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Introduction: Despite spectacular visuals and the seemingly convincing rationale of using indocyanine-green-enhanced fluorescence in assessing bowel perfusion during colorectal resections, a lingering sense of subjectivity remains in the challenge of quantifying this fluorescence. This prospective study analyzed the application of O2C® spectrophotometry to quantify zones of fluorescence on the large bowel during low anterior resection. Materials and methods: Patients receiving a low anterior resection for cancer of the mid- and lower rectum were enrolled in this observational prospective study between February 2020 and December 2022. O2C® blood-flow measurement was performed at three different zones of fluorescence intensity (optimal [O], sufficient [S], and absent [A]), visualized at the designated and already skeletonized site of colon transection. The primary end point was to assess whether the O2C® flow value exceeds 164 arbitrary units (AU) at the zone of optimal fluorescence. The secondary objective was to assess whether there were statistically significant differences in flow parameters between the three zones, thus confirming reproducibility of measurements. Results: A total of 40 patients were enrolled in this study. Of these, 38 patients remained for statistical analysis with regard to O2C® measurement of the fluorescence zones. The O2C® flow parameter measured at the zone of optimal fluorescence was greater than 164 AU in all cases (100%, p < 0.0001). There were statistically significant differences in flow parameters measured at the three different zones of fluorescence (O-S: p < 0.0001; O-A: p < 0.0001; S-A: p = 0.0023). Conclusion: This study proves the feasibility and reproducibility of quantifying zones of indocyanine green (ICG)-enhanced fluorescence on the bowel. All O2C® flow measurements that were collected at the zone of optimal fluorescence exceeded 164 AU, thereby adding more evidence to this value as a suggested cut-off parameter in terms of bowel perfusion. [ABSTRACT FROM AUTHOR]

PurposeAnastomotic leak is a dreaded complication of colorectal surgery. An endoscopic grading score of the perianastomotic mucosa has been previously developed at our institution (UCI) to assess colorectal anastomotic integrity. The objective of this study is to validate the UCI anastomotic score and determine its impact in anastomotic failure.MethodsAs a follow-up study of the UCI grading score implementation during 2011 to 2014, patients undergoing stapled colorectal anastomoses after sigmoidectomy or proctectomy at a single institution from 2015 to 2018 were retrospectively reviewed. Patients were grouped into three tiers based on endoscopic appearance (grade 1, circumferentially normal mucosa; grade 2, ischemia/congestion  30% of circumference).ResultsOn the basis of endoscopic mucosal evaluation, grade 1 anastomosis was observed in 299 patients (94%), grade 2 anastomosis in 14 patients (4.4%), and grade 3 anastomosis in 5 patients (1.6%). All grade 3 classifications were immediately and successfully revised intraoperatively with reclassification as a grade 1 anastomosis. The anastomotic leak rate of the follow-up study period from 2015 to 2018 was 6.4% which was lower compared to the anastomotic leak rate of 12.2% in the original study period from 2011 to 2014 (p = 0.07). Anastomotic leak rate for the entire patient series was 8.5%. A grade 2 anastomosis was associated with higher anastomotic leak rate compared to a grade 1 anastomosis (35.7% vs. 7.4%, p

Background: Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. Method: This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. Results: A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was − €74,915.28 per patient without anastomotic complications. Conclusion: The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks. [ABSTRACT FROM AUTHOR]

Background: The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines. Methods: Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1β, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP). Results: A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications. Conclusions: This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories. [ABSTRACT FROM AUTHOR]

Background: Computed tomography (CT) scan with rectal contrast enema (RCE-CT) could increase the detection rate of anastomotic leaks (AL) in the early postoperative period following colorectal surgery, compared to CT scan without RCE. The aim of this study was to assess the benefit of RCE-CT for the early diagnosis of AL following colorectal surgery. Methods: Patients who had a RCE-CT for suspected AL in the early postoperative period following colorectal surgery with anastomosis between January 2012 and July 2019 at the Dijon University Hospital were retrospectively included. All images were reviewed by two independent observers who were blinded to the original report. The reviewers reported for each patient whether an AL was present or not in each imaging modality (CT scan, then RCE-CT). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were then calculated to determine the diagnostic performance of each modality. Results: One hundred and thirty-nine patients were included. RCE-CT had an increased NPV compared to CT scan (82% vs 77% (p = 0.02) and 84% vs 68% (p < 0.0001) for observers 1 and 2, respectively). RCE-CT had an increased sensitivity compared to CT scan (79% vs 48% (p < 0.0001) for observer 2). RCE-CT had a significant lower false-negative rate for both observers: 18% vs 23% (p = 0.02) and 16% vs 32% (p < 0.0001). Conclusions: RCE-CT improved the detection rates of AL in the early period following colorectal surgery. RCE-CT should be recommended when a CT scan is negative and AL is still suspected. [ABSTRACT FROM AUTHOR]

