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Aim: Diverting stomas are routinely used in restorative surgery following total mesorectal exicision (TME) for rectal cancer to mitigate the clinical risks of anastomotic leakage (AL). However, routine diverting stomas are associated with their own complication profile and may not be required in all patients. A tailored approach based on personalized risk of AL and selective use of diverting stoma may be more appropriate. The aim of the TAilored SToma policY (TASTY) project was to design and pilot a standardized, tailored approach to diverting stoma in low rectal cancer. Method: A mixed‐methods approach was employed. Phase I externally validated the anastomotic failure observed risk score (AFORS). We compared the observed rate of AL in our cohort to the theoretical, predicted risk of the AFORS score. To identify the subset of patients who would benefit from early closure of the diverting stoma using C‐reactive protein (CRP) we calculated the Youden index. Phase II designed the TASTY approach based on the results of Phase I. This was evaluated within a second prospective cohort study in patients undergoing TME for rectal cancer between April 2018 and April 2020. Results: A total of 80 patients undergoing TME surgery for rectal cancer between 2016 and 2018 participated in the external validation of the AFORS score. The overall observed AL rate in this cohort of patients was 17.5% (n = 14). There was a positive correlation between the predicted and observed rates of AL using the AFORS score. Using ROC curves, we calculated a CRP cutoff value of 115 mg/L on postoperative day 2 for AL with a sensitivity of 86% and a negative predictive value of 96%. The TASTY approach was designed to allocate patients with a low risk AFORS score to primary anastomosis with no diverting stoma and high risk AFORS score patients to a diverting stoma, with early closure at 8–14 days, if CRP values and postoperative CT were satisfactory. The TASTY approach was piloted in 122 patients, 48 (39%) were identified as low risk (AFORS score 0–1) and 74 (61%) were considered as high risk (AFORS score 2–6). The AL rate was 10% in the low‐risk cohort of patient compared to 23% in the high‐risk cohort of patients, p = 0.078 The grade of Clavien‐Dindo morbidity was equivalent. The incidence of major LARS was lowest in the no stoma cohort at 3 months (p = 0.014). Conclusion: This study demonstrates the feasibility and safety of employing a selective approach to diverting stoma in patients with a low anastomosis following TME surgery for rectal cancer. [ABSTRACT FROM AUTHOR]

The article discusses the use of preoperative oral antibiotics in colorectal surgery, highlighting the divergent practices between Europe and North America. Various meta-analyses have shown that combining oral and IV antibiotics can reduce surgical site infections and anastomotic leaks. While there is no international consensus on the use of oral antibiotics, ongoing research, such as the CABE trial, aims to evaluate their effectiveness in improving patient outcomes. The article also emphasizes the importance of antimicrobial stewardship to avoid bacterial resistance. [Extracted from the article]

Aim: Splenic flexure mobilization (SFM) is commonly performed during left‐sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left‐sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). Method: This study was a PRISMA‐compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. Results: Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47–34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06–1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. Conclusions: SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies. [ABSTRACT FROM AUTHOR]

Aim: While postoperative C‐reactive protein (CRP) is used routinely as an early indicator of anastomotic leak (AL), preoperative CRP remains to be established as a potential predictor of AL for elective colorectal surgery. The aim of this systematic review and meta‐analysis is to examine the association between preoperative CRP and postoperative complications including AL. Method: MEDLINE, EMBASE, Web of Science, PubMed, Cochrane Library and CINAHL databases were searched. Studies with reported preoperative CRP values and short‐term surgical outcomes after elective colorectal surgery were included. An inverse variance random effects meta‐analysis was performed for all meta‐analysed outcomes to determine if patients with or without complications and AL differed in their preoperative CRP levels. Risk of bias was assessed with MINORS and certainty of evidence with GRADE. Results: From 1945 citations, 23 studies evaluating 7147 patients were included. Patients experiencing postoperative infective complications had significantly greater preoperative CRP values [eight studies, n = 2421 patients, mean difference (MD) 8.0, 95% CI 3.77–12.23, p < 0.01]. A significant interaction was observed with subgroup analysis based on whether patients were undergoing surgery for inflammatory bowel disease (X2 = 8.99, p < 0.01). Preoperative CRP values were not significantly different between patients experiencing and not experiencing AL (seven studies, n = 3317, MD 2.15, 95% CI −2.35 to 6.66, p = 0.35), nor were they different between patients experiencing and not experiencing overall postoperative morbidity (nine studies, n = 2958, MD 4.54, 95% CI −2.55 to 11.62, p = 0.31) after elective colorectal surgery. Conclusion: Higher preoperative CRP levels are associated with increased rates of overall infective complications, but not with AL alone or with overall morbidity in patients undergoing elective colorectal surgery. [ABSTRACT FROM AUTHOR]

