Intraoperative testing of colorectal anastomosis and the incidence of anastomotic leak: A meta-analysis.
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SUBMITTER: Kryzauskas M
PROVIDER: S-EPMC7676546 | biostudies-literature | 2020 Nov
REPOSITORIES: biostudies-literature
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Intraoperative testing of colorectal anastomosis and the incidence of anastomotic leak: A meta-analysis.
Kryzauskas Marius M Bausys Augustinas A Jakubauskas Matas M Valciukiene Jurate J Makunaite Gabija G Jasiunas Eugenijus E Bausys Rimantas R Poskus Eligijus E Strupas Kestutis K Poskus Tomas T
Medicine 20201101 47
<h4>Background</h4>AL remains one of the most threatening complications in colorectal surgery. Significant efforts are put to understand the pathophysiological mechanisms involved in the development of leakage and to create the strategies to prevent it. We aimed to determine whether intraoperative testing of mechanical integrity and perfusion of colorectal anastomosis could reduce the incidence of AL.<h4>Methods</h4>A systematic review and meta-analysis of papers published before November 2019 o ...[more]
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Project description:ObjectiveObservational studies have shown that fluorescence angiography (FA) decreases the incidence of anastomotic leak (AL) in colorectal surgery, but high-quality pooled evidence was lacking. Therefore, we aimed at confirming this preliminary finding using a systematic review and meta-analysis of randomised controlled trials (RCTs) in the field.MethodsMEDLINE, Embase and CENTRAL were searched for RCTs assessing the effect of intra-operative FA versus standard assessment of bowel perfusion on the incidence of AL of colorectal anastomosis. The systematic review complied with the PRISMA 2020 and AMSTAR2 recommendations and was registered in PROSPERO. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Heterogeneity was assessed using the Q-test and quantified using the I2 value. Certainty of evidence was assessed using the GRADE Pro tool.ResultsOne hundred and eleven articles were screened, 108 were excluded and three were kept for inclusion. The three included RCTs compared assessment of the perfusion of the bowel during creation of a colorectal anastomosis using FA versus standard practice. In meta-analysis, FA was significantly protective against AL (3 RCTs, 964 patients, RR: 0.67, 95% CI: 0.46 to 0.99, I2: 0%, p = 0.04). The RD of AL was non-significantly decreased by 4 percentage points (95%CI: - 0.08 to 0, I2: 8%, p = 0.06) when using FA. Certainty of evidence was considered as moderate.ConclusionThe effect of FA on prevention of AL in colorectal surgery exists but is potentially of small magnitude. Considering the potential magnitude of effect of FA, we advise that future RCTs have an adequate sample size, include a cost-benefit analysis of the technique and better define the subpopulation who could benefit from FA.
| S-EPMC9485176 | biostudies-literature
Project description:IntroductionAnastomotic leaks (AL) following ovarian cytoreduction surgery could be detrimental, leading to significant delays in commencing adjuvant chemotherapy, prolonged hospital stays and increased morbidity. The aim of this study was to investigate risk factors associated with anastomotic leaks after ovarian cytoreduction surgery.Material and methodsThe MEDLINE (via PubMed), Cochrane Library, EMBASE and Scopus bibliographical databases were searched. Original clinical studies investigating risk factors for AL in ovarian cytoreduction surgery were included.ResultsEighteen studies with non-overlapping populations reporting on patients undergoing cytoreduction surgery for ovarian cancer (n = 4622, including 344 cases complicated by AL) were included in our analysis. Patients undergoing ovarian cytoreduction surgery complicated by AL had a significantly higher rate of 30-day mortality but no difference in 60-day mortality. Multiple bowel resections were associated with an increased risk of postoperative AL, while no association was observed with body mass index (BMI), American Society of Anesthesiologists (ASA) score, age, smoking, operative approach (primary versus interval cytoreductive, stapled versus hand-sewn anastomoses and formation of diverting stoma), neoadjuvant chemotherapy and use of hyperthermic intraperitoneal chemotherapy (HIPEC).DiscussionMultiple bowel resections were the only clinical risk factor associated with increased risk for AL after bowel surgery in the ovarian cancer population. The increased 30-day mortality rate in patients undergoing ovarian cytoreduction complicated by AL highlights the need to minimize the number of bowel resections in this population. Further studies are required to clarify any association between neoadjuvant chemotherapy and decreased AL rates.
