Purpose
The aim of this study was to explore the choice of modality for diagnosis, treatments, and consequences of anastomotic leakage.
Methods
This is a retrospective study of consecutive patients ...who underwent surgery that included a colorectal anastomosis due to colorectal cancer, diverticulitis, inflammatory bowel disease (IBD), or benign polyps.
Results
A total of 600 patients were included during 2010–2012, and 60 (10%) had an anastomotic leakage. It took in mean 8.8 days (range 2–42) until the anastomotic leakage was diagnosed. A total of 44/60 of the patients with a leakage had a CT scan of the abdomen; 11 (25%) were initially negative for anastomotic leakage. Among all leakages, the anastomosis was taken down in 45 patients (76.3%). All patients with a grade B leakage (
n
= 6) were treated with antibiotics, and two also received transanal drainage. The overall complication rate was also significantly higher in those with leakage (93.3 vs. 28.5%,
p
< 0.001), and it was more common with more than three complications (70 vs. 1.5%,
p
< 0.001). There was a higher mortality in the leakage group.
Conclusion
This study demonstrated that one fourth of the CT scans that were executed were initially negative for leakage. Most patients with a grade C leakage will not have an intact anastomosis. An anastomotic leakage leads to significantly more severe postoperative complications, higher rate of reoperations, and higher mortality. An earlier relaparotomy instead of a CT scan and improved postoperative surveillance could possibly reduce the consequences of the anastomotic leakage.
Randomized trials demonstrated oncologic safety and short-term benefits of laparoscopy. We investigated if the benefit of laparoscopy on short-term outcomes is greater for older adults compared with ...younger adults.
We identified all older (≥70 years old) and younger (<70) adults with primary sigmoid and rectal cancer treated with resection between 2002 and 2018 from an institutional database. We compared 30-day postoperative outcomes using multivariable logistic regression with an interaction term between age group and surgical approach. Primary outcomes were death, major (Clavien-Dindo III-IV) and minor (Clavien-Dindo I-II) complications, and wound complications.
We included 792 patients, 293 (37%) older and 499 (63%) younger. Use of laparoscopy was similar between age groups: 120/293 (41%) older, 204/499 (41%) younger (p = .98). All patients had 30-day follow-up. Compared with open resection, minimally-invasive resection was associated with a greater reduction in deaths in older adults than in younger adults (absolute difference in older adults 7.0% less versus 2.1% less in younger adults; adjusted odds ratio aOR older 3.01, 95% confidence interval CI 1.31–7.33; aOR younger 0.31, 95% CI 0.05–1.24; interaction p = .01). Similarly, minimally-invasive resection was associated with a greater reduction in major complications in older adults than in younger adults (absolute difference in older adults 6.4% less versus 2.4% less in younger adults; aOR older 1.91, 95% CI 1.07–3.41; aOR younger 0.70, 95% CI 0.34–1.38; interaction p = .03).
Minimally-invasive compared with open surgery demonstrated a differential benefit on postoperative death and major complications between younger and older adults.
Decreased surgical site infections (SSIs) and morbidity have been reported with mechanical and oral antibiotic bowel preparation (MOABP) compared with no bowel preparation (NBP) in colonic surgery. ...Several societies have recommended routine use of MOABP in patients undergoing colon resection on the basis of these data. Our aim was to investigate this recommendation in a prospective randomised context.
In this multicentre, parallel, single-blinded trial, patients undergoing colon resection were randomly assigned (1:1) to either MOABP or NBP in four hospitals in Finland, using a web-based randomisation technique. Randomly varying block sizes (four, six, and eight) were used for randomisation, and stratification was done according to centre. The recruiters, treating physicians, operating surgeons, data collectors, and analysts were masked to the allocated treatment. Key exclusion criteria were need for emergency surgery; bowel obstruction; colonoscopy planned during surgery; allergy to polyethylene glycol, neomycin, or metronidazole; and age younger than 18 years or older than 95 years. Study nurses opened numbered opaque envelopes containing the patient allocated group, and instructed the patients according to the allocation group to either prepare the bowel, or not prepare the bowel. Patients allocated to MOABP prepared their bowel by drinking 2 L of polyethylene glycol and 1 L of clear fluid before 6 pm on the day before surgery and took 2 g of neomycin orally at 7 pm and 2 g of metronidazole orally at 11 pm the day before surgery. The primary outcome was SSI within 30 days after surgery, analysed in the modified intention-to-treat population (all patients who were randomly allocated to and underwent elective colon resection with an anastomosis) along with safety analyses. The trial is registered with ClinicalTrials.gov, NCT02652637, and EudraCT, 2015–004559–38, and is closed to new participants.