Background: The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery. Methods: A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion. Results: Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150–350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50–100 ml (OR 1.14, p = 0.007), 250–300 ml (OR 2.06, p < 0.001), and 400–500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100–200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200–500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150–200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200–500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02). Conclusions: Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject. [ABSTRACT FROM AUTHOR]

Background: Theoretical advantages of Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) are a reduced risk of anastomotic leak and therefore avoidance of stoma. Gradually abandoned in favor of immediate coloanal anastomosis (ICAA) with diverting stoma, DCAA has regained popularity in recent years in reconstructive surgery for low RC, especially when combined with minimally invasive surgery (MIS). The aim of this study was to perform the first meta-analysis, exploring the safety and outcomes of DCAA compared to ICAA with protective stoma. Methods: A systematic search of MEDLINE, EMBASE, and CENTRAL and Google Scholar databases was performed for studies published from January 2000 until December 2020. The systematic review and meta-analysis were performed according to the Cochrane Handbook for Systematic Review on Interventions recommendations and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Results: Out of 2626 studies screened, 9 were included in the systematic review and 4 studies in the meta-analysis. Outcomes included were postoperative complications, pelvic sepsis and risk of definitive stoma. Considering postoperative complications classified as Clavien–Dindo III, no significant difference existed in the rate of postoperative morbidity between DCAA and ICAA (13% versus 21%; OR 1.17; 95% CI 0.38–3.62; p = 0.78; I2 = 20%). Patients in the DCAA group experienced a lower rate of postoperative pelvic sepsis compared with patients undergoing ICAA with diverting stoma (7% versus 14%; OR 0.37; 95% CI 0.16–0.85; p = 0.02; I2 = 0%). The risk of definitive stoma was comparable between the two groups (2% versus 2% OR 0.77; 95% CI 0.15–3.85; p = 0.75; I2 = 0%). Conclusions: According to the limited current evidence, DCAA is associated with a significant decrease in pelvic sepsis. Further prospective trials focusing on oncologic and functional outcomes are needed. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage (AL) is a major complication of colorectal surgery resulting in morbidity, mortality and poorer quality of life. The early diagnosis of AL is challenging due to the poor positive predictive value of tests available and reliance on clinical presentation which may be delayed. The aim of this systematic review was to assess the applicability of peritoneal cytokine levels as an early predictive test of AL in postoperative colorectal cancer patients. Methods: A comprehensive literature search was performed from inception to January 2021, in MEDLINE and EMBASE databases using MeSH and non-MeSH terms in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies evaluating peritoneal cytokines in the context of AL were included in this review. Results: Two hundred ninety-two abstracts were screened, 30 full manuscripts evaluated, and 12 prospective studies were included. There were 8 peritoneal cytokines evaluated (interleukin [IL]-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor [VEGF], tumour necrosis factor alpha [TNF alpha] and matrix metalloproteinase [MMP]2 and MMP9) between AL and non-AL groups on postoperative day 1. Those that included IL-6 (7 studies), IL-10 (4 studies), TNF alpha (6 studies) and MMP9 (2 studies) were included in the meta-analysis. IL-10 was the only cytokine in the meta-analysis that was significantly (p < 0.05) raised in drain fluid on postoperative day 1 in AL patients. Conclusions: Peritoneal IL-10 was significantly raised on postoperative day 1 in patients who subsequently developed AL. This may be a useful early predictor of AL and aid in an earlier diagnosis for postoperative colorectal patients. The range of cytokines investigated within the literature is limited and from heterogeneous studies which suggests more research is needed. [ABSTRACT FROM AUTHOR]

