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Background: We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. Methods: A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). Results: The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4–142] days vs. 70 [8–604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). Conclusions: EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy. [ABSTRACT FROM AUTHOR]

Background: Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes. Methods: We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011–2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet. Results: One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5–49). Negative margins were achieved in all cases (95% confidence interval [CI] 98–100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17–32%), 90-day mortality was 2.0% (0.4–5.8%), and reoperation was 5.4% (2.4–10%). Three patients (2.0%, 0.4–5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52–5240). Nine patients (6.1%, 2.8–11%) developed anastomotic strictures. Conclusions: Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks. [ABSTRACT FROM AUTHOR]

Background: It is unclear how early- and delayed-onset organ/space surgical site infections (SSIs) affect the long-term prognosis of patients with colorectal cancer, who are potential candidates for adjuvant chemotherapy. This study aimed to investigate the association between the timing of SSI onset and clinical outcome. Methods: This retrospective, multicenter cohort study evaluated patients who were diagnosed with high-risk stage II or III colorectal cancer and underwent elective surgery between 2010 and 2020. Five-year recurrence-free survival (RFS) was the primary endpoint and was compared between early SSI, delayed SSI (divided based on the median date of SSI onset), and non-SSI groups. Results: A total of 2,065 patients were included. Organ/space SSI was diagnosed in 91 patients (4.4%), with a median onset of 6 days after surgery. The early-onset SSI group had a higher proportion of patients with Clavien–Dindo grade ≥IIIb SSI than the delayed-onset SSI. Patients who received adjuvant chemotherapy (AC) had earlier organ/space SSI onset than those who did not. The adjusted hazard ratio of 5-year RFS in the delayed-onset SSI was 2.58 (95% confidence interval: 1.43–4.65; p = 0.002): higher than that in the early-onset SSI, with the non-SSI as the reference. Conclusions: Delayed-onset organ/space SSI worsened long-term prognosis compared to early-onset, and this may be due to delayed initiation of AC. Patients who are clinically suspected of having lymph node metastasis might need additional intervention to prevent delays in commencing AC due to the delayed SSI. [ABSTRACT FROM AUTHOR]

This article discusses a study that examines the use of C-reactive protein (CRP) levels on postoperative day 3 as a predictor of anastomotic leak (AL) in patients undergoing colorectal surgery. The study finds that patients without AL had a decrease in CRP levels on day 3, while those with AL had consistently high CRP levels on days 4-5. The study suggests that a CRP cutoff value of <182 mg/L on day 3 could be used to identify patients who can be discharged early. However, the study acknowledges limitations such as a small sample size and potential bias towards the usefulness of CRP. [Extracted from the article]

Background : Morbid obesity is becoming more prevalent and is a known risk factor for esophageal cancer. Esophagectomy in this population is technically more challenging than the non-obese, thus increasing the risks of surgery. This study hypothesizes that higher body mass index (BMI) is associated with higher anastomotic leak rates after esophagectomy. Methods: This study is a retrospective review of patients undergoing esophagectomy in the National Surgical Quality Improvement Program (NSQIP) Targeted Esophagectomy database from 2016 to 2019. Patients were stratified by BMI < 35 versus BMI > 35, with the primary outcome being leak post-esophagectomy. Univariate analyses were performed for demographics and post-operative outcomes, and multivariate analyses were performed specifically for the primary outcome of anastomotic leak (all diagnoses and malignancy/dysplasia subgroup). This study was approved by the Institutional Review Board. Results: Of 4165 patients, 439 (10.5%) had a BMI > 35. Patients with BMI > 35 were often younger (mean age 60 vs 64 years, p < 0.001), White (p < 0.001), female (p < 0.001), non-smoker (p < 0.001), diabetic (p < 0.001), with hypertension (p < 0.001), and ASA ≥ 3 (p < 0.001). There were no differences between BMI groups with regard to indication for esophagectomy (malignancy/dysphasia vs other), conversion to open, mortality, or length of stay. The BMI > 35 cohort reported higher operative times (p < 0.001), open operative approach (p = 0.04), superficial surgical site infection (p < 0.001), return to operating room (p = 0.01), and leak (13.5% vs 10.1%, p = 0.01). BMI > 35 was not an independent predictor of leak for all diagnoses; however, the subgroup analysis of esophagectomy for malignancy/dysplasia demonstrated that BMI > 35 was predictive of leak (OR 1.42, 95% CI 1.05–1.91), as well as operative time and hypertension. Conclusion: Patients with a BMI > 35 and who undergo esophagectomy have a higher rate of anastomotic leak. BMI > 35 was also an independent predictor of leak when esophagectomy was performed for malignancy/dysplasia, but not for all diagnoses. The risk of anastomotic leak should be considered in morbidly obese patients undergoing esophagectomy, particularly for malignancy. [ABSTRACT FROM AUTHOR]

