Link between postoperative ileus and anastomotic leakage: A structural equation modelling approach

Postoperative anastomotic leaks are one of the most devastating consequences of colorectal surgery. Diagnostic imaging for upper gastrointestinal anastomotic leaks has been evaluated and reported on extensively. No study has compared the utility and effectiveness of CT scans and water-soluble enemas for the identification of postoperative lower gastrointestinal anastomotic leaks. The present study was designed to evaluate and compare these two common radiographic imaging modalities in detecting lower gastrointestinal anastomotic leaks. A retrospective chart review was performed that identified 36 patients during a seven-year period who underwent reoperative surgery for a lower gastrointestinal anastomotic leak. Patient's imaging studies were classified as positive if extravasation of contrast material was demonstrated. When negative, a study was retrospectively reviewed in an attempt to identify findings suggestive of an anastomotic leak. There were 36 patients identified with a postoperative lower gastrointestinal leak requiring surgical intervention. There were 28 of 36 patients (78 percent) re-explored on the basis of a radiologic study demonstrating an anastomotic leak. A total of 27 CT scans were performed, of which 4 (14.8 percent) were considered positive for an anastomotic leak. On review of the remaining negative CT scans, nine (33.3 percent) were considered descriptive positive with a large amount of fluid or air in the peritoneal cavity but without obvious extravasation of contrast. Eighteen patients were evaluated with a water-soluble enema and 15 (83.3 percent) demonstrated extravasation of contrast material. In the 26 patients with a distal anastomotic leak, 17 water-soluble enemas were performed, with 15 (88 percent) demonstrating a leak. In contrast, only 2 of 17 (12 percent) CT scans were positive in this group of patients (P < 0.001). There were ten patients who initially had a CT scan followed by a water-soluble enema. Of these patients, eight of nine (88 percent) initially had a negative CT scan but were considered to be clinically suspicious of having an anastomotic leak and subsequently had a leak demonstrated on a water-soluble enema. Early intervention in patients who develop an anastomotic leak can be shown to improve the ultimate outcome, especially with respect to mortality. It is usually necessary to obtain objective tests of anastomotic integrity because of the nonspecificity of clinical signs. Our study supported the superiority of water-soluble enema to CT imaging in patients in whom both modalities were used. This difference was most pronounced for distal anastomotic leaks, whereas no radiologic imaging study proved effective in evaluating proximal anastomoses.

The advent of the da Vinci robotic prostatectomy has several advantages over open and laparoscopic prostatectomy, including fewer complications, better continence and potency. We evaluate the incidence and imaging features of urinary leaks after robotic prostatectomy. A retrospective study examining the anastomotic leak rates from 490 consecutive robotic prostatectomy patients. Routine postoperative cystography on day 7 was reviewed for presence and severity of urinary anastomotic leaks. A total of 490 patients were reviewed, of which 442 had cystographic imaging postoperatively (n = 442). A total of 67 urinary leaks were identified; 40 were small, limited extraperitoneal leaks confined to the surgical bed, 21 were moderate sized leaks limited to the extraperitoneal pelvic space, and six extended in to the peritoneal cavity. Two of these six patients required CT-guided drainage for peritoneal urinoma. Other cystography findings included two cases of vesicoureteral reflux and one case of colovesical fistula. The incidence of postoperative anastomotic urinary leaks following robotic prostatectomy (13.6%) is the same or better than laparoscopic prostatectomy and traditional radical retropubic prostatectomy. The vast majority of urethrovesical leaks are transient, requiring no follow-up intervention. The incidence of large anastomotic leaks requiring CT guided intervention is exceedingly low 2/490 (<0.5%).

BackgroundThe impact of a patient’s gender on the development of anastomotic leak (AL) in rectal cancer patients following total mesorectal excision (TME) remains controversial. The aim of this study was to evaluate the association between patients’ gender and the risk of AL.MethodsAll rectal cancer patients following TME with a primary anastomosis during the study period from 2010 to 2014 were examined. Comparisons of the post-operative AL incidence rate between male and female patients were performed.ResultsOf all patients examined (n = 956), 587 (61.4%) were males and 369 (38.6%) were females. Male patients were more likely to have a history of smoking and drinking alcohol, but less likely to have a history of abdominal surgery compared to female patients. A higher incidence rate of pre-operative bowel obstruction and larger tumor volume in male patients was observed in our study. Of all the patients, 81 (8.5%) developed post-operative AL. More male patients (n = 62, 10.6%) suffered from AL than females (n = 19, 5.1%) (P = 0.003). Multivariate logistic regression analyses confirmed the association between male gender and AL [odds ratio (OR): 2.41, 95% confidence interval (CI): 1.37–4.23, P = 0.002]. Similar results were also obtained in patients who underwent laparoscopic TME (OR: 2.11, 95% CI: 1.15–3.89, P = 0.016).ConclusionsMale patents were found to have an increased risk for AL following TME with a primary anastomosis. A temporary protecting stoma may help to protect the anastomosis and lessen the risk for AL especially in male patients.

