL-6R complex (14).We hypothesized that serum spg130 might be altered in insulin-resistant conditions in humans and might be related to insulin sensitivity. To test this hypothesis, we studied serum sgp130, IL-6, and sIL-6R in relation to insulin sensitivity in lean and obese women with PCOS and BMI-matched healthy control subjects.