Background: Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC). Methods: Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA). Results: One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33–124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01). Conclusion: Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted. [ABSTRACT FROM AUTHOR]

Background: It remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy. Methods: Patients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively. Results: Three hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups. Conclusions: Conduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks. [ABSTRACT FROM AUTHOR]

Background: Indocyanine green fluorescence angiography (ICG-FA) has been used in colorectal surgery to assess anastomotic perfusion and reduce the risks of anastomotic leaks. The main objective of this paper is to review the data on the transanal application of ICG-FA for the intraluminal assessment of colorectal anastomosis. Methods: A literature search was conducted for articles published between 2011 and 2021 using PubMed and Cochrane databases, related to the application of ICG for the intraluminal assessment of colorectal anastomosis. Original scientific manuscripts, review articles, meta-analyses, and case reports were considered eligible. Results: A total of 305 studies have been identified. After abstract screening for duplicates, 285 articles remained. Of those, 271 were not related to the topic of interest, 4 were written in a language other than English, and 4 had incomplete data. Six articles remained for the final analysis. The intraluminal assessment of colorectal anastomosis with ICG-FA is feasible, safe, and may reduce the incidence of leaks. Conclusion: The intraluminal assessment of anastomotic perfusion via ICG-FA may be a promising novel application of ICG technology. More data is needed to support this application further to reduce leak rates after colorectal surgery, and future randomized clinical trials are awaited. [ABSTRACT FROM AUTHOR]

Keywords: Esophagectomy; Transhiatal Esophagectomy; Anastomotic Leak EN Esophagectomy Transhiatal Esophagectomy Anastomotic Leak 398 401 4 03/02/23 20230201 NES 230201 Shankar Logarajah and Shawn Cudworth contributed equally to this work. Anastomotic leak (leak) remains a source of significant morbidity and accounts for approximately 40% of postoperative mortality after esophagectomy.[2] We sought to examine the risk factors associated with the development of leak after transhiatal esophagectomy (THE) at our institution. [Extracted from the article]

Eighty-three (36%) patients had hypovitaminosis C: 42 patients (18%) were deficient in vitamin C, and another 41 patients (18%) had vitamin C depletion. Using plasma vitamin C concentration as a continuous variable, multivariable linear regression (Table 2) demonstrated that age, increased frailty score, presence of pancreatic head tumor/obstructive pancreatitis, and lower serum albumin were significant factors associated with lower vitamin C levels. The critical finding of our study is that hypovitaminosis C was present in 36% of our patients, with 18% having true vitamin C deficiency. [Extracted from the article]

Background: Anastomotic leak (AL) is a feared complication after colorectal surgery. Prompt diagnosis and treatment are crucial. C-reactive protein (CRP) and procalcitonin (PCT) have been proposed as early AL indicators. The aim of this systematic review was to evaluate the CRP and CPT predictive values for early AL diagnosis after colorectal surgery. Methods: Systematic literature search to identify studies evaluating the diagnostic accuracy of postoperative CRP and CPT for AL. A Bayesian meta-analysis was carried out using a random-effects model and pooled predictive parameters to determine postoperative CRP and PCT cut-off values at different postoperative days (POD). Results: Twenty-five studies (11,144 patients) were included. The pooled prevalence of AL was 8% (95 CI 7–9%), and the median time to diagnosis was 6.9 days (range 3–10). The derived POD3, POD4 and POD5 CRP cut-off were 15.9 mg/dl, 11.4 mg/dl and 10.9 mg/dl respectively. The diagnostic accuracy was comparable with a pooled area under the curve (AUC) of 0.80 (95% CIs 0.23–0.85), 0.84 (95% CIs 0.18–0.86) and 0.84 (95% CIs 0.18–0.89) respectively. Negative likelihood ratios (LR−) showed moderate evidence to rule out AL on POD 3 (LR− 0.29), POD4 (LR− 0.24) and POD5 (LR− 0.26). The derived POD3 and POD5 CPT cut-off were 0.75 ng/ml (AUC = 0.84) and 0.9 ng/ml (AUC = 0.92) respectively. The pooled POD5 negative LR (−0.18) showed moderate evidence to rule out AL. Conclusions: In the setting of colorectal surgery, CRP and CPT serum concentrations lower than the derived cut-offs on POD3-POD5, may be useful to rule out AL thus possibly identifying patients at low risk for AL development. [ABSTRACT FROM AUTHOR]