Aim: Ileorectal anastomosis (IRA) following total abdominal colectomy (TAC) allows for resortation of bowel continuity but prior studies have reported rates of anastomotic leak (AL) to be as high as 23%. We aimed to report rates of AL and complications in a large cohort of patients undergoing IRA. We hypothesized that AL rates were lower than previously reported and that selective use of diverting loop ileostomy (DLI) is associated with decreased AL rates. Method: Patients undergoing TAC or end‐ileostomy reversal with IRA, with or without DLI, between 1980 and 2021 were identified from a prospectively maintained institutional database and retrospectively analysed. Redo IRA cases were excluded. Short‐term (30‐day) surgical outcomes were collected using our database. AL was defined using a combination of imaging and, in the case of return to the operating room, intraoperative findings. Results: Of 823 patients in the study cohort, DLI was performed in 27% and performed more frequently for constipation and inflammatory bowel disease. The overall AL rate was 3% (1% and 4% in those with and without DLI, respectively) and diversion was found to be protective against leak (OR 0.28, 95% CI 0.08–0.94, p = 0.04). However, patients undergoing diversion had a higher overall rate of postoperative complications (51% vs. 36%, p < 0.001) including superficial wound infection, urinary tract infection, dehydration, blood transfusion and portomesenteric venous thrombosis (all p < 0.04). Conclusion: Our study represents the largest series of patients undergoing IRA reported to date and demonstrates an AL rate of 3%. While IRA appears to be a viable surgical option for diverse indications, our study underscores the importance of careful patient selection and thoughtful consideration of staging the anastomosis and temporary faecal diversion when necessary. [ABSTRACT FROM AUTHOR]

Aim: Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end‐to‐end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity. Method: This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left‐sided colon resection with double‐stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak. Results: Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end‐colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05–0.87, p = 0.03). Conclusions: For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks. [ABSTRACT FROM AUTHOR]

Aim: Colorectal anastomotic leakage (AL) is a serious complication. Studies on the impact of AL on health‐related quality of life (HRQoL) are scarce. We aimed to investigate the association between AL and HRQoL in colorectal cancer patients up to 2 years after diagnosis, and to evaluate whether AL is associated with a clinically relevant decrease in HRQoL over time. Methods: Patients diagnosed with Stage I–III colorectal cancer undergoing elective surgical resection with primary anastomosis between 2010 and 2017 were included. HRQoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, represented by the summary score, and analysed at diagnosis and at 6 months and 2 years post‐diagnosis. Multivariable linear regression was performed to assess the association between AL and HRQoL, while multivariable logistic regression was used to investigate the association between AL and a clinically relevant HRQoL decrease (≥10 points) during follow‐up compared to the time of diagnosis. Results: In total, 1197 patients were included of whom 63 (5%) developed AL. AL was not associated with HRQoL at 6 months post‐diagnosis nor at 2 years post‐diagnosis. However, having AL was associated with an increased risk of a clinically relevant decrease in HRQoL at 6 months post‐diagnosis (OR 3.65, 95% CI 1.62–8.21) but not at 2 years after diagnosis (OR 1.91, 95% CI 0.62–5.93). Conclusion: Although AL was not associated with HRQoL at 6 months or 2 years post‐diagnosis, AL was a determinant of a clinically relevant decrease in HRQoL at 6 months after diagnosis. Future work should identify feasible and effective strategies to prevent declines in QoL in this patient population. [ABSTRACT FROM AUTHOR]

Aim: The management of anastomotic leak after sigmoid colectomy for diverticular disease has not been well defined. Specifically, there is a lack of literature on optimal types of reoperations for leaks. The aim of this study was to describe and compare reoperative approaches and their postoperative outcomes. Methods: We performed a retrospective cohort study using the NSQIP Colectomy Module (2012–2019) and single‐institution chart review. Patients with diverticular disease who underwent elective sigmoid colectomy were included. Primary outcomes were anastomotic leak requiring reoperation and management of anastomotic leak. Results: Of 37,471 patients who underwent sigmoid colectomy for diverticular disease, 1003 (2.7%) suffered an anastomotic leak, of whom 583 underwent reoperation. Of the 572 patients who were not initially diverted and underwent reoperation for leak, 302 (52.8%) were managed with stoma creation – 200 (35.0%) with colostomy and 102 (17.8%) with ileostomy. The remaining 47.2% underwent colectomy with reanastomosis, suturing of large bowel, and drainage. There were no differences in length of stay, readmission, or mortality between patients who underwent ileostomy or colostomy at reoperation (p > 0.05). Single‐institution analysis demonstrated that 100% of patients with ileostomies underwent subsequent ileostomy closure, compared to 60% of patients with colostomies. Conclusions: In patients who suffer anastomotic leaks after sigmoid colectomy for diverticular disease and undergo reoperations, ileostomy at the time of reoperation appears to be safe, with comparable results to colostomy. Ileostomies were more frequently closed than colostomies. When faced with a colorectal anastomotic leak, ileostomy creation may be considered. [ABSTRACT FROM AUTHOR]