Background: Defunctioning ileostomy creation and closure are both associated with morbidity. There is little data available about complications after ileostomy closure. The aim of this study was to evaluate morbidity related to loop ileostomy closure (LIC) and to determine if patients with postoperative complications in primary surgery suffer from more postoperative complications during stoma closure. Methods: This was a retrospective study on prospectively registered consecutive patients undergoing elective LIC in a single centre in Spain between April 2010 and December 2017. Baseline characteristics, postoperative complications after primary surgery and after stoma closure were recorded. Primary surgery included any colorectal resection, elective or urgent associated with a diverting loop ileostomy either as a protective stoma or rescue procedure. A logistic regression model was used to assess the effects of baseline variables and postoperative complications after primary surgery on the existence of postoperative complications related to LIC. Results: Four hundred and twenty-eight patients (288 men, median age 64.5 years [IQR 55.1–72.3 years]) were included in the study, and 37.4%, developed complications after LIC. The most common was paralytic ileus. Only chronic kidney disease (OR 2.31; 95% CI 1.03–5.33, p = 0.043), existence of postoperative complications after primary surgery (OR 2.25; 95% CI 1.41–3.66, p = < 0.001) and ileostomy closure later than 10 months after primary surgery (OR 1.52; 95% CI 1.00–2.33, p = 0.049) were statistically significant in the multivariate analysis. Conclusions: Patients with chronic kidney disease, those who had any complication after primary surgery and those who had LIC > 10 months after primary surgery have a significantly higher risk of developing postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak following elective sigmoidectomy performed due to sigmoid volvulus (SV) is a devastating complication. The aim of this study was to identify the incidence and risk factors associated with leak in this specific group of patients. Methods: A retrospective study was performed at two university-affiliated tertiary centres in Israel. All consecutive patients between January 2014 and April 2020 treated for SV with elective sigmoidectomy and primary anastomosis were reviewed and those suffering from anastomotic leak identified. Factors associated with this complication were assessed using univariate analysis and odds ratios subsequently calculated. Results: Of the 99 patients initially identified, 58 were included in the study group [45 males and 13 females (77.6% versus 22.4% respectively) mean age 67.4 years, range 13–97]. There were 10 anastomotic leaks identified (17.2%). On univariate analysis recurrent decompression (OR 8.28, p = 0.027), age > 80-years (OR 6.88, p = 0.027), open rather than laparoscopic surgery (OR = 5.83, p = 0.005) and ASA grade 3/4 (OR 0.132, p = 0.023) were significantly associated with anastomotic leak. Male sex approached but not reach statistical significance. Conclusions: Recurrent endoscopic decompression, age > 80 years, open surgery and ASA grade 3/4 are associated with anastomotic leak and these patients should be considered for formation of a colostomy instead. If an anastomosis is performed, patients should be appropriately counselled and monitored in the perioperative period. [ABSTRACT FROM AUTHOR]

Background: Air leak tests (ALTs) and dye leak tests (DLTs) are the most common techniques for Intraoperative colorectal anastomosis assessment. The aim of our study was to compare the sensitivity of ALT with DLT in intraoperative evaluation of colorectal anastomotic integrity and to quantify the pressures routinely used in these tests. Methods: A prospective clinical trial was conducted on patients who had elective colorectal resection and primary anastomosis from November 2017 until July 2019 in a single academic referral center. Each patient underwent both tests. The ALT was a transanal insufflation of CO2 and inspection of escaping bubbles around the anastomosis immersed in saline. The DLT was a transanal infusion of diluted methylene blue and inspection of dye stains on surgical gauze wrapping the anastomosis. Peak pressures were measured. Primary endpoints were the sensitivity of ALT and DLT in detecting intraoperative leaks, quantification of intraluminal pressure routinely used in these settings and assessment of postoperative complications such as a clinical leak. Results: Forty patients underwent elective colorectal resection and anastomosis for malignant (67%) or benign n (33%) etiology. Height of anastomoses ranged from 1 to 25 cm (mean ± SD 12 ± 6 cm). Mean pressures measured were 26.5 ± 6.6 mmHg for the DLT and 22 ± 4 mmHg for the ALT (p < 0.01). Twenty percent of the DLTs were positive (8 patients) compared to 2.5% (1 patient) of the ALTs (RR 1.97, CI 1.2–2.7; p = 0.03). All patients who had positive tests had a suture reinforcement of the anastomosis. Only 1 patient, who had a positive DLT and ALT, developed a clinical leak Conclusions: DLT is more sensitive in detecting anastomotic leak intraoperatively. This is the first study measuring anastomotic tests' pressures used in-vivo in humans demonstrating a range of 20-30 mmHg. Based on our data we believe that a positive DLT with a negative ALT may be treated with suture reinforcement alone. Clinical trial number: NCT03316677–10/17/2017 [ABSTRACT FROM AUTHOR]

Background: Several risk factors for anastomotic leakage (AL) following colorectal surgery have been described. Improvement in devices for performing anastomosis is a modifiable factor that could reduce AL rates. The aim of this study was to assess the impact of technical improvements in the Echelon Circular™ powered stapler (ECPS) on the left-sided colorectal AL rate compared to current manual circular staplers (MCS). Methods: A cohort study was carried out on consecutive patients between January 2017 and February 2020 in whom left-sided stapled colorectal anastomosis above 5 cm from anal verge was performed. The primary end point was the risk of AL depending on the type of circular stapler used. The ECPS cases were matched to MCS cases by propensity score matching to obtain comparable groups of patients. Results: Two hundred seventy-nine patients met the inclusion criteria. A MCS anastomosis was performed in 218 patients and ECPS anastomosis in 61 (21.9%). Overall, AL was observed in 25 (9%) cases. Factors significantly associated with AL were American Society of Anesthesiologists score (p = 0.025) and type of circular stapler used (p = 0.021). After adjusting the cases with propensity score matching (119 cases MCS versus 60 ECPS), AL was observed in 14 (11.8%) patients in MCS group and in 1 (1.7%) patient in the ECPS group (p = 0.022). AL in the MCS group required reoperation in seven cases (5.8%), the remaining seven patients were treated conservatively. The patient in the ECSP group required an urgent Hartmann's procedure Conclusions: The ECPS device could have a positive impact by reducing AL rates in left-sided colorectal anastomosis. Multicenter controlled trials are needed for stronger evidence to change practice. [ABSTRACT FROM AUTHOR]

