Risk Factors for Anastomotic Leak Following Colorectal Surgery A Case-Control Study

ArticleinArchives of surgery (Chicago, Ill.: 1960) 145(4):371-6; discussion 376 · April 2010with39 Reads
DOI: 10.1001/archsurg.2010.40 · Source: PubMed
Abstract
To assess anastomotic leak (AL) risk factors in a large patient series. Case-control study. The Mount Sinai Hospital. Ninety patients with AL following colorectal resection and 180 patients who underwent uncomplicated procedures. Risk factors associated with development of AL. The AL rate was 2.6%. Five risk factors for AL were identified: (1) preoperative albumin level lower than 3.5 g/dL (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.3-5.1) (P = .03); (2) operative time of 200 minutes or longer (OR, 3.4; 95% CI, 2.0-5.8) (P = .01); (3) intraoperative blood loss of 200 mL or more (OR, 3.1; 95% CI, 1.9-5.3) (P = .01); (4) intraoperative transfusion requirement (OR, 2.3; 95% CI, 1.2-4.5) (P = .02); and (5) histologic specimen margin involvement in disease process in patients with inflammatory bowel disease (IBD) (OR, 2.9; 95% CI, 1.4-6.1) (P = .01). Patients with all 3 intraoperative risk factors had an OR of 22.1; 95% CI, 2.8-175.4 (P < .001) for development of AL. Histologic resection margin involvement in disease process in patients with IBD, preoperative albumin levels lower than 3.5 g/dL, intraoperative blood loss of 200 mL or more, operative time of 200 minutes or more, and/or intraoperative transfusion requirement increased AL risk. Enteral nutritional optimization prior to elective surgery is essential. Proximal diversion should be considered for patients with all 3 intraoperative risk factors because they are at high risk for AL.
    • "T and/or B lymphocytes in the intestinal mucosa are reduced in patients receiving TPN [20] , and intestinal and respiratory IgA levels de- crease [21]. Nutrition is a well-known influence on the healing of colonic anostomosis [3, 22]. Good nutrition must include adequate intake of energy, nitrogen, vitamins and trace elements [18, 23, 24]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives. Complications after colorectal surgery have not been reduced in recent years. Anastomotic leakage is responsible for nearly all morbidity in colonic surgery and for about one third of the mortality. Material and Methods. For the study, 34 albino Wistar rats (about 155–190 g in weight) were divided into four experimental groups. Each of the rats underwent an abdominal incision and resection of the colon 4 cm distal to the cecum to form a colo-colonic anastomosis. In the post-operative period, the first group (n = 8) were fed with standard rat food and water, the second group (n = 9) with dextrose + Ringer solution, the third group (n = 9) with Biosorb® (Nutricia, Zoetermeer, The Netherlands), and the fourth group (n = 8) with Impact® (Novartis Nutrition, USA). Results. The blow-out pressure of the anastomoses was significantly different in the group fed 5% dextrose + + Ringer solution group than in the Biosorb® and Impact® groups. Conclusions. None of the various nutrients investigated in the present study were significantly superior to standard foods in terms of the blow-out pressures. On the other hand, immunonutrients were more beneficial effects than other nutrients in terms of the healing of colonic anastomoses and post-operative weight loss.
    Full-text · Article · May 2015
    • "Anastomotic leakage is the most serious complication since it has been found to lead to severe sepsis followed by death or postoperative anastomotic stricture [20] and poor postoperative anorectal function [21]. In this study we reported 33.3% leakage, much higher when compared to the literature anastomotic leakage rates of 0.9–24%222324 , which varied depending on whether asymptomatic leaks were radiologically detected. This high percentage might be explained by the adverse effect of neo-adjuvant chemo-radiation and the early phase of the learning curve. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Abdomino-perineal resection has been the standard treatment for rectal tumors located ⩽5 cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome. Aim: Is to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR). Patients & methods: Between the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2–5 cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP). Results: Among the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0–5 cm from the anal verge (median 2.3 cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1–4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%. Conclusion: Intersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.
    Full-text · Article · Jun 2014
    • "The constant bleeding from the right colon mass was temporarily arrested by endoscopic argon coagulation. After 12 h surveillance in the ICU, no other bowel bleeding was found and we decided upon an urgent right colectomy without primary anastomosis due to the patient's poor nutritional status (serum albumin 2.7 g/dL; prealbumin 112 mg/L) and the important previous body weight loss (>10%), which are recognized risk factors for anastomotic leak and mortality in elderly patients13141516 . Although the patient was stable, the risk of rebleeding and related complications was considered high, which led us to decide upon an urgent colectomy. "
    [Show abstract] [Hide abstract] ABSTRACT: Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient's poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon's experience and the right selection of candidate patients cannot be understated.
    Full-text · Article · Apr 2014
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