Aim: There is scant evidence regarding surgical outcomes of patients with colon cancer in Latin America. The aim of this work was to compare perioperative (30 day) outcomes of patients undergoing surgery for right colon cancer in Latin America based on centre volume. Method: This is a multi‐institutional retrospective cohort study. Individuals operated on for right colon cancer with curative intent in an urgent or elective setting between 2016 and 2021 were eligible for inclusion in the study. Patients were divided into two groups according to whether they were operated on in low‐volume or high‐volume centres (defined as more than 30 cases/year). Results: A total of 2676 patients from 46 hospitals in 11 countries of Latin America were included, with 389 (14.5%) in the low‐volume group. The median age was 67.37 years. The high‐volume group presented higher rates of laparoscopic procedures (56.8 vs. 35.7%, p < 0.001, OR 2.36), with lower conversion rates, fewer intraoperative complications and a shorter operating time. The high‐volume group had a shorter length of hospital stay. The overall complication rate for the whole group was 15.9%, with a lower incidence of these events in the high‐volume group (13.7 vs. 28.7%, p < 0.001, OR 0.40). Overall, anastomotic leakage, reoperation and mortality rates were 5.6%, 9.2% and 6.1%, respectively, with differences favouring high‐volume centres. On multivariate analysis, low‐volume group, history of cardiac disease, emergency surgery, operation performed by a general surgeon, open approach and intraoperative complications were independent predictors of major postoperative complications. Conclusion: This is the first study in Latin America to show better postoperative outcomes at a regional scale when surgery for right colon cancer is performed in high‐volume centres. Further studies are needed to validate these data and to identify which of the factors can explain the present results. [ABSTRACT FROM AUTHOR]

Aim: Anastomotic leak results in increased morbidity and affects functional and oncological outcomes after colectomy. Measurement of C‐reactive protein (CRP) allows early detection of anastomotic leaks. The aim of this study was to evaluate the benefit to the patient of earlier diagnosis and management of anastomotic leaks, namely avoiding takedown of the anastomosis. Method: Patients with an anastomotic fistula after elective colorectal surgery from 2010 to 2020 were included. Three periods were defined according to progressive adherence to the CRP protocol in our department. A comparison was made between the periods 'before' (2010–2013) and 'after' (2016–2020) in terms of morbidity, mortality, anastomotic salvage, days spent in hospital within the first postoperative month, timely adjuvant chemotherapy and anastomotic stenosis. Results: Out of 2655 elective colorectal operations, 171 patients presented with an anastomotic leak and 123 patients were included in the study. In univariate analysis, patients in the 'after' group had fewer severe complications (Clavien–Dindo Grade III to IV, 66.7% vs. 56.9; p = 0.017); the difference did not reach significance regarding timely postoperative chemotherapy (p = 0.058) and anastomotic stenosis (p = 0.682). In both, univariate and multivariate analysis, the 'after' period increased the chances of preserving the anastomosis (OR = 2.37 [1.08–5.17]) and increased the number of days out of hospital (p = 0.0002). Conclusion: A CRP‐based protocol for the screening of anastomotic leaks after colorectal surgery was related to increased anastomotic conservation, a decreased impact and severity of the leak and a shorter length of hospital stay. [ABSTRACT FROM AUTHOR]

Aim: The Turnbull–Cutait pull‐through procedure (TCO) restores intestinal continuity in the setting of chronic pelvic sepsis, colorectal anastomotic leak, complex pelvic fistulas and technical challenges related to complicated rectal cancer. The aim of this study was to evaluate the outcomes of the TCO for salvaging complex pelvic conditions and to compare it to hand‐sewn immediate coloanal anastomosis (CAA). Methods: This is a retrospective single‐institution study where we searched a prospectively maintained database to identify patients who underwent the TCO. Patient demographics, operative indications and outcomes were analysed. TCO success was defined as maintenance of intestinal continuity and being stoma‐free. Kaplan–Meier analysis was employed for stoma‐free survival analysis. Results: A total of 81 patients with TCO and 129 patients with CAA were included. The TCO success rate was 69% at a median of 1.4 years' follow‐up with 25 (31%) patients ending up with a permanent stoma compared to 22 (17%) in the CAA group with a median follow‐up of 4 years (P = 0.03). The Kaplan–Meier cumulative incidence of TCO success at 1, 3 and 5 years was 79%, 60% and 51%, respectively, compared to 91%, 81% and 73% after CAA. Conclusion: The TCO has a high success rate for patients with complex pelvic conditions who may be facing a permanent stoma as their only option. [ABSTRACT FROM AUTHOR]