Background: The current data on the intraoperative use of indocyanine green (ICG) fluorescence imaging to reduce the anastomotic leak (AL) rate in rectal cancer surgery remain controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ICG fluorescence imaging in decreasing the AL rate after rectal cancer surgery. Methods: Studies comparing ICG fluorescence imaging with standard care in patients with rectal cancer were systematically searched from PubMed, Embase, Web of Science and Cochrane Library through January 2020. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the baseline features, AL rate and other surgical outcomes. RevMan version 5.3 software was used for the present meta-analysis. Results: Nine studies with a total of 2088 patients with rectal cancer (926 in the ICG group and 1162 in the control group) were included in the present study. In the pooled analysis, the available patient and tumour-related baseline data were all comparable and without significant heterogeneity. In the present pooled analysis, the AL rate in the ICG group was significantly lower (OR 0.34; 95% CI 0.22–0.52; p < 0.0001) than that in the control group. Additionally, intraoperative use of ICG was associated with a decreased overall complication rate (OR 0.57; 95% CI 0.42–0.78; p = 0.0003) and reduced reoperation rate (OR 0.26; 95% CI 0.08–0.86; p = 0.03) in patients who had rectal cancer surgery. Conclusions: The present study demonstrated the superiority of the intraoperative use of ICG in reducing the AL rate. However, considering the limitations of the included studies, more high-quality prospective studies and randomized controlled trials are needed. [ABSTRACT FROM AUTHOR]

Background: Placement of a transanal tube (TAT) into the rectum is a strategy used to attempt to prevent anastomotic leak (AL) in anterior resection surgery. There is a wide variation in materials and tube design in devices used as TATs and previous meta-analyses have not considered TAT design in their analyses. This study reviews the impact that design of TAT has on AL rates. Methods: A systematic review of the literature was performed with the aim of identifying studies evaluating the use of TATs for preventing AL and then defining the design of TATs. Studies were then compared in groups based on TAT design in a meta-analysis to evaluate whether design is an important variable in outcomes. Results: Thirty-three studies were included. There was a wide variety of tubes used as TATs. On meta-analysis, catheter-type TATs were associated with a substantially lower rate of AL (OR: 0.46; 95% CI 0.30, 0.68). By contrast, stent-type TATs were not associated with any reduction in the incidence of AL (OR: 1.06, 95% CI 0.50, 2.22). Catheter-type TATs were also associated with substantial reductions in the rate of reoperation (OR: 0.32; 95% CI 0.20, 0.50), whereas stent-type TATs showed no benefit in the rate of reoperation (OR: 0.79; 95% CI 0.37, 1.65). Conclusions: Off-the-shelf catheter-type transanal tubes appeared effective in preventing AL, whereas custom-designed stent-type TATs were not demonstrated to be effective; although high quality evidence is limited. TAT design should be an important consideration in further research of the use of TATs in anterior resection surgery. [ABSTRACT FROM AUTHOR]

Background: Ileal pouch-anal anastomosis (IPAA) is an effective surgical alternative to a permanent ileostomy following proctocolectomy in patients with ulcerative colitis (UC). Anastomotic leakage (AL) is a serious postoperative complication of an intestinal anastomosis that is associated with increased morbidity and mortality. The aim of this study was to evaluate the longitudinal long-term functional outcomes of patients who had IPAA that was complicated by AL. Methods: A retrospective longitudinal cohort study was performed of patients who had an IPAA procedure at a tertiary referral centre and a metropolitan private centre in Australia, over a 14-year period (October 2003–October 2017). The long-term functional outcome was assessed using objective clinical measures such as the number of bowel motions during the day and overnight, ability to defer defaecation and the presence of faecal incontinence, and repeated at annual intervals. Results: A total of 138 patients [mean age 38.5 (± 16.9) years, 72 males] satisfied the inclusion criteria. AL was diagnosed in 14 (10%) patients [mean age 38.8 (± 17) years, 10 males], 11 (79%) of which were managed with surgery. The median bowel motion frequency during the day and overnight remained stable over a median of 62 (28–91) months follow-up, with no significant difference between those who had AL or not (p = 0.6, p = 0.1 respectively). The incidence of faecal incontinence remained low, and the majority of patients in both groups were able to defer defaecation for more than 60 min. Six patients (4.3%) had their pouch excised. Conclusions: There is no statistical difference in longitudinal function between patients who experienced AL after IPAA surgery for UC compared with those who did not. Therefore, an acute AL does not negatively impact long-term functional outcomes in IPAA patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS). Methods: A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL. Results: A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0–5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04–8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36–23.53]) were associated with AL. Conclusions: Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer. [ABSTRACT FROM AUTHOR]