Background: Procedure-specific complications can have devastating consequences. Machine learning–based tools have the potential to outperform traditional statistical modeling in predicting their risk and guiding decision-making. We sought to develop and compare deep neural network (NN) models, a type of machine learning, to logistic regression (LR) for predicting anastomotic leak after colectomy, bile leak after hepatectomy, and pancreatic fistula after pancreaticoduodenectomy (PD). Methods: The colectomy, hepatectomy, and PD National Surgical Quality Improvement Program (NSQIP) databases were analyzed. Each dataset was split into training, validation, and testing sets in a 60/20/20 ratio, with fivefold cross-validation. Models were created using NN and LR for each outcome. Models were evaluated primarily with area under the receiver operating characteristic curve (AUROC). Results: A total of 197,488 patients were included for colectomy, 25,403 for hepatectomy, and 23,333 for PD. For anastomotic leak, AUROC for NN was 0.676 (95% 0.666–0.687), compared with 0.633 (95% CI 0.620–0.647) for LR. For bile leak, AUROC for NN was 0.750 (95% CI 0.739–0.761), compared with 0.722 (95% CI 0.698–0.746) for LR. For pancreatic fistula, AUROC for NN was 0.746 (95% CI 0.733–0.760), compared with 0.713 (95% CI 0.703–0.723) for LR. Variables related to intra-operative information, such as surgical approach, biliary reconstruction, and pancreatic gland texture were highly important for model predictions. Discussion: Machine learning showed a marginal advantage over traditional statistical techniques in predicting procedure-specific outcomes. However, models that included intra-operative information performed better than those that did not, suggesting that NSQIP procedure-targeted datasets may be strengthened by including relevant intra-operative information. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy.Methods: A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy.Results: Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 "asymptomatic radiographic leak tests" (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent "symptomatic radiographic leak tests" (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( -), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0-5.5) and 9.0 days (IQR 6.0-13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively.Conclusions: Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging. [ABSTRACT FROM AUTHOR]

Background: Gastric conduit has emerged as the preferred treatment option for both esophageal bypass and replacement for corrosive stricture of the esophagus. There is a lack of consensus and a dearth of published literature regarding the short- and long-term complications of using a gastric conduit. This meta-analysis aims to evaluate the outcomes, morbidity, and complications associated with it. Methods: MEDLINE, Cochrane Library, and Google Scholar (January 1960 to May 2020) were systematically searched for all studies reporting short- and/or long-term outcomes and complications following the use of a gastric conduit for corrosive esophageal stricture. Results: Seven observational studies involving 489 patients (53.2% males, mean age ranging from 22.1 to 41 years) who had ingested a corrosive substance (acid in 74.8%, alkali in 20.7%, and unknown in the rest) were analyzed. Gastric pull-up was performed in 56.03% (274/489) of patients. Median blood loss in the procedure was 187.5 ml with a mean operative duration of 298.75 ± 55.73 min. The overall pooled prevalence rate of anastomotic leak was 14.4% [95% CI (6.2–24.0); p < 0.05, I2 = 67.38], and anastomotic stricture was 27.2% [95% CI (13–42.8); p < 0.001, I2 = 80.11]. Recurrent dysphagia according to pooled prevalence estimates occurred in 14.4% patients [95% CI (5.4–25.1); p < 0.05, I2 = 69.1] and 90-day mortality in 4.8% patients [95% CI (1.5–9.1%); I2 = 31.1, p = 0.202]. The dreaded complication of conduit necrosis had a pooled prevalence of 1.3% [95% CI (0.1–3.4%); I2 = 0, p = 0.734]. Conclusion: The stomach can be safely used as the conduit of choice in corrosive strictures with an acceptable rate of complications, postoperative morbidity, and mortality. [ABSTRACT FROM AUTHOR]

Background: When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative. Methods: The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity. Results: No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak. Conclusions: At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative. [ABSTRACT FROM AUTHOR]

Background: Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL.Methods: All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging.Results: 42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28).Conclusion: Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies. [ABSTRACT FROM AUTHOR]

Crohn's disease, Inflammatory bowel diseases, Ileocolic resection, Stapled anastomosis, Oversewn anastomosis, Anastomotic leak Methods This was a single centre, retrospective cohort study comparing CD patients that received a side-to-side ileocolic anastomosis either with or without oversewing. Does Oversewing Stapled Ileocolic Anastomoses for Crohn's Disease Reduce Anastomotic Complications?. [Extracted from the article]

BackgroundThe NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA.MethodsA non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed.ResultsTwenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion.ConclusionThe CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.