Aim: The decision‐making process to defunction a pelvic colorectal anastomosis involves complex heuristics and is framed by surgeon personality factors. Risk taking propensity may be an important factor in these decisions and patient preferences have not been evaluated alongside surgeons and nurses. Methods: A prospective cross‐sectional study involving a one‐off interview and questionnaire assessing how risk taking propensity affects nurse, surgeon and patient preferences for a temporary defunctioning ileostomy (TDI) was performed. The risk taking index (RTI) was employed to evaluate risk taking propensity and the validated prospective measures of preference instruments to evaluate preferences for stoma avoidance in several scenarios by asking the individual to consider trading or gambling years of remaining life expectancy. Results: One hundred and fifty participants met the inclusion criteria, which included 30 (20.0%) surgical nurses, 20 (13.3%) colorectal surgeons and 100 (66.7%) patients. Surgeons had a significantly higher RTI (mean ± SD: 26.8 ± 6.7) than patients (mean ± SD: 20.0 ± 9.8) and nurses (mean ± SD: 23.0 ± 6.6) p = 0.002. Surgeons would consider that it would be in a patient's best interest to have a TDI at an AL rate of 15% or greater, whereas nurses and patients would do so at 28% and 25%, respectively (p = 0.007). Conclusion: Surgeons were shown to have a higher risk taking propensity than patients and nurses but a significantly lower threshold of AL where they would consider a TDI is in the best interest of the patient. [ABSTRACT FROM AUTHOR]

Aim: Anastomotic leak (AL) is the most important complication of intestinal surgery with an anastomosis. Whilst a number of studies have defined risk factors for AL, frustratingly, low‐risk patients still develop AL. Studies have looked at drain fluid analysis for detection of AL, but these findings have failed to translate into routine clinical practice. This umbrella systematic review aims to provide an overview of the promising candidate biomarkers (BMs) that show potential to translate into clinical practice. Methods: A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane, KSR Evidence and the Epistemonikos databases on the 14 April 2021. Only systematic reviews of cohort or controlled studies measuring drain fluid biomarkers in humans were included. The methodological quality of the reviews was assessed using the AMSTAR 2 instrument. Clinical trial registries were searched for trials actively investigating drain fluid BMs. Candidate BMs were classified, and threshold values investigated. Results: Nine systematic reviews, published between 2007 and 2020, met the inclusion criteria, and contained a total of 36 cohort studies. A total of 38 different BMs were studied. The most promising category of drain fluid BM was the extravasated intra‐luminal substances (EILS) and five registered trials of these BMs were found. Two of nine reviews were of moderate quality. Conclusions: The majority of BMs show inconsistent threshold values and are in the experimental stage. A number are not readily available for adoption into routine clinical practice. Most do not state a cut‐off value to be considered as diagnostic. [ABSTRACT FROM AUTHOR]

Aim: The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time‐related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end‐points are quality of life and functional outcome. Methods: Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web‐based software platform www.covidence.org was used for primary screening of the title, abstract, full‐text review and data extraction. Results: The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. Conclusions: Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow‐up. [ABSTRACT FROM AUTHOR]

Aim: Cohort data suggest that anastomotic leak occurs after 8% of right colectomies causing significant morbidity and mortality. Patient selection, intra‐operative factors, and technical variation all contribute to risk of leak. The EAGLE study will assess whether implementation of the European Society of Coloproctology (ESCP) Safe Anastomosis Intervention reduces anastomotic leak following right colectomy. Methods: An international, multi‐centre, cluster randomised trial will be undertaken with hospitals as clusters. Hospitals will be recruited in a number of distinct phases, with each phase following the same research plan, in which clusters are randomised to one of three, staggered (dog‐leg) schedules for implementation of the Safe Anastomosis Intervention. Results: Results from different phases will be meta‐analysed. The intervention is a three‐component behavioural change programme for surgeons, anaesthetists and operating room staff, supported by an online learning environment. All colorectal surgical units around the world will be eligible. Adults undergoing elective or emergency right colectomy or ileocaecal resection, by any approach and for any indication will be included. The primary outcome is 30‐day anastomotic leak rate, defined as clinical or radiologically‐detected leak or intra‐abdominal or pelvic collection. Assuming hospitals provide data for an average of 10 patients per two month recruitment period, 333 clusters (4440 patients in total) will allow for detection of an absolute risk reduction of anastomotic leak from 8.1% to 5.6% (relative risk reduction 30%). This protocol adheres to Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT). Discussion: The protocol describes the methods for an evaluation of a hospital‐level, education‐based quality improvement intervention targeted to reduce the life‐threatening surgical complication of anastomotic leak. [ABSTRACT FROM AUTHOR]