Background: Aortoiliac calcification may be a surrogate marker of decreased visceral perfusion causing anastomotic leak (AL). The aim of this study was to evaluate the predictive role of aortoiliac calcification for AL after rectal cancer surgery. Methods: We enrolled patients with primary rectal cancer who had restorative resection at our institution between January 2013 and December 2015. An aortoiliac calcification score was calculated as the sum of calcification scores at the infrarenal aorta (0: no, 1: ≤ 3 cm, 2: > 3 cm) and the common iliac arteries (0: no, 1: unilateral, 2: bilateral). AL was classified into three grades: grade A, requiring no intervention; grade B, requiring therapeutic intervention without re-laparotomy; and grade C, requiring re-laparotomy. Clinicopathological characteristics were analyzed to identify risk factors for AL. Results: There were 583 patients. Three-hundred forty-five (59.2%) had an aortoiliac calcification score ≥ 3, and 37 (6.3%) patients experienced AL, in 30 cases (5.1%) grade C AL. Patients with an aortoiliac calcification score ≥ 3 had a higher incidence of grade C AL (6.7% vs. 2.9%, p = 0.045). Multivariate logistic regression analysis revealed that an aortoiliac calcification score ≥ 3 was an independent risk factor for grade C AL (odds ratio = 2.669, 95% confidence interval 1.066–6.686, p = 0.036). Conclusions: Aortoiliac calcification may be considered a risk factor for grade C AL after rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE®) in the treatment of rectal anastomotic leaks. Methods: All studies looking at endoluminal vacuum therapy with Endo-SPONGE® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes Results: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0–44%), with random effects model of 0.17 (95% CI 0.11–0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity. Conclusions: Endo-SPONGE® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to perform a systematic review and meta-analysis of cancer-specific outcomes after curative rectal cancer surgery comparing anastomotic leak (AL) with no leak. Methods: PubMed, Medline and Embase databases were searched to identify studies comparing cancer-specific outcomes after rectal cancer surgery in patients with AL and without. A meta-analysis with a random-effects model was used to calculate pooled odds ratios (OR) and confidence intervals (CI) for each outcome measure. Results: A total of 18 studies were included for meta-analysis, comprising a total of 18,039 patients after curative rectal resection (1764 AL, 16,275 without AL). The overall rate of AL was 9.8%. After AL and excluding 30-day mortality there was an increased risk of local recurrence (OR 1.50; CI 1.23, 1.82), worse overall survival (OR 0.69; CI 0.60–0.81), decreased disease free survival (OR 0.51; CI 0.36–0.73) and cancer specific survival (OR 0.71; CI 0.54–0.94). Distant recurrence (OR 1.10; CI 0.89–1.37) and overall recurrence (OR 1.33; CI 0.64–2.76) were not significantly different between the two groups. Conclusions: AL may negatively impact cancer-specific outcomes after curative rectal cancer surgery and could be considered an independent negative prognostic factor. [ABSTRACT FROM AUTHOR]

Background: The most important advancement in the surgical management of rectal cancer has been the introduction of total mesorectal excision (TME). Technical limitations to approaching mid and distal lesions remain. The recently described transanal TME makes it possible to minimize some of the difficulties by improving access. Anastomotic leak is a persistent concern after colorectal surgery no matter what technique is used. The objective of this study was to explore the impact of experience on the incidence of anastomotic leak after transanal TME. Secondary endpoints were local recurrence and margin status. Methods: A retrospective cohort study was conducted over a period of 3 years at a tertiary care center in Northern Ontario with high volume of rectal cancer patients. The initial 100 consecutive patients with rectal neoplasia who had transanal TME surgery were included. All cases were performed by a single team. The main outcome assessed was the incidence of anastomotic leak beyond a pre-determined learning curve, as previously established in the literature. For statistical analysis, associations between patient characteristics and outcomes were estimated using ordinary least squares and logistic regression. Results: Six cases of anastomotic leak occurred over the course of the study, the last of which occurred in the 37th patient. Relative to a baseline anastomotic leak rate of 7.8%, cumulative sum (CUSUM) analysis indicated that a 50% improvement in risk occurred at trial 50 of 85 patients that had an anastomosis performed. Two patients developed local recurrence during the study period. No correlation between learning curve and oncologic outcomes was identified. Conclusions: Proficiency is likely to have a positive effect on the 30-day occurrence of anastomotic leak. Larger studies are required to explore the impact of experience on local recurrence. [ABSTRACT FROM AUTHOR]