Background: Biliary fistula after pancreatoduodenectomy (PD) is associated with significant morbidity and mortality. The aim of this study was to determine the risk of early postoperative biliary fistula for developing biliary anastomotic stricture after PD. Methods: Retrospective review of all PD performed for various indications at a single institution between 2013 and 2018. Postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS) as grade A–C. Multivariable analysis was performed for all comparative patient subgroups. Results: A total of 843 patients underwent PD for malignant (68%) and benign (32%) indications. Postoperative biliary fistula developed in 66 (8%) patients; ISGLS grade A in 29 (3%), grade B in 32 (4%), and grade C in 5 (0.6%). Ninety-day mortality was 3% (25 patients). The remaining 818 patients were evaluated with a median follow-up of 16 months (IQR, 5–32 months). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6–18 months) postoperatively. Strictures were managed with percutaneous (27 patients, 66%) or endoscopic (14 patients, 34%) stenting. No biliary stricture required operative anastomotic revision. Postoperative biliary fistula (HR, 4.4; 95% CI, 2.0–9.9; P = 0.0002) was associated with biliary anastomotic stricture; an increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4–16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2–10.9; P = 0.02) postoperative biliary fistula. Conclusion: Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting. [ABSTRACT FROM AUTHOR]

Background: Previous work from our group has suggested a pivotal role for collagenolytic bacteria in the development of anastomotic complications. Tumor necrosis factor antagonists are a mainstay of treatment for patients with inflammatory bowel disease. The reported impact of these agents on key surgical outcomes such as anastomotic leak has been inconsistent. The objective of this study is to assess the impact of infliximab on the anastomotic microbiome in a mouse model of colon resection.Design: BALB/c mice underwent colon resection with primary anastomosis. Mice were randomly assigned to receive either an intraperitoneal dose of saline (control) or 10 mg/kg of infliximab for 8 weeks prior to surgery. On postoperative day 7, the animals were sacrificed. Anastomotic tissues were analyzed by histology with TUNNEL staining as a marker of epithelial apoptosis. In order to assess compositional and functional changes of the local microbiome, anastomotic tissues were further analyzed by 16S rRNA V4 region sequencing and for the presence of collagenolytic strains that may impair anastomotic healing. The main outcome measures were microbiome community structure and the presence of collagenolytic bacteria.Results: Infliximab-treated mice demonstrated an increase in epithelial apoptosis, consistent with the expected drug effect. Although infliximab modified the perianastomotic microbiome, no increase in the presence of collagenolytic bacteria was observed.Conclusions: Infliximab did not promote the emergence of collagenolytic bacteria or demonstrably impair anastomotic healing in a mouse model of colon resection and anastomosis. [ABSTRACT FROM AUTHOR]

Background: Anastomotic complications are among the most devastating consequences of gastrointestinal surgery. Despite its high morbidity, the factors responsible for anastomotic regeneration following surgical construction remain poorly understood. The aim of this review is to provide an overview of the typical and atypical factors that have been implicated in anastomotic healing.Methods: A review and analysis of select literature on anastomotic healing was performed.Results: The healing of an anastomotic wound mirrors the phases of cutaneous wound healing- inflammation, proliferation, and remodeling. The evidence supporting much of the traditional dogma for optimal anastomotic healing (ischemia, tension, nutrition) is sparse. More recent research has implicated atypical factors that influence anastomotic healing, including the microbiome, the mesentery, and geometry. As technology evolves, endoscopic approaches may improve anastomotic healing and in some cases may eliminate the anastomosis altogether.Discussion: Much remains unknown regarding the mechanisms of anastomotic healing, and research should focus on elucidating the dynamics of healing at a molecular level. Doing so may help facilitate the transition from traditional surgical dogma to evidence-based medicine in the operating room. [ABSTRACT FROM AUTHOR]