Aim: Transanal total mesorectal excision (TaTME) is a surgical approach for treating mid to low rectal cancer as well as other colorectal diseases. Since the procedure is difficult to master, perioperative complications of TaTME should be examined precisely, especially during the early implementation phase of this procedure. The primary aim of this review was to determine a pooled morbidity and anastomotic leakage (AL) rate after TaTME surgery, and the secondary aim was to show the completeness of reporting of complications among the included studies, as well as the correlation between completeness and reported incidence of complications. Method: A systematic review of literature was conducted using Medline, Embase and Cochrane databases, searching for observational studies reporting on complications after TaTME. Studies published between 1 January 2010 and 15 October 2019 were included. Meta‐analysis on the proportion of morbidity, AL and intraoperative complications was performed. Results: Forty‐one studies (2446 TaTME cases), consisting of 27 noncomparative studies and 14 comparative studies, were included, after screening 1711 possible studies. The pooled rates of overall morbidity and AL were 30.0% (95% CI 26.4%–34.0%) and 6.8% (95% CI 5.2%–8.9%), respectively. Subgroup analysis showed that the morbidity rate in studies that reported 30‐day results (35.5%; 95% CI 31.8%–39.4%) was significantly higher than the rate in studies that did not define the follow‐up length for complications (23.4%; 95% CI 17.8%–30.1%; p = 0.003). The rates of intraoperative urethral injury, rectal injury, vaginal injury and bladder injury were 0.3% (95% CI 0.1%–1.7%), 0.4% (95% CI 0.1%–2.2%), 0.3% (95% CI 0.1%–0.8%) and 0.3% (95% CI 0.1%–1.7%), respectively. Conclusion: This meta‐analysis shows that pooled perioperative complication rates were within acceptable ranges. However, the significant difference in overall morbidity rate between the studies with 30‐day results and the studies without a specified follow‐up time, indicates a large under‐reporting of complications in many studies. [ABSTRACT FROM AUTHOR]

Aim: The study aimed to show if transanal reinforcement of the suture line can prevent anastomotic leakage (AL) after rectal cancer surgery, thus avoiding the need for a covering ileostomy. Methods: This is a prospective, multicentre, parallel‐arm randomized controlled equivalence trial. After standard total mesorectal excision, patients with anastomotic line at 1–3 cm from the dentate line were randomized to have transanal suture reinforcement (TAR group) or protective ileostomy (PI group). Results: Twenty‐nine patients had PI, 25 had TAR. The two groups were comparable both for baseline characteristics and intra‐operative aspects. Clinically evident AL occurred in four (16%) and five (17.24%) patients of the TAR and PI group, respectively, resulting in a difference of −1.20% (90% CI −17.93, 15.45), while subclinical AL at proctography was absent in 15 (65.22%) and 13 (50%) patients of the TAR and PI groups, respectively, resulting in a difference of 15% (90% CI −7.74 to 38.17). Conclusion: Preliminary data suggest that transanal reinforcement of the suture line performed in rectal cancer patients with suture line at 1–3 cm from the dentate line carries a similar (even if not equivalent) AL rate to covering ileostomy, suggesting that a covering ileostomy could be avoided in this selected group of patients. This indication needs to be addressed with future larger trials (clinicaltrials.gov ID number NCT02279771). [ABSTRACT FROM AUTHOR]

Aim: Intra‐operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left‐sided colonic or low anterior resection with anastomosis for colorectal cancer. Methods: All patients with left‐sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA−). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end‐point. Results: In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra‐operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788–0.998, P < 0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA− group compared to the IOFA+ group (16.7% vs 2.4%, P = 0.026) involving significantly more anastomotic dehiscence which required re‐intervention (19% vs 2.4%, P = 0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA− group compared with the IOFA+ group (9.5% vs 0%, P = 0.040). Conclusion: In this prospective case‐matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible. [ABSTRACT FROM AUTHOR]

Aim: An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect long‐term survival is less clear because data are scarce. The aim of the study was to investigate the long‐term impact of Grade C anastomotic leak in a large, population‐based cohort. Method: Data on patients undergoing resection for Stage I–III colon cancer between 2008 and 2012 were collected from the Swedish, Norwegian and Danish Colorectal Cancer Registries. Overall relative survival and conditional 5‐year relative survival, under the condition of surviving 1 year, were calculated for all patients and stratified by stage of disease. Results: A total of 22 985 patients were analysed. Anastomotic leak occurred in 849 patients (3.7%). Five‐year relative survival in patients with anastomotic leak was 64.7% compared with 87.0% for patients with no leak (P < 0.001). Five‐year relative survival among the patients who survived the first year was 88.6% vs 81.3% (P = 0.003). Stratification by cancer stage showed that anastomotic leak was significantly associated with decreased relative survival in patients with Stage III disease (P = 0.001), but not in patients with Stage I or II (P = 0.950 and 0.247, respectively). Conclusion: Anastomotic leak after surgery for Stage III colon cancer was associated with significantly decreased long‐term relative survival. [ABSTRACT FROM AUTHOR]