| S-EPMC9653973 | biostudies-literature
Project description:BackgroundAnastomotic leakage (AL) is a common and serious complication following esophagectomy. We aimed to provide an up-to-date review and critical appraisal of the efficacy and safety of all previous interventions aiming to reduce AL risk.MethodsWe searched MEDLINE and Embase from 1946 to January 2019 for randomized controlled trials (RCTs) evaluating interventions to minimize esophagogastric AL. Pooled risk ratios (RR) for AL were obtained using a random effects model.ResultsTwo reviewers screened 441 abstracts and identified 17 RCTs eligible for inclusion; 11 studies were meta-analyzed. Omentoplasty significantly reduced the risk of AL by 78% [RR: 0.22; 95% CI: 0.10, 0.50] compared to conventional anastomosis (3 studies, n = 611 patients). Early removal of NG tube significantly reduced the risk of AL by 62% [RR: 0.38; 95% CI: 0.02, 0.65] compared to prolonged NG tube removal (2 studies, n = 293 patients); Stapled anastomosis did not significantly reduce the risk of AL [RR: 0.92; 95% CI: 0.45, 1.87] compared to hand-sewn anastomosis (6 studies, n = 1454 patients). The quality of evidence was high for omentoplasty (vs. conventional anastomosis), moderate for early NG tube removal (vs. prolonged NG tube removal), and very low for stapled anastomosis (vs. hand-sewn anastomosis).ConclusionsThis is the first meta-analysis to summarize the graded quality of evidence for all RCT interventions designed to reduce the risk of AL following esophagectomy. Our findings demonstrated that omentoplasty significantly reduced the risk of AL with a high quality of evidence. Although early NG tube removal significantly reduced AL risk, there is a need for further research to strengthen the quality of evidence for this finding. Evidence profiles presented in our review may help inform the development of future clinical practice recommendations. Systematic review registration: CRD42019127181.
| S-EPMC7814645 | biostudies-literature
Project description:BackgroundIntraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB).MethodsThis is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes.ResultsWe included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission.ConclusionsUse of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.
| S-EPMC6679992 | biostudies-literature
Project description:Anastomotic leakage following colorectal resection remains one of the most significant complications with relevant morbidity and mortality. There is evidence that a higher number of stapler firings for rectal division can affect the leak rate in double stapling anastomosis. However, there are no data concerning compression anastomosis. We present our institutional experience addressing this issue.This is a retrospective review of a prospective institutional database of patients undergoing colonic and rectal resection for benign and malignant indications between January 2008 and December 2014 at the surgical department of the St. John of God Hospital, Vienna. Inclusion criteria were rectal division with linear stapling devices and construction of anastomosis to the rectal stump using a circular stapler or compression device.Three hundred eighty two (196 female; 51.3%) patients were included. Mean age was 65.8 years (range: 18-95) Indications for the operation included diverticular disease (44.8%), colorectal carcinoma (51.6%), inflammatory bowel disease (1.8%), and adenoma (1.8%). A laparoscopic approach was employed in 334 cases (87.4%); in 170 patients (44.9%), a compression anastomosis was created. One, two, and three or more stapler cartridges were used for rectal division in 58.4, 33.5, and 8.1%, respectively. Male gender, neoadjuvant therapy, rectal cancer as an underlying disease, laparoscopic surgical approach, and duration of operation longer than 200 min are leading causes for the usage of more than one stapler cartridge. Overall leak rate was 4.7% (18/382). The only factor associated with the occurrence of leakage was the use of three or more stapler cartridges for the closure of the rectal stump (p = 0.002).Our data support that multiple stapler firings for rectal division following colorectal resection has a major impact on anastomotic leak rate. Especially in laparoscopic surgery efforts should be made to minimize the number of stapler cartridges used.
| S-EPMC5715046 | biostudies-literature
Project description:BackgroundAnastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.MethodsWe performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.ResultsOf 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 109/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.ConclusionThis population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.
| S-EPMC5433895 | biostudies-literature
Project description:BACKGROUND:Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients. OBJECTIVE:To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications. METHODS:We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms "colorectal" or "colon/colonic" or "rectum/rectal" and "anastomo*" and "drain or drainage." Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data. RESULTS:Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR)?=?1.14, 95 % confidence interval (CI) 0.80-1.62, P?=?0.47), (2) clinical anastomotic leakage (RR?=?1.39, 95 % CI 0.80-2.39, P?=?0.24), (3) radiologic anastomotic leakage (RR?=?0.92, 95 % CI 0.56-1.51, P?=?0.74), (4) mortality (RR?=?0.94, 95 % CI 0.57-1.55, P?=?0.81), (5) wound infection (RR?=?1.19, 95 % CI 0.84-1.69, P?=?0.34), (6) re-operation (RR?=?1.18, 95 % CI 0.75-1.85, P?=?0.47), and (7) respiratory complications (RR?=?0.82, 95 % CI 0.55-1.23, P?=?0.34). CONCLUSIONS:Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.