Introduction: C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery.Methods: A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy.Results: A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5.Conclusions: The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak is a feared complication after left-sided colectomy, but its risk can potentially be reduced with the use of a diverting ostomy. However, an ostomy has its own associated negative sequelae; therefore, it is critical to appropriately identify patients to divert. This is difficult in practice since many risk factors for anastomotic leak exist and outside factors bias this decision. We aimed to develop and validate a risk score to predict an individual's risk of anastomotic leak and aid in the decision.Methods: The American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted PUF was queried from 2012 to 2016 for patients undergoing elective left-sided resection for malignancy, benign neoplasm, or diverticular disease. Multivariable logistic regression identified predictors of anastomotic leak in non-diverted patients, and a risk score was developed and validated.Results: 38,475 patients underwent resection with an overall anastomotic leak rate of 3%. Independent risk factors for anastomotic leak included younger age, male sex, tobacco use, and omission of combined bowel preparation. A risk score incorporating independent predictors demonstrated excellent calibration. There was strong visual correspondence between predicted and observed anastomotic leak rates. 3960 patients underwent resection with diversion, yet over half of these patients had a predicted leak rate of less than 4%.Conclusion: A novel risk score can be used to stratify patients according to anastomotic leak risk after elective left-sided resection. Intraoperative calculation of scores for patients can help guide surgical decision-making in both diverting the highest risk patients and avoiding diversion in low-risk patients. [ABSTRACT FROM AUTHOR]

Introduction: The standard technique for Ivor Lewis minimally invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure.Technique: We describe our technique for a one-stage hand-assisted minimally invasive esophagectomy that allows sequential access to the chest and abdomen within the same surgical field, eliminating the need for repositioning. The patient is positioned in a "corkscrew" configuration with the abdomen supine and the chest rotated to the left to allow access to the right chest. The abdomen and chest are prepped into a single operative field. This technique allows sequential access to the abdomen for gastric mobilization, chest for division of the esophagus, abdomen for construction of the gastric conduit, and chest for intrathoracic anastomosis.Conclusion: This approach enables extracorporeal construction of the conduit, which helps ensure a clear distal margin on the specimen and facilitates conduit length by placing the stomach on stretch during stapling. [ABSTRACT FROM AUTHOR]

Background: The use of synthetic adhesives such as cyanoacrylates has been established previously for a wide range of clinical indications. However, more research is necessary to evaluate their use in digestive closures or anastomosis. New chemical formulations developed to achieve more flexibility of synthetic adhesives (i.e., based on n-butyl-2-cyanoacrylate) could be an alternative to achieve this purpose. The aim of this study was to investigate the feasibility of using flexible cyanoacrylate adhesives for large gastric incision closure in an animal model.Methods: Twelve farm pigs were divided in two groups depending on the type of closure method applied. In all cases, extra-large seven centimeters gastrostomies were performed. Braided absorbable hand-sewn interrupted suture versus n-butyl-2-cyanoacrylate with softener closure were compared during a 3-week follow-up period. Histopathological aspects, hematologic and inflammatory biomarkers, and endoluminal pressure tolerated until leakage were assessed. The time spent on both closing procedures was compared.Results: No differences between the two groups were found in any of the histopathological and inflammatory variables evaluated. The glued group tolerated a significantly higher pressure than the manual suture group. A reduction of surgery time was also observed.Conclusions: Our results suggest that flexible cyanoacrylates could be a feasible alternative to improve the clinical outcome of the closure of hollow viscera through more efficient sutureless procedures. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak after gastroesophageal surgery is a life-threatening complication. Self-expanding metal stent (SEMS) implantation or endoscopic vacuum therapy (EVT) have been established as alternatives to reoperation. This study compares the outcome of both interventions for anastomotic leak clinical management.Methods: In this retrospective study, we identified all patients who received SEMS or EVT for anastomotic leaks after oncological gastroesophageal surgery between January 2007 and December 2016. Only patients with type II leaks according to the Esophagectomy Complications Consensus Group were included. Sealing rates, intervention-related complications, demographic characteristics, clinical history, leak characteristics, therapy duration, and in-hospital mortality were analyzed.Results: One hundred eleven patients who received SEMS (n = 76) or EVT (n = 35) were identified and categorized by primary and final treatment. The overall closure rate in the final treatment analysis was 85.7% for EVT and 72.4% for SEMS (p = 0.152). ICU stay ranged from 0 to 60 days (median 6 days) for EVT and from 0 to 295 days (median 9 days) for SEMS (p = 0.704). EVT patients were hospitalized for 19-119 days (median 39 days) and SEMS patients for 13-296 days (median 37 days; p = 0.812). Demographic factors, comorbidities, and surgical parameters did not correlate with treatment or treatment success.Conclusions: SEMS and EVT show comparable results for anastomotic leak management after oncologic gastroesophageal surgery. No superior outcome could be found for either one of the two treatments options. [ABSTRACT FROM AUTHOR]