Aim: Management of anastomotic leakage (AL) following rectal resection has evolved with increasing use of less invasive techniques. The aim of this study was to review the management of AL following restorative rectal cancer resection in a tertiary referral centre. Method: A retrospective review of a prospectively maintained database was performed. The primary outcome was successful management of AL. The secondary outcome was the impact of AL on oncological outcome. Results: Five hundred and two restorative rectal cancer resections were performed during the study period. The incidence of AL was 9.9% (n = 50). AL occurred more commonly following neoadjuvant chemoradiotherapy (n = 31/252, 12.3%) than in those who did not receive neoadjuvant chemoradiotherapy (n = 19/250, 7.6%; P = 0.107); however, this was not statistically significant. Successful minimally invasive drainage was achieved in 28 patients (56%, radiological n = 24, surgical n = 4). Trans‐rectal drainage was the most common drainage method (n = 14). The median duration of drainage was longer in the neoadjuvant group (27 vs 18 days). Surgical intervention was required in 11 patients, with anastomotic takedown and end‐colostomy formation was most commonly required. Successful management of AL with drainage (maintenance of the anastomosis without the need for further intervention) was achieved in 26 of the 28 patients. There were no significant differences in overall or disease‐free survival when patients with AL were compared with patients without AL (69.4% vs 72.6%, P = 0.99 and 78.7% vs 71.3%, P = 0.45, respectively). Conclusion: In selected patients, AL following restorative rectal resection can be effectively controlled using minimally invasive radiological or surgical drainage without the need for further intervention. [ABSTRACT FROM AUTHOR]

Aim: Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left‐sided colonic resection, comparing the use of intra‐operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity. Methods: PubMed/MEDLINE and Embase online databases were searched for non‐randomized and randomized case–control studies that investigated postoperative AL and/or AB rates in left‐sided colonic resections, comparing intra‐operative FE against conventional tests. Data from eligible studies were pooled, and a meta‐analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates. Results: Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra‐operative FE: 0.37 (95% CI 0.21–0.68, P = 0.001) for AL and 0.35 (95% CI 0.15–0.82, P = 0.02) for AB. Conclusion: This meta‐analysis showed that the use of intra‐operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods. [ABSTRACT FROM AUTHOR]

Aim: We studied the levels of amylase in drain fluid to investigate its utility as a biomarker of anastomotic leak in ileal pouch patients who did not have a covering loop ileostomy. The luminal contents of the small intestine are high in amylase. Ileal J pouches are formed for restoration of continuity in patients with ulcerative colitis after removal of the colon and rectum. A drain is placed alongside the ileal pouch in the pelvis. Method: This study is a retrospective analysis of prospectively collected daily drain fluid amylase levels in consecutive patients undergoing restorative proctectomy and ileal J pouch anal anastomosis, without a covering loop ileostomy, between November 2016 and April 2018. Results: Thirteen patients underwent surgery without a covering loop ileostomy. Two patients suffered an anastomotic leak and were returned to theatre, one on day 5 and the other on day 6 postoperatively. The mean daily drain fluid amylase level in those who did not leak was between 25 and 46 U/l with a range of 22–139 U/l for all samples collected. In the two patients who suffered a clinical leak the drain fluid amylase level rose to 22 432 and 10 212 U/l on the day of clinical leak diagnosis. The mean rectal tube (intraluminal) amylase level was 63 097 U/l as measured on day 1 postoperatively. Conclusion: In this small cohort of patients, the measurement of drain fluid amylase is a highly sensitive biomarker of clinical anastomotic leak. [ABSTRACT FROM AUTHOR]

Aim: Anastomotic leakage (AL) is often identified 7–10 days after colorectal surgery. However, in retrospect, abnormalities may be evident much earlier. This study aims to identify the clinical time point when AL occurs. Method: This is a retrospective case‐matched cohort comparison study, assessing patients undergoing left‐sided colorectal resection between 2006 and 2015 at a specialist colorectal unit. Patients who developed AL (LEAK) were case‐matched to two CONTROL patients by procedure, gender, laparoscopic modality and diverting stoma. Case note review allowed the collection of basic observation data and blood tests (leukocyte count, C‐reactive protein, bilirubin, alanine transaminase, creatinine) up to postoperative day (POD) 4. The cohorts were compared, with the main outcome measure being changes in basic observation data. Results: Of 554 patients, 49 developed AL. These were matched to 98 CONTROL patients. Notes were available for 105 patients (32 LEAK/73 CONTROL). Groups were similar in demographics, tumour or nodal status, preoperative radiotherapy, intra‐operative air‐leak integrity and drain usage. AL was detected clinically at a median of 7.5 days postoperatively. There was a significantly increased heart rate by the evening on POD 1 in LEAK patients (82.8 ± 14.2/min vs 75.1 ± 12.7/min, P = 0.0081) which persisted for the rest of the study. By POD 3, there was a significant increase in respiratory rate (18.0 ± 4.2/min vs 16.5 ± 1.3/min, P = 0.0069) and temperature (37.0 ± 0.4C vs 36.7 ± 0.3C, P = 0.0006) in LEAK patients. C‐reactive protein was significantly higher in LEAK patients from POD 2 (165 ± 95 mg/l vs 121 ± 75 mg/l, P = 0.023). Conclusions: Physiological and biochemical changes associated with AL happen very early postoperatively, suggesting that AL may occur within 36 h after surgery, despite much later clinical detection. [ABSTRACT FROM AUTHOR]