Between March 17, 2016, and Aug 20, 2018, 738 patients were assessed for eligibility. Of the 417 patients who were randomised (209 to MOABP and 208 to NBP), 13 in the MOABP group and eight in the NBP were excluded before undergoing colonic resection; therefore, the modified intention-to-treat analysis included 396 patients (196 for MOABP and 200 for NBP). SSI was detected in 13 (7%) of 196 patients randomised to MOABP, and in 21 (11%) of 200 patients randomised to NBP (odds ratio 1·65, 95% CI 0·80–3·40; p=0·17). Anastomotic dehiscence was reported in 7 (4%) of 196 patients in the MOABP group and in 8 (4%) of 200 in the NBP group, and reoperations were necessary in 16 (8%) of 196 compared with 13 (7%) of 200 patients. Two patients died in the NBP group and none in the MOABP group within 30 days.
MOABP does not reduce SSIs or the overall morbidity of colon surgery compared with NBP. We therefore propose that the current recommendations of using MOABP for colectomies to reduce SSIs or morbidity should be reconsidered.
Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, and Helsinki University Hospital research funds.
Appendiceal diverticulosis is a rare finding associated with appendiceal neoplasms. Both can masquerade as appendicitis in patients and are overlooked in differentials of right upper quadrant pain. A ...37-year-old African American female presented with appendicitis-like symptoms to the emergency room with fever and leukocytosis. Appendectomy was performed with pathological evaluation revealing coexisting appendiceal diverticula and carcinoid of the appendix with lymphovascular invasion and mesoappendiceal involvement. In line with the National Comprehensive Cancer Network guidelines, right hemicolectomy with lymph node dissection was performed which was negative for neoplastic invasion but positive for colonic diverticulosis. While there have been many case reports of appendiceal diverticula with coexisting appendiceal carcinoid, a concurrent colonic diverticulum in the right hemicolectomy specimen during the oncologic resection of the appendiceal carcinoid has not been previously reported. We propose colonic diverticula as another possible feature that may be associated with appendiceal diverticula especially with an underlying appendiceal neoplasm.
Insufflation-Free, Perianal Work Platform Buchwald, Henry; Menchaca, Hector; Michalek, Van ...
Surgical innovation,
08/2024, Letnik:
31, Številka:
4
Journal Article
Recenzirano
There is an ever increasing volume of colorectal surgery being performed endoscopically by anal access, as well as greater employment of robotics for these procedures. Intraluminal visualization for ...perianal operations is today dependent on insufflation of the bowel. When full-thickness resections above the peritoneal reflection become necessary, the peritoneal cavity becomes inflated, facilitating infection and necessitating general anesthesia and patient intubation. Our patented tool was originally envisioned to enable abdominal cavity access via a single 2cm port incision, suitable for insufflation-free laparoscopic surgery, under local anesthesia (e.g., cholecystectomy). On further consideration, this instrument was modified to be used for perianal colorectal surgery.
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) ...prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative ...time were less important than complication and readmission rates in defining good outcomes and hence the learning curve.
A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers.
A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons).
In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons' willingness to attempt more difficult cases rather than an accurate representation of a "learning curve." Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.
The influence of physical activity on patient-reported recovery of physical functioning after colorectal cancer (CRC) surgery is unknown. Therefore, we studied recovery of physical functioning after ...hospital discharge by (a) a relative increase in physical activity level and (b) absolute activity levels before and after surgery.
We included 327 incident CRC patients (stages I-III) from a prospective observational study. Patients completed questionnaires that assessed physical functioning and moderate-to-vigorous physical activity shortly after diagnosis and 6 months later. Cox regression models were used to calculate prevalence ratios (PRs) of no recovery of physical functioning. All PRs were adjusted for age, sex, physical functioning before surgery, stage of disease, ostomy and body mass index.
At 6 months post-diagnosis 54% of CRC patients had not recovered to pre-operative physical functioning. Patients who increased their activity by at least 60 min/week were 43% more likely to recover physical function (adjusted PR 0.57 95%CI 0.39-0.82), compared with those with stable activity levels. Higher post-surgery levels of physical activity were also positively associated with recovery (P for trend = 0.01). In contrast, activity level before surgery was not associated with recovery (P for trend = 0.24).