The microbiome exerts a remarkable effect on human physiology. The study of the human-microbiome relationship is a burgeoning field with great potential to improve our understanding of health and disease. In this review, we address common surgical problems influenced by the human microbiome and explore what is thus far known about this relationship. These include inflammatory bowel disease, colorectal neoplasms, and diverticular disease. We will also discuss the effect of the microbiome on surgical complications, specifically anastomotic leak. We hope that further research in this field will enlighten our management of these and other surgical problems. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to investigate the impact of ketorolac and other nonsteroidal anti-inflammatory drugs on anastomotic leakage after surgery for gastro-esophageal-junction cancer. Within the last two decades, the incidence of gastro-esophageal-junction cancer has increased in the western world and surgery is the curative treatment modality of choice. Anastomotic leakage is a feared complication of gastro-esophageal surgery, as it increases recurrence, morbidity, and mortality. Nonsteroidal anti-inflammatory drugs are widely used for postoperative pain relief. Nonsteroidal anti-inflammatory drugs have, however, in colorectal surgery, been shown to increase the risk of anastomotic leakage.Method: In a historical cohort study, we investigated the impact of nonsteroidal anti-inflammatory drugs on anastomotic leakage in 557 patients undergoing surgery for gastro-esophageal-junction cancer. Data were collected from a prospective maintained database, the Danish National Patient Registry, and patient medical records. Data were analyzed using univariate and multivariate statistical models and were stratified for theoretical confounders.Results: In univariate analysis, we did not observe any difference in age, gender, tobacco exposure, or comorbidity status between patients experiencing anastomotic leakage and those without. In multivariate analysis, gender, histology, and type of anastomosis proved to affect odds ratios for anastomotic leakage. After adjustment for possible confounders, we found an odds ratio of 6.05 (95% confidence interval 2.71; 13.5) for ketorolac use and of 5.24 (95% confidence interval 1.85; 14.8) for use of other nonsteroidal anti-inflammatory drugs for anastomotic leakage during the first seven postoperative days.Conclusion: In the present study, we found a strong association between the postoperative use of ketorolac and other nonsteroidal anti-inflammatory drugs and the risk for anastomotic leakage after surgery for gastro-esophageal-junction cancers. [ABSTRACT FROM AUTHOR]

Background: Treatment of left-sided colorectal anastomotic leaks often requires fecal stream diversion for prevention of further septic complications. To manage anastomotic leak, it is unclear if diverting ileostomy provides similar outcomes to Hartmann resection with colostomy.Methods: We identified all patients who developed anastomotic leak following left-sided colorectal resections from 1/2012 through 12/2014 using the American College of Surgeons National Surgical Quality Improvement Program. Then, we examined the risk of mortality and abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection.Results: There were 1745 patients who experienced an anastomotic leak in a cohort of 63,748 patients (3.7%). Two hundred thirty-five patients had a reoperation for anastomotic leak involving the formation of a diverting ileostomy (n = 77) or Hartmann resection (n = 158). There was no difference in mortality or abdominal reoperation in patients treated with diverting ileostomy (3.9, 7.8%) versus Hartmann resection (3.8, 6.3%) (p = 0.8).Conclusion: There was no difference in the outcomes of mortality or need for second abdominal reoperation in patients treated with diverting ileostomy as compared to Hartmann resection for left-sided colorectal anastomotic leak. Thus, select patients with left-sided colorectal anastomotic leaks may be safely managed with diverting ileostomy. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage is one of the most severe complications following esophageal resection. Among other strategies, gastric ischemic preconditioning has been proposed to improve anastomotic integrity. The aim of this systematic review is to investigate whether gastric preconditioning has influence on peri- or postoperative outcomes after esophageal resection.Methods: A systematic literature search was performed to identify studies comparing gastric preconditioning with non-preconditioned patients for any indication of esophageal resection. Random-effects meta-analyses were conducted for main outcomes.Results: Gastric preconditioning did not reduce anastomotic leakages (OR 0.76; 95%-CI 0.51 to 1.13; p = 0.18), anastomotic strictures (OR 1.10; 95%-CI 0.58 to 2.10; p = 0.76;), major complications (OR 1.14; 95%-CI 0.60 to 2.14; p = 0.69), or in-hospital mortality (OR 0.62; 95%-CI 0.28 to 1.40; p = 0.25). However, preconditioning reduced the rate of severe leaks requiring reoperation (OR 0.20; 95%-CI 0.08 to 0.53; p = 0.001). Increasing the period between preconditioning and esophageal resection over 2 weeks did not reduce anastomotic leakage compared to shorter waiting times (OR 0.65; 95%-CI 0.38 to 1.13; p = 0.13).Conclusion: With current evidence, gastric preconditioning does not seem to reduce overall rates of anastomotic leakage after esophageal resection but seems to reduce severity of leakages. [ABSTRACT FROM AUTHOR]