Background: Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections. Methods: A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25–29 mm or 30–33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications. Results: Four hundred seventy-three cases were evaluated, 185 (39.1%) were in the 25–29 mm group and 288 (60.9%) in the 30–33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30–33 mm than with the 25–29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25–29 mm than with the 30–33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032). Conclusions: The 25–29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30–33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature. Methods: A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy. Results: In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases. Conclusions: VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made. [ABSTRACT FROM AUTHOR]

Background: An anastomotic leak is the most dreaded complication after low anterior resection. Adipose tissue grafting may induce healing in a persistent anastomotic defect. The aim of the present study was to report retrospectively reviewed outcomes for a series of patients who were managed with heterotopic grafted adipose tissue to facilitate anastomotic healing. Methods: Patients with anastomotic leakage after low anterior resection sequentially treated with grafting of adipose tissue were included in the study. All patients had pelvic radiation during treatment and had a diverting ileostomy in situ. The cohort had a persistent defect despite being treated with available modalities such as suture repair, fibrin glue, Endo-Sponge and surgical debridement. The outcomes were reviewed and reported. Results: There were 11 patients (8 males and 3 females) with a median age of 54 years (range 33–72 years). Five patients experienced complete healing of the anastomotic defect with successful reversal of the diverting ileostomy. The anastomotic defect of one other patient in the series appeared to have healed and hence his diverting ileostomy was reversed. However, he presented with a recurrent leak, which ultimately necessitated an abdominoperineal resection. Another patient had a persistent defect after an attempt at adipose tissue grafting and opted to proceed with a takedown of the anastomosis. In the remaining four patients, the outcome after adipose tissue grafting remains unknown, as two patients succumbed to metastatic disease, one was lost to follow-up and the remaining patient developed a recurrence which required pelvic exenteration. Procedural associated morbidity occurred in one patient who developed fat embolism, which was treated expectantly. Conclusions: Adipose tissue grafting is safe and feasible, though its effectiveness remains uncertain. It may be useful selectively in the management of persistent anastomotic leak after radiation and low anterior resection. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma. Objective: The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma. Methods: Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak. Results: Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model's probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity. Conclusions: We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online (http://www.real-score.org). [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) and intraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. Methods: A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. Results: Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14–0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21–1.30) and IOC (RR 0.49; Crl 0.10–1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14–0.87) and IOC (RR 0.44; Crl 0.14–0.87). Conclusions: This study suggests that intraoperative testing for a good blood supply using ICG may reduce the AL rate following colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak after rectal surgery is reported in 9% (range 3–28%) of patients. The aim of our study was to evaluate the effectiveness of endosponge therapy for anastomotic. Endpoints were the rate of restored continuity and the functional bowel outcome after anastomotic leakage. Methods: This was a multicenter retrospective observational cohort study. All patients with symptomatic anastomotic leakage after rectal surgery who had endosponge therapy between January 2012 and August 2017 were included. Functional bowel outcome was measured using the low anterior resection syndrome (LARS) score system. Results: Twenty patients were included. Eighteen patients had low anterior resection (90%) for rectal cancer. A diverting ileostomy was performed at primary surgical intervention in 14 patients (70%). Fourteen patients (70%) were treated with neoadjuvant (chemo-)radiotherapy. The median time between primary surgical intervention and first endosponge placement was 21 (5–537) days. The median number of endosponge changes was 9 (2–28). The success rate of the endosponge treatment was 88% and the restored gastrointestinal continuity rate was 73%. A chronic sinus occurred in three patients (15%). All patients developed LARS, of which 77% reported major LARS. Conclusions: Endosponge therapy is an effective treatment for the closure of presacral cavities with high success rate and leading to restored gastrointestinal continuity in 73%. However, despite endosponge therapy many patients develop major LARS. [ABSTRACT FROM AUTHOR]