| S-EPMC4834107 | biostudies-literature
Project description:BACKGROUND:Early suspicion, diagnosis, and timely treatment of anastomotic leak after esophagectomy is essential. Retrospective studies have investigated the role of C-reactive protein (CRP) as early marker of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP after esophageal resection. METHODS:A literature search was conducted to identify all reports including serial postoperative CRP measurements to predict anastomotic leakage after elective open or minimally invasive esophagectomy. Fully Bayesian meta-analysis was carried out using random-effects model for pooling diagnostic accuracy measures along with CRP cut-off values at different postoperative day. RESULTS:Five studies published between 2012 and 2018 met the inclusion criteria. Overall, 850 patients were included. Ivor-Lewis esophagectomy was the most common surgical procedure (72.3%) and half of the patients had squamous-cell carcinoma (50.4%). The estimated pooled prevalence of anastomotic leak was 11% (95% CI = 8-14%). The serum CRP level on POD3 and POD5 had comparable diagnostic accuracy with a pooled area under the curve of 0.80 (95% CIs 0.77-0.92) and 0.83 (95% CIs 0.61-0.96), respectively. The derived pooled CRP cut-off values were 17.6 mg/dl on POD 3 and 13.2 mg/dl on POD 5; the negative likelihood ratio were 0.35 (95% CIs 0.096-0.62) and 0.195 (95% CIs 0.04-0.52). CONCLUSION:After esophagectomy, a CRP value lower than 17.6 mg/dl on POD3 and 13.2 mg/dl on POD5 combined with reassuring clinical and radiological signs may be useful to rule-out leakage. In the context of ERAS protocols, this may help to avoid contrast radiological studies, anticipate oral feeding, accelerate hospital discharge, and reduce costs.
| S-EPMC6296520 | biostudies-literature
Project description:BackgroundThis targeted chart review study reports the first ever detailed global account of clinical approaches adopted to detect and manage anastomotic leaks identified during surgery in routine clinical practice.Method156 surgeons from eight countries retrospectively extracted data from surgical records of 458 patients who underwent colorectal surgery with an identified intraoperative leak at the circular anastomosis. Demographic details, procedures, and outcomes were analyzed descriptively, by country.ResultsMost surgeries were performed laparoscopically (57.6%), followed by open surgeries (35.8%). The burden of intraoperative leaks on the healthcare system is driven in large part by the additional interventions such as using a sealant, recreating the anastomosis, and diverting the anastomosis to a colostomy bag, undertaken to manage the leak. The mean duration of hospitalization was 19.9 days. Postoperative anastomotic leaks occurred in 62 patients (13.5%), most frequently 4 to 7 days after surgery. Overall, country-specific differences were observed in patient characteristics, surgical procedures, method of diagnosis of intraoperative leak, interventions, and length of hospital stay.ConclusionThe potential cost of time and material needed to repair intraoperative leaks during surgery is substantial and often hidden to the healthcare system, potentially leading to an underestimation of the impact of this complication.
| S-EPMC5488233 | biostudies-literature
Project description:BackgroundAnastomotic leakage (AL) is the most frequent life-threating complication following colorectal surgery. Several attempts have been made to prevent AL. This prospective, randomized, multicentre trial aimed to evaluate the safety and efficacy of nebulised modified cyanoacrylate in preventing AL after rectal surgery.MethodsPatients submitted to colorectal surgery for carcinoma of the high-medium rectum across five high-volume centres between June 2021 and January 2023 entered the study and were randomized into group A (anastomotic reinforcement with cyanoacrylate) and group B (no reinforcement) and followed up for 30 days. Anastomotic reinforcement was performed via nebulisation of 1 mL of a modified cyanoacrylate glue. Preoperative features and intraoperative and postoperative results were recorded and compared. The study was registered at ClinicalTrials.gov (ID number NCT03941938).ResultsOut of 152 patients, 133 (control group, n = 72; cyanoacrylate group, n = 61) completed the follow-up. ALs were detected in nine patients (12.5%) in the control group (four grade B and five grade C) and in four patients (6.6%), in the cyanoacrylate group (three grade B and one grade C); however, despite this trend, the differences were not statistically significant (p = 0.36). However, Clavien-Dindo complications grade > 2 were significantly higher in the control group (12.5% vs. 3.3%, p = 0.04). No adverse effects related to the glue application were reported.ConclusionThe role of modified cyanoacrylate application in AL prevention remains unclear. However its use to seal colorectal anastomoses is safe and could help to reduce severe postoperative complications.
| S-EPMC11300475 | biostudies-literature