Aim: Reports detailing the morbidity–mortality after left colectomy are sparse and do not allow definitive conclusions to be drawn. We aimed to identify risk factors for anastomotic leakage, perioperative mortality and complications following left colectomy for colonic malignancies. Method: We undertook a STROBE‐compliant analysis of left colectomies included in a national prospective online database. Forty‐two variables were analysed as potential independent risk factors for anastomotic leakage, postoperative morbidity and mortality. Variables were selected using the 'least absolute shrinkage and selection operator' (LASSO) method. Results: We analysed 1111 patients. Eight per cent of patients had a leakage and in 80% of them reoperation or surgical drainage was needed. A quarter of patients (24.9%) experienced at least one minor complication. Perioperative mortality was 2%, leakage being responsible for 47.6% of deaths. Obesity (OR 2.8, 95% CI 1.00–7.05, P = 0.04) and total parenteral nutrition (TPN) (OR 3.7, 95% CI 1.58–8.51, P = 0.002) were associated with increased risk of leakage, whereas female patients had a lower risk (OR 0.36, 95% CI 0.18–0.67, P = 0.002). Corticosteroids (P = 0.03) and oral anticoagulants (P = 0.01) doubled the risk of complications, which was lower with hyperlipidaemia (OR 0.3, P = 0.02). Patients on TPN had more complications (OR 4.02, 95% CI 2.03–8.07, P = 0.04) and higher mortality (OR 8.7, 95% CI 1.8–40.9, P = 0.006). Liver disease and advanced age impaired survival, corticosteroids being the strongest predictor of mortality (OR 21.5, P = 0.001). Conclusion: Requirement for TPN was associated with more leaks, complications and mortality. Leakage was presumably responsible for almost half of deaths. Hyperlipidaemia and female gender were associated with lower rates of complications. These findings warrant a better understanding of metabolic status on perioperative outcome after left colectomy. [ABSTRACT FROM AUTHOR]

Aim: There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Method: Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side‐to‐side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. Results: One thousand three hundred and forty‐seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54–1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52–1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46–4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04–2.64, P = 0.04). Conclusion: This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high‐risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Some evidence suggests that primary anastomosis following left sided colorectal resection in the emergency setting may be safe in selected patients, and confer favourable outcomes to permanent enterostomy. The aim of this study was to compare the major postoperative complication rate in patients undergoing end stoma vs primary anastomosis following emergency left sided colorectal resection. Methods: A pre‐planned analysis of the European Society of Coloproctology 2017 audit. Adult patients (> 16 years) who underwent emergency (unplanned, within 24 h of hospital admission) left sided colonic or rectal resection were included. The primary endpoint was the 30‐day major complication rate (Clavien‐Dindo grade 3 to 5). Results: From 591 patients, 455 (77%) received an end stoma, 103 a primary anastomosis (17%) and 33 primary anastomosis with defunctioning stoma (6%). In multivariable models, anastomosis was associated with a similar major complication rate to end stoma (adjusted odds ratio for end stoma 1.52, 95%CI 0.83–2.79, P = 0.173). Although a defunctioning stoma was not associated with reduced anastomotic leak (12% defunctioned [4/33] vs 13% not defunctioned [13/97], adjusted odds ratio 2.19, 95%CI 0.43–11.02, P = 0.343), it was associated with less severe complications (75% [3/4] with defunctioning stoma, 86.7% anastomosis only [13/15]), a lower mortality rate (0% [0/4] vs 20% [3/15]), and fewer reoperations (50% [2/4] vs 73% [11/15]) when a leak did occur. Conclusions: Primary anastomosis in selected patients appears safe after left sided emergency colorectal resection. A defunctioning stoma might mitigate against risk of subsequent complications. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case‐mix adjustment using a mixed‐effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P = 0.02) but MBP was not (OR 0.92, 0.63–1.36, P = 0.69) compared to NBP. Conclusion: This non‐randomised study adds ‘real‐world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10–15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near‐infrared laparoscopy can minimize the rate of AL leak compared with conventional white‐light laparoscopy. Two mechanistic sub‐studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies. Method: IntAct is a prospective, unblinded, parallel‐group, multicentre, European, randomized controlled trial comparing surgery with intra‐operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end‐point is rate of clinical AL at 90 days following surgery. Secondary end‐points include all AL (clinical and radiological), change in planned anastomosis, complications and re‐interventions, use of stoma, cost‐effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days. Discussion: IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning. [ABSTRACT FROM AUTHOR]

Abstract: Aim: An airtight anastomosis on intra‐operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left‐sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra‐operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra‐operative air leak. Method: This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left‐sided colorectal or ileorectal anastomoses and evidence of air leak during intra‐operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre‐existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days. Results: From a sample of 2360 patients, 119 had an intra‐operative air leak during leak testing. Sixty‐eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2–15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm. Conclusion: Suture repair alone does not meet the criteria for noninferiority for the management of intra‐operative air leak during left‐sided colorectal anastomosis. Further repair of intra‐operative air leak by suture repair alone should be reconsidered given these findings. [ABSTRACT FROM AUTHOR]