Background: Radiologically defined sarcopenia has been shown to predict negative outcomes after cancer surgery, however radiological assessment of sarcopenia often requires additional software and standardisation against anthropomorphic data. Measuring psoas density using hospital Picture Archiving and Communication Systems (PACS), universally available in the UK, may have advantages over methods requiring the use of additional specialist and often costly software. The aim of this study was to assess the association between radiologically defined sarcopenia measured by psoas density and postoperative outcome in patients having a colorectal cancer resection. Methods: All patients having a resection for colorectal cancer, discussed by the colorectal multi-disciplinary team in one institution between 1/1/15 and 31/12/15, were retrospectively identified. Mean psoas density at the level of the L3 vertebra was analysed from preoperative computed tomography (CT) scans to define sarcopenia using the Picture Archiving and Communication Systems (PACS). Postoperative complications and mortality were recorded. Results: One hundred and sixty-nine patients had a colorectal resection for cancer and 140 of these had a primary anastomosis. Ninety-day mortality and 1-year mortality were 1.1% and 7.1%, respectively. Eighteen (10.7%) patients suffered a Clavien–Dindo grade 3 or 4 complication of which 6 (33%) were anastomotic leaks. In the whole cohort, sarcopenia was associated with an increased risk of Clavien–Dindo grade 3 or 4 complications [adjusted OR 6.33 (1.65–24.23) p = 0.007]. In those who had an anastomosis, sarcopenia was associated with an increased risk of anastomotic leak [adjusted OR 14.37 (1.37–150.04) p = 0.026]. Conclusions: A quick and easy radiological assessment of sarcopenia by measuring psoas density on preoperative CT scan using software universally available in the UK is highly predictive of postoperative morbidity in colorectal cancer patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC).Methods: This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates.Results: Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%.Conclusions: FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: In patients who undergo restorative proctocoletomy (RPC) a pouchogram is often used to assess the integrity of the ileal pouch—anal anastomosis (IPAA) before closing the covering ileostomy. There are no good data to support this practice. The aim of the study was to investigate whether contrast pouchography was clinically useful after RPC.Methods: We conducted a retrospective study of patients who had undergone RPC with a covering ileostomy between September 2013 and September 2015.Results: 61 patients were included. 7 (11%) presented with anastomotic leak and 2 (3%) with pelvic collection, detected on cross-sectional imaging for early postoperative symptoms. In the remaining 52 patients, without immediate postoperative complications, pouchography was performed at a median of 14 weeks (range 7-71 weeks) after RPC. Each patient also underwent examination under anaesthesia (EUA) to assess the integrity of the IPAA on the day of the ileostomy closure. One asymptomatic patient (2%) had an anastomotic leak demonstrated on pouchogram which was subsequently confirmed at EUA. Two patients (3%) with a normal pouchogram, 1 symptomatic and 1 asymptomatic, subsequently had an anastomotic leak demonstrated at EUA.Conclusions: Pouchogram has a low sensitivity in identifying anastomotic leak before ileostomy reversal in patients after RPC and only rarely changes management. In our series it identified the diagnosis of anastomotic leak in only 1 patient and gave false reassurance in two others. Complications are more frequently detected by clinical history and formal EUA before ileostomy closure. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to assess the short-term and long-term consequences of diverting loop ileostomy (DLI) omission in ileal pouch-anal anastomosis (IPAA) surgery complicated by postoperative pelvic sepsis.Methods: This was a retrospective review of a prospectively maintained database. Of 4031 patients who underwent IPAA in 1983–2014, 357 developed IPAA-related pelvic sepsis with or without anastomotic dehiscence. Patients with Crohn’s disease or cancer were excluded. The patient cohort was divided into two groups, depending on the presence or absence of DLI. Patient characteristics, short-term and long-term outcomes were compared. Long-term pouch survival was estimated with the Kaplan–Meier method. Quality of life (QOL) in the groups was compared at the latest follow-up.Results: Three hundred and twenty-six patients developing pelvic sepsis had diversion at the time of IPAA (D group) and in 31 who developed pelvic sepsis DLI had been omitted (O group). The length of hospital stay was significantly longer in the O group 11.5 (3–33) days versus 8 (2–59) days in the D group (p = 0.006). Forty-eight percent of patients from the O group with anastomotic leak underwent reoperation and had a DLI formed at this second procedure versus 12% in the D group requiring reoperation (p < 0.0001). In long-term follow-up, there was no difference in pouch survival between the groups: 99 versus 97% after 5 years and 88 versus 87% after 10 years, in the O group and D group, respectively (p = 0.40). There was no difference in QOL observed between the groups.Conclusions: Omission of DLI in selected patients who had IPAA surgery did not increase pouch failure or adversely affect QOL in the long term, if pelvic sepsis occurred. [ABSTRACT FROM AUTHOR]