ObjectiveTo evaluate the anastomotic leakage (AL) rates in cancerous and non-cancerous intestinal anastomoses and analyze the general risk factors for AL.MethodsThe primary endpoint of this study is to investigate whether there is a difference in terms of AL between patients who underwent sigmoid colon resection + colorectal anastomosis due to primary colon cancer (Group 1) and patients with a completely healthy colorectal region who underwent sigmoid colon resection + colorectal anastomosis for use in the orthotopic bladder during radical cystoprostatectomy (Group 2). The secondary endpoint, considering all the patients, is to evaluate and investigate the risk factors affecting the AL rates.ResultsA total of 178 patients, including 63 (35.4%) patients in Group 1 and 115 (64.6%) patients in Group 2, were included in the study. The mean age of all patients was 61.7 ± 9.9 years, and there was no statistical difference between the mean ages of the groups (62.8 ± 11.3 vs 60.7 ± 6.1, p = 0.106, respectively). Thirty-six (20.2%) of the patients were female, and 142 (79.8%) were male. There was no significant difference between the groups in terms of AL in the postoperative period. Postoperative AL was seen in three patients (4.8%) and six patients (5.2%) in Group 1 and Group 2, respectively (p = 0.642). According to univariate and multiple logistic regression analysis, the risk of AL increased in patients with comorbidities, in the presence of previous abdominal surgery, in patients with high neutrophil-to-lymphocyte ratio, and patients with postoperative ileus (p values are 0.042, 0.010, 0.029 and 0.048, respectively).ConclusionOur data suggest that anastomosis due to colon cancer resection does not increase the risk of AL compared with healthy bowel anastomoses. In addition, some clinical factors have been found to compromise anastomotic safety and are risk factors for AL. In addition, some clinical factors have been found to endanger anastomotic safety and are risk factors for AL.

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

ObjectiveLittle is known about intestinal anastomotic leakage and stenosis in young children (≤3 years of age). The purpose of this study is to answer the following questions: (1) what is...

Although a few reports have suggested transanal drainage tube (TDT) can reduce the pressure in the anastomotic portion, it remains unclear whether TDT can prevent anastomotic leakage (AL). In addition, little is known about the relationship between AL and daily fecal volume through TDT. This study investigated the role of TDT for the prevention of AL following laparoscopic low anterior resection (LAR). This is a retrospective analysis of a prospectively maintained database of 201 rectal cancer patients who underwent laparoscopic LAR. The relationship between AL and daily fecal volume through TDT was examined. AL occurred in 25 patients. Based on the TDT grouping, AL occurred in 10.7% (19/178) of the TDT group, whereas it occurred in 26.1% (6/23) of the non-TDT group (P = 0.046). In the 178 patients with TDT placement, the daily fecal volumes on postoperative days (PODs) 2-5 were significantly higher compared with those on POD 1 (P < 0.05). The daily fecal volume was observed to be gradually increasing until POD 3 or 4 (median, 25 or 23ml/day, respectively) and then significantly decreasing on POD 5 (10ml/day) (P < 0.05). The AL rate of the patients whose daily fecal volume exceeded 100ml/day in two or more days was significantly higher than that of those in 0 or 1day (26.9 vs. 7.9%; P < 0.01). TDT could be efficient to prevent AL following laparoscopic LAR. Postoperative fecal volume may be a reliable predictor of AL.

The objective of this study was to determine the effect of polyphosphate on intestinal bacterial collagenase production and anastomotic leak in mice undergoing colon surgery. We have previously shown that anastomotic leak can be caused by intestinal pathogens that produce collagenase. Because bacteria harbor sensory systems to detect the extracellular concentration of phosphate which controls their virulence, we tested whether local phosphate administration in the form of polyphosphate could attenuate pathogen virulence and prevent leak without affecting bacterial growth. Groups of mice underwent a colorectal anastomosis which was then exposed to collagenolytic strains of either Serratia marcescens or Pseudomonas aeruginosa via enema. Mice were then randomly assigned to drink water or water supplemented with a 6-mer of polyphosphate (PPi-6). All mice were sacrificed on postoperative day 10 and anastomoses assessed for leakage, the presence of collagenolytic bacteria, and anastomotic PPi-6 concentration. PPi-6 markedly attenuated collagenase and biofilm production, and also swimming and swarming motility in both S. marcescens and P. aeruginosa while supporting their normal growth. Mice drinking PPi-6 demonstrated increased levels of PPi-6 and decreased colonization of S. marcescens and P. aeruginosa, and collagenase activity at anastomotic tissues. PPi-6 prevented anastomotic abscess formation and leak in mice after anastomotic exposure to S. marcescens and P. aeruginosa. Polyphosphate administration may be an alternative approach to prevent anastomotic leak induced by collagenolytic bacteria with the advantage of preserving the intestinal microbiome and its colonization resistance.