Aim Anastomotic leak ( AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C-reactive protein ( CRP) to predict AL in the first week after anterior resection for rectal cancer. Method A retrospective review of a prospectively maintained database that included all patients undergoing anterior resection between January 2008 and December 2013 was performed. The ability of CRP to predict AL was assessed using area under the receiver-operating characteristics (AUC) curves. The severity of AL was defined using the International Study Group of Rectal Cancer ( ISREC) grading system. Results Two-hundred and eleven patients were included in the study. Statistically significant differences in mean CRP values were found between those with and without an AL on postoperative days 5, 6 and 7. A CRP value of 132 mg/l on postoperative day 5 had an AUC of 0.75, corresponding to a sensitivity of 70%, a specificity of 76.6%, a positive predictive value of 16.3% and a negative predictive value of 97.5%. Multivariable analysis found that a CRP of > 132 mg/l on postoperative day 5 was the only statistically significant patient factor that was linked to an increased risk of AL ( HR = 8.023, 95% CI: 1.936-33.238, P = 0.004). Conclusion Early detection of AL may minimize postoperative complications. CRP is a useful negative predictive test for the development of AL following anterior resection. [ABSTRACT FROM AUTHOR]

Aim The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results This study included 3208 patients, of whom 78.4% ( n = 2515) underwent surgery for malignancy and 11.7% ( n = 375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% ( n = 3041) of patients, which was handsewn in 38.9% ( n = 1183) and stapled in 61.1% ( n = 1858). Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques ( P = 0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR = 1.43; 95% CI: 1.04-1.95; P = 0.03). Conclusion Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. [ABSTRACT FROM AUTHOR]

Aim To determine the earliest time point at which anastomotic leaks can be detected in patients undergoing total colectomy with primary ileorectal anastomosis for familial adenomatous polyposis. Method This was a case-controlled study of 10 anastomotic leak patients vs 20 controls following laparoscopic total colectomy with ileorectal anastomosis for familial adenomatous polyposis (from 96 consecutive patients between 2006 and 2013). Panel time-series data regression was performed using a double subscript structure to include both variables. A generalized least squares multivariate approach was applied in a random effects setting to calculate correlations for observations, with anastomotic leak being the dependent variable. Univariate and multivariate regression calculations were then performed according to individual observations at each recorded time point. Time-series analysis was used to determine when a variable became significant in the leak group. Results Multivariate analysis identified a significant difference between leak and control groups in mean heart rate ( P < 0.001), mean respiratory rate ( P = 0.017) and mean urine output ( P = 0.001). Time-point analysis showed that heart rate was significantly different between leak and control groups at postoperative day 4.25. Multivariate analysis identified a significant difference between groups in alanine transaminase ( P = 0.006), bilirubin ( P = 0.008), creatinine ( P = 0.001), haemoglobin ( P < 0.001) and urea ( P = 0.007). There were no differences between groups with regard to markers of inflammation such as albumin, white blood cell count, neutrophil count and C-reactive protein. Conclusion Anastomotic leaks can be detected early (within 4.5 days of surgery) through changes in physiological, blood test and observational parameters, providing an opportunity for early intervention in these patients to salvage the anastomosis. [ABSTRACT FROM AUTHOR]

Aim This study aimed to assess the influence of the C-reactive protein ( CRP) level on the early outcome after elective colorectal resection. Method Patients with colorectal cancer operated on between 2006 and 2013 were identified retrospectively. They were divided into a study group operated on between 2010 and 2013 when CRP was measured routinely on the fourth postoperative day and a control group operated on between 2006 and 2009 when the CRP level was not measured routinely. Mortality, intra-abdominal septic complications ( IASC), abscesses and anastomotic leakage ( AL), the need for reoperation, the interval from index surgery to relaparotomy, length of hospital stay and imaging studies were compared by multivariate analysis. Results A total of 1189 patients were assessed, including 598 (50.3%) in the study group (mean age 61.3 ± 13 years; 282 female) and 591 (49.7%) in the control group (mean age 61.8 ± 11 years; 267 female). There were seven (1.2%) postoperative deaths in the study group and nine (1.5%) in the control group ( P = 0.598). Abdominal ultrasound ( US) was performed more often in the study group [97 (16.2%) vs 71 (12.0%); P = 0.037]. In the study group the interval to diagnosis of IASC was shorter than in the control group (5.7 ± 1.5 days vs 7.3 ± 1.3 days; P = 0.029). The decision to reoperate was also made earlier in the study group (6.2 ± 1.7 days vs 7.4 ± 2.8 days; P = 0.043). Conclusion Routine measurement of CRP can help to make an earlier diagnosis of IASC and earlier decision for relaparotomy, without any influence on mortality or length of hospital stay. [ABSTRACT FROM AUTHOR]

Aim Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. Method This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage. Results A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion ( OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure ( OR up to 8.44, P < 0.0001). Conclusion In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons. [ABSTRACT FROM AUTHOR]