Background: Indocyanine green (ICG) fluorescence imaging has been proven to be an effective tool to assess anastomotic perfusion. The aim of this systematic review and meta-analysis was to evaluate its efficacy in reducing the anastomotic leakage (AL) rate after colorectal surgery.Methods: PubMed, Scopus, WOS, Google Scholar and Cochrane Library were searched up to January 2017 for studies comparing fluorescence imaging with standard care. ClinicalTrials.gov register was searched for ongoing trials. The primary outcome measure was AL rate with at least 1 month of follow-up. ROBINS-I tool was used for quality assessment. A meta-analysis with random-effects model was performed to calculate odds ratios (ORs) from the original data.Results: One thousand three hundred and two patients from 5 non-randomized studies were included. Fluorescence imaging significantly reduced the AL rate in patients undergoing surgery for colorectal cancer (OR 0.34; CI 0.16–0.74; p = 0.006). Low AL rates were shown in rectal cancer surgery (ICG 1.1% vs non-ICG 6.1%; p = 0.02). There was no significant decrease in the AL rate when colorectal procedures for benign and malignant disease were combined. To date, there are no published randomized control trials (RCTs) on this subject, though 3 ongoing RCTs were identified.Conclusions: ICG fluorescence imaging seems to reduce AL rates following colorectal surgery for cancer. However, the inherent bias of the non-randomized studies included, and their differences in AL definition and diagnosis could have influenced results. Large well-designed RCTs are needed to provide evidence for its routine use in colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Recently published data support the use of a web-based risk calculator () for the prediction of anastomotic leak after colectomy. The aim of this study was to externally validate this calculator on a larger dataset. Methods: Consecutive adult patients undergoing elective or emergency colectomy for colon cancer at a single institution over a 9-year period were identified using the Binational Colorectal Cancer Audit database. Patients with a rectosigmoid cancer, an R2 resection, or a diverting ostomy were excluded. The primary outcome was anastomotic leak within 90 days as defined by previously published criteria. Area under receiver operating characteristic curve (AUROC) was derived and compared with that of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator and the colon leakage score (CLS) calculator for left colectomy. Commercially available artificial intelligence-based analytics software was used to further interrogate the prediction algorithm. Results: A total of 626 patients were identified. Four hundred and fifty-six patients met the inclusion criteria, and 402 had complete data available for all the calculator variables (126 had a left colectomy). Laparoscopic surgery was performed in 39.6% and emergency surgery in 14.7%. The anastomotic leak rate was 7.2%, with 31.0% requiring reoperation. The anastomoticleak.com calculator was significantly predictive of leak and performed better than the ACS NSQIP calculator (AUROC 0.73 vs 0.58) and the CLS calculator (AUROC 0.96 vs 0.80) for left colectomy. Artificial intelligence-predictive analysis supported these findings and identified an improved prediction model. Conclusions: The anastomotic leak risk calculator is significantly predictive of anastomotic leak after colon cancer resection. Wider investigation of artificial intelligence-based analytics for risk prediction is warranted. [ABSTRACT FROM AUTHOR]

Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak can be a devastating complication, and early prediction is difficult. The aim of this study is to prospectively validate a simple anastomotic leak risk calculator and compare its predictive value with the estimate of the primary operating surgeon. Methods: Consecutive patients undergoing elective or emergency colon cancer surgery with a primary anastomosis over a 1-year period were prospectively included. A recently published anastomotic leak risk nomogram was converted to an online calculator (). The calculator-derived risk of anastomotic leak and the risk estimated by the primary operating surgeon were recorded at the completion of surgery. The primary outcome was anastomotic leak within 90 days as defined by previously published criteria. Area under receiver operating characteristic curve analysis (AUROC) was performed for both risk estimates. Results: A total of 105 patients were screened for inclusion during the study period, of whom 83 met the inclusion criteria. The overall anastomotic leak rate was 9.6%. The anastomotic leak calculator was highly predictive of anastomotic leak (AUROC 0.84, P = 0.002), whereas the surgeon estimate was not predictive (AUROC 0.40, P = 0.243). Conclusions: A simple anastomotic leak risk calculator is significantly better at predicting anastomotic leak than the estimate of the primary surgeon. Further external validation on a larger data set is required. [ABSTRACT FROM AUTHOR]

Anastomotic leaks are a feared complication of colorectal resections and novel techniques that have the potential to decrease them are still sought. This study aimed to compare the anastomotic leak rates in patients undergoing compression anastomoses versus hand-sewn or stapled anastomoses. Randomized controlled trials (RCTs) comparing outcomes of compression versus conventional (hand-sewn and stapled) colorectal anastomosis were collected from MEDLINE, Embase and the Cochrane Library. The quality of the RCTs and the potential risk of bias were assessed. Pooled odds ratios (OR) were calculated for categorical outcomes and weighted mean differences for continuous data. Ten RCTs were included, comprising 1969 patients (752 sutured, 225 stapled, and 992 compression anastomoses). Most used the biofragmentable anastomotic ring. There was no significant difference between the two groups in terms of anastomotic leak rates (OR 0.80, 95 % confidence interval (CI) 0.47, 1.37; p = 0.42), stricture (OR 0.54: 95 % CI 0.18, 1.64; p = 0.28) or mortality (OR 0.70; 95 % CI 0.39, 1.26; p = 0.24). Compression anastomosis was associated with an earlier return of bowel function: 1.02 (95 % CI 1.37, 0.66) days earlier ( p < 0.001) and a shorter postoperative stay; 1.13 (95 % CI 1.52, 0.74) days shorter ( p < 0.001), but significant heterogeneity among studies was observed. There was an increased risk of postoperative bowel obstruction in the compression group (OR 1.87; 95 % CI 1.07, 3.26; p = 0.03). There was no significant difference in wound-related and general complications, or length of surgery. Compression devices do not appear to provide an advantage over conventional techniques in fashioning colorectal anastomoses and are associated with an increased risk of bowel obstruction. [ABSTRACT FROM AUTHOR]