Anastomotic leakage (AL) is a severe complication following colorectal surgery. C-reactive protein (CRP) is considered to be an indicator of postoperative complications. Between August 2002 and August 2005 342 colorectal resections with primary anastomosis were performed at the Department of General and Vascular Surgery. Johann Wolfgang Goethe-University Frankfurt. For this retrospective study serum CRP was measured daily until postoperative day 7, and in cases of AL it was excluded from statistical analysis beginning with the day on which the AL was diagnosed. Twenty-six of 342 (7.6%) patients developed AL at a mean of 8.7 days postoperatively. The in-hospital mortality was 3.5% for all patients and was significantly higher in the AL group (11.5 versus 2.8%). The CRP level in the two groups showed a peak on day 2.5 and day 2.2, respectively. In case of postoperative AL the CRP level did not show a marked decline during the next few days. Compared to the cases where AL did not develop, there was a significantly higher increase in CRP from the preoperative level to the levels measured on postoperative day 3, 5, 6 and 7. Higher CRP levels were observed in patients experiencing pneumonia or urinary tract infection, but the decrease of CRP values was not as slow as in cases of AL. This study shows serum CRP level to be a relevant marker in detecting postoperative complications in colorectal surgery. Prolonged elevation and a missing decline in CRP level precede the occurrence of AL.

The International Study Group of Rectal Cancer (ISREC) has proposed a new definition of anastomotic leakage (AL) which was simply classified into three grades; however, these criteria have not been assessed well. The aims of this study are to assess the new definition and to show the clinical features of AL after an anterior resection for rectal cancer. Fifty consecutive patients developed AL after an anterior resection for rectal cancer was retrospectively assessed. AL was defined by the ISREC criteria. Twenty-seven (54 %) patients with AL were diagnosed by drain contents. The postoperative day of diagnosis for AL was later in grade A versus grades B and C (p = 0.038 vs p = 0.006, respectively). Permanent stoma (PS) was significantly more frequent in patients with grade C but not grade B compared to the patients with no AL (p < 0.001 and p = 0.171, respectively). In patients without diverting stoma, there was more serious grade of AL (p < 0.001). Differences were observed in the postoperative day of diagnosis, the creation rate of PS, and impact on diverting stoma after AL between each grade of leakage. The new classification was easy and reasonable to evaluate AL. As a result, it should be widely used in future studies.

Anastomotic stricture is one of the crucial complications after the esophageal cancer surgery. Although anastomotic leakage is said to be a risk factor, anastomotic stricture can also occur without anastomotic leakage. From 2008, we have routinely conducted endoscopy on postoperative day 1, and evaluated the anastomotic site or mucosal condition of reconstructed organ. Among these data, we focused on the mucosal congestive change and examined the association with postoperative anastomotic stricture. From 2010 to 2015, 203 esophageal cancer patients were conducted esophagectomy with retrosternal gastric tube reconstruction in Tokyo Medical and Dental University. Among them, 197 patients for which endoscopic data on postoperative day 1 were obtained were included in this study. Mucosal congestion was defined as blue or black color on endoscopic findings, and classified into four groups as absent, mild, moderate, and severe. Univariate and multivariate analysis were performed to clarify the relationship between the mucosal congestive change on endoscopic findings and occurrence of postoperative anastomotic stricture. Among 197 patients, 60 patients (30.4%) experienced postoperative anastomotic stricture. Univariate and multivariate analysis revealed that the mucosal congestive change as moderate or severe was the independent risk factor for postoperative anastomotic stricture along with lower pathological Stage. Circular stapler size used for esophago-gastric anastomosis or postoperative anastomotic leakage were not independent risk factors for postoperative anastomotic stricture in this study. It is said that congestive change induces secondary ischemia because of the high internal tissue pressure, and sometimes causes more severe damage than arterial ischemia. Our postoperative endoscopic evaluation method is useful to detect the risk of developing anastomotic stricture in early postoperative state. In such cases, management of postoperative fluid balance might be important to prevent postoperative anastomotic stricture, but it requires further investigation.