At 6 month post-diagnosis, about half of CRC patients had not recovered to preoperative functioning. An increase in moderate-to-vigorous physical activity after CRC surgery was associated with enhanced recovery of physical functioning. This benefit was seen regardless of physical activity level before surgery. These associations provide evidence to further explore connections between physical activity and recovery from CRC surgery after discharge from the hospital.
Background
Laparoscopic approach is related to, among others, educing abdominal wall complications such as incisional hernia (IH). However, there are scarce data concerning laparoscopic colorectal ...surgery (LCRS). The aim of this study was to evaluate related factors and incidence of IH following this approach.
Methods
A retrospective analysis of consecutive patients who underwent colorectal surgery with laparoscopic approach in a single center was performed. Patients with a minimum follow-up of 6 months, and also converted to open surgery were included. Uni- and multi-variate analyses were performed using the following variables: age; gender; type of surgery (left, right, total, or segmental colectomy); comorbidities diabetes and chronic pulmonary obstructive disease (COPD); previous surgery; colorectal disease (benign and malignant); operative time; surgical site infection (SSI); and body mass index (BMI). Midline incisions (right colectomy) and off-midline incisions (left colectomies and rectal resections) were also compared.
Results
During a period of 12 years, 1051 laparoscopic colorectal surgeries were performed. The incidence of IH was 6 % (
n
= 63). Univariate analysis showed that BMI > 30 kg/m
2
p
< 0.01, OR: 2.3 (1.3–4.7), SSI
p
< 0.01, OR: 6.5 (3.4–12.5), operative time >180 min
p
< 0.01, OR: 2.1 (1.2–3.6) and conversion to open surgery (
p
= 0.01, OR: 2.4 1.1–5.0) were related to incisional hernias. BMI and SSI have a statistically significant relation with the incidence of IH in multivariate analysis (
p
< 0.01). No statistical difference between right and left colectomy was observed (6.6 vs. 6.4 %, respectively).
Conclusion
The incidence of IH after LCRS seems to be acceptable. BMI over 30 kg/m
2
and SSI are strongly associated to this complication.
Introduction: Hospital length of stay (LOS) remains a vital metric for assessing patient outcomes and healthcare resource utilization. Given the substantial financial impact of diagnosing and ...treating colorectal anomalies, coupled with an increased susceptibility to postoperative complications, it is crucial to understand the factors affecting LOS following colorectal surgery. Our primary objective was to investigate the preoperative, intraoperative, and postoperative risk factors that have substantial influence over LOS following a colorectal procedure. Methods: This study analyzed data from a retrospective study of adults who underwent various colorectal surgeries (colostomy, ileostomy, small bowel resection, etc.) at Cleveland Clinic Foundation (January 2005 - December 2014). Predictor variables were categorized into preoperative (patient demographics, medical history, comorbidities, lifestyle factors), intraoperative, and postoperative factors. LOS was grouped into short-term (SLOS) (≤ 7 days), medium-term (MLOS) (8-30 days), and long-term (LLOS) (> 30 days) stays. Multinomial logistic regression models assessed predictor effects on LOS. Results: Among the 7874 patients, 50.7% were females, with a minimum age of 20 years. SLOS were observed in 61.1%, MLOS in 37.6%, and LLOS in 1.3% of patients. Advanced age correlated with prolonged LOS, possibly due to age-related health challenges like weak immune systems. Coagulopathy, and fluid and electrolyte disorders raised MLOS and LLOS risk, likely due to complications like significant bleeding and electrolyte imbalances. Surgery duration predicted longer LOS, elevating LLOS and MLOS by 52% and 42%. Postoperative infections were associated to extended stays, possibly due to subsequent interventions, monitoring and recovery delays. Conclusion: Our study revealed that key preoperative predictors of LOS included Age, coagulopathy, fluid and electrolyte disorders, severe weight loss, and drug abuse. Notably, intraoperative factors such as surgical approach (open vs laparoscopic) and surgery duration, alongside postoperative complications including superficial and serious infections, significantly influenced LOS. By incorporating these insights into the preoperative planning, clinicians could potentially develop tailored interventions to mitigate risk factors and enhance postoperative recovery, thus potentially reducing LOS and improving patient outcomes.
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