Introduction: Hepaticojejunostomy leaks are less frequent than pancreatic leaks after pancreatoduodenectomy, and the current literature suggests comparable outcomes. The purpose of this study was to determine if the hepaticojejunostomy leak adversely affected patient outcomes.Methods: Consecutive cases of pancreatoduodenectomy (n = 924) were reviewed at a single high-volume institution over an 8-year period (2006-2014).Results: Pancreaticojejunostomy leaks were identified in 217 (23%) patients and hepaticojejunostomy leaks were identified in 24 patients (3%); combined hepaticojejunostomy/pancreaticojejunostomy leaks were identified in 31 patients (3%). Those with hepaticojejunostomy leaks or combined leaks had a significantly increased risk of morbidity when compared to pancreaticojejunostomy leaks or no leak (54 and 58 vs. 34 and 24%, respectively, p < 0.05). The median length of stay was significantly greater for hepaticojejunostomy leaks or combined leaks when compared to pancreatojejunostomy leaks (17 or 14 vs. 9 days, p = 0.001) and those with no leak (17 or 14 vs. 7 days, p = 0.001). Ninety-day mortality for all patients was 3.6%. Hepaticojejunostomy leaks and combined leaks significantly increased 90-day mortality rate (17 and 32%, respectively, p < 0.05).Conclusions: Hepaticojejunostomy and combined leaks after pancreatoduodenectomy are rarer than pancreaticojejunostomy leaks; these patients are at a significantly increased risk of major morbidity and mortality. [ABSTRACT FROM AUTHOR]

Many studies have showed that routine upper gastrointestinal contrast agent examinations (RCE) for testing the patency of the anastomosis after esophagectomy or the stapler line after sleeve gastrectomy cannot be recommended due to low sensitivity. However, the clinical value of RCE after gastrectomy for gastric cancer remains unclear. We have retrospectively analyzed the clinical course of 377 consecutive patients who underwent gastrectomy for gastric cancer in our institution between 2005 and 2015. To date, we have performed a RCE on the fifth postoperative day before removal of the nasogastric tube and return to oral intake. In total, we have observed 14 anastomotic leaks (AL) (4%) after oncologic gastrectomy. Four AL (28.6%) occurred before the scheduled RCE on the fifth postoperative day (POD) and 7 (50%) late AL after POD 5. Three patients (21.4%) without any clinical symptoms were diagnosed by the RCE. Sensitivity of RCE was 50%. A significant percentage of patients with AL was diagnosed by computed tomography (CT) of the abdomen (50%). The standard therapy for AL after gastrectomy was endoscopic stent placement (n = 11), including three cases of stenting after surgical revision. Based on our data, we cannot recommend a RCE after gastrectomy for gastric cancer. The majority of AL occurs before or after a RCE and the sensitivity of the examination is low. In case of clinical suspicion of AL, a CT scan (with oral contrast agent) should be performed. In unclear cases, endoscopy is the preferable method providing the option of direct treatment. [ABSTRACT FROM AUTHOR]

After total gastrectomy, anastomosis-related complications such as leak or stricture can be highly morbid. Between July 2005 and December 2015, a linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy (modified Orringer technique) was used for Roux-en-Y reconstruction after prophylactic total gastrectomy in 22 germline CDH1 mutation carriers and after therapeutic total gastrectomy in 18 patients diagnosed with gastric adenocarcinoma. All operations were performed by the same surgeon. No patient in either cohort developed a clinically evident anastomotic leak, one patient (2.5%) developed a contained radiographic leak that healed without intervention, and one patient (2.5%) developed an anastomotic stricture treated by endoscopic dilatation 7 months after operation. These rates were lower than radiographic leak and stricture rates in a comparison group of 32 patients who received a completely hand-sewn esophagojejunostomy (6.3 and 3.1%, respectively). Here, we describe how to perform the linear-stapled esophagojejunostomy anastomosis. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak is one of the most feared complications of gastrointestinal surgery. Surgeons routinely perform a diverting loop ileostomy (DLI) to protect high-risk colo-rectal anastomoses.Study Design: The NSQIP database was queried from 2012 to 2013 for patients undergoing open ileo-colic resection with and without a DLI. The primary outcome was the development of any anastomotic leak-including those managed operatively and non-operatively. Secondary outcomes included overall complication rate, return to the OR, readmission, and 30-day mortality.Results: Four thousand one hundred fifty-nine patients underwent open ileo-colic resection during the study period. One hundred eighty-six (4.5 %) underwent a DLI. Factors associated with the addition of a DLI included emergency surgery, pre-operative sepsis, and IBD. There were 197 anastomotic leaks (4.7 %) with 100 patients requiring reoperation (2.4 %). DLI was associated with a decrease in anastomotic leaks requiring reoperation (DLI vs no DLI: 0 (0 %) vs 100 (2.5 %); p = 0.02) and with increased readmission (OR 1.93; 95 % CI 1.30-2.85; p = 0.001).Conclusion: DLI is rarely used for open ileo-colic resection. There were no serious leaks requiring reoperation in the DLI group. A DLI was associated with an almost two-fold increase in the odds of readmission. Surgeons must weigh the reduction in serious leak rate with postoperative morbidity when considering a DLI for open ileo-colic resection. [ABSTRACT FROM AUTHOR]

Background: Despite ever more powerful antibiotics, newer surgical techniques, and enhanced recovery programs, anastomotic leaks remain a clear and present danger to patients. Previous work from our laboratory suggests that anastomotic leakage may be caused by Enterococcus faecalis strains that express a high collagenase phenotype (i.e., collagenolytic). Yet the mechanisms by which the practice of surgery shifts or selects for collagenolytic phenotypes to colonize anastomotic tissues remain unknown.Methods: Here, we hypothesized that morphine, an analgesic agent universally used in gastrointestinal surgery, promotes tissue colonization with collagenolytic E. faecalis and causes anastomotic leak. To test this, rats were administered morphine in a chronic release form as would occur during routine surgery or vehicle. Rats were observed for 6 days and then underwent exploratory laparotomy for anastomotic inspection and tissue harvest for microbial analysis. These results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery.Results: Results demonstrated that compared to placebo-treated rats, morphine-treated rats demonstrated markedly impaired anastomotic healing and gross leaks that correlated with the presence of high collagenase-producing E. faecalis adherent to anastomotic tissues. To determine the direct role of morphine on this response, various isolates of E. faecalis from the rats were exposed to morphine and their collagenase activity and adherence capacity determined in vitro. Morphine increased both the adhesiveness and collagenase production of four strains of E. faecalis harvested from anastomotic tissues, two that were low collagenase producers at baseline, and two that were high collagenase producers at baseline.Conclusion: These results provide further rationale to enhanced recovery after surgery (i.e., ERAS) programs that suggest limiting or avoiding the use of opioids in gastrointestinal surgery. [ABSTRACT FROM AUTHOR]

Introduction: Anastomotic leakage is a serious complication after colorectal resection. Recent studies suggest that nonsteroidal anti-inflammatory drugs may increase the risk of anastomotic leakage. We investigated this association in our enhanced recovery population.Material and Methods: Patients undergoing an elective colon or rectal resection with primary anastomosis because of malignancy and treated within our enhanced recovery program were included. Univariable and multivariable logistic regression analyses were used to study risk factors for anastomotic leakage.Results: Between 2006 and 2013, 856 patients were included. The anastomotic leakage rate was significantly higher in the group that received nonsteroidal anti-inflammatory drugs compared to patients who did not: 9.2 vs. 5.3%, p = 0.038. This higher rate was only seen in patients receiving diclofenac: for colonic resections, 11.8 vs. 6.0%, p = 0.016; for rectal resections, 13.1 vs. 0%, p = 0.017. Only male sex (odds ratio 2.20, p = 0.005) was also independently associated with anastomotic leakage.Conclusion: The results of this study are in line with other comparable studies in the literature, showing an increased risk for anastomotic leakage with diclofenac. The use of diclofenac in colorectal surgery can no longer be recommended. Alternatives for postoperative analgesia need to be explored within an enhanced recovery program. [ABSTRACT FROM AUTHOR]