Introduction Anastomotic leakage (AL) is one of the most feared complications after esophagectomy for esophageal cancer. We investigated the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL. Methods This is a retrospective study of 193 patients who underwent a minimally invasive Ivor-Lewis procedure between January 2017 and October 2021. Mean CRP and median drain amylase levels between patients with and without AL were compared during the first five postoperative days (POD). ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP. Results In 30 of the 193 patients (16%), AL was diagnosed with a median time to diagnosis of 9 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 59, 110 and 106 mg/L had a high sensitivity of 93%, 90% and 90% on POD 3, 4 and 5. No difference in median drain amylase levels was observed. Conclusions CRP levels with a cut-off point of 110 mg/L on POD 4 do not improve earlier detection of AL, but have a high sensitivity for excluding AL. The value of drain amylase in the first 5 days after surgery is limited.

Objective To verify the accuracy of the mathematical model of gastrointestinal decompression after esophagectomy of esophageal cancer and explore predictive value of the mathematical model in the postoperative complications. Methods The retrospective case-control study was conducted. The clinicopatholo-gical data of 192 patients with esophageal cancer who underwent esophagectomy in the Beijing Chaoyang Hospital of Capital Medical University between October 2013 and October 2016 were collected. Among 192 patients, 160 didn′t have postoperative complications and 32 had postoperative complications (7 with postoperative anastomotic leakage, 9 with pulmonary infection and 16 with dysfunction of gastralintestinal tract). Patients selected the appropriate surgical procedures according to individual conditions, and then volume of gastrointestinal decompression was recorded daily. According to the regression equation of influencing factors of volume of postoperative gastrointestinal decompression: average daily drainage volume within 5 days (mL)=262.287+ 132.873×tubular stomach-72.160×smoking history-27.904×pathological type of tumor-36.368×age, predictive value of postoperative gastrointestinal decompression was calculated and compared with real volume of gastrointestinal decompression. Observation indicators: (1) comparison between predictive value and real volume of postoperative gastrointestinal decompression in patients without complications; (2) comparison between predictive value and real volume of postoperative gastrointestinal decompression in patients with complications. Measurement data with normal distribution were represented as ±s and comparison was analyzed using the paired-samples t test. Measurement data with skewed distribution were described as M (range), and comparison was analyzed using the Wilcoxon signed rank tests. Results (1) Comparison between predictive value and real volume of postoperative gastrointestinal decompression in patients without complications: predictive value and real volume of postoperative gastrointestinal decompression in 160 patients without complications were respectively 187 mL (range, 58-392 mL) and 207 mL (range, 20-570 mL), with no statistically significant difference (Z=-1.106, P>0.05). (2) Comparison between predictive value and real volume of postoperative gastrointestinal decompression in patients with complications: 7 patients had postoperative anastomotic leakage, including 1 with cervical anastomotic leakage and 6 with chest anastomotic leakage. The predictive value and real volume of postoperative gastrointestinal decompression in 7 patients with anastomotic leakage were respectively (215±58)mL and (338±106)mL, with a statistically significant difference (t=-3.139, P 0.05). The predictive value and real volume of postoperative gastrointestinal decompression in 16 patients with dysfunction of gastralintestinal tract were respectively (236±60)mL and (357±107)mL, with a statistically significant difference (t=-4.716, P<0.05). Conclusions The mathematical model of gastrointestinal decompression after esophagectomy of esophageal cancer is correct and feasible. There is a predictive value for patients with postoperative anastomotic leakage and dysfunction of gastralintestinal tract. Key words: Esophageal neoplasms; Esophagectomy; Gastrointestinal decompression; Postoperative complications; Multivariable linear regression

Defining severe postoperative ileus in terms of consequences could help physicians standardize the management of this condition. The recently described classification based on consequences requires further investigation. The aim of this study was to obtain a snapshot of postoperative ileus in patients undergoing colorectal surgery within enhanced recovery programs and to identify factors associated with non-severe and severe postoperative ileus. This prospective registry data analysis was conducted in 40 centers in five different countries. A total of 786 patients scheduled for colorectal surgery within enhanced recovery programs were included. The primary endpoint was the incidence rate of postoperative ileus as defined by Vather et al. RESULTS: A total of 121 patients experienced postoperative ileus (15.4%). Non-severe POI occurred in 48 patients (6.1%), and severe postoperative ileus occurred in 73 patients (9.3%). In multivariate analysis, the male gender and intra-abdominal complications were associated with severe postoperative ileus: odd ratio (OR) = 2.03 [95% confidence interval (CI) 1.14-3.59], p = 0.01 and OR = 3.60[95% CI 1.75-7.40], p < 0.0001, respectively. Conversely, open laparotomy and urinary retention were associated with non-severe POI: OR = 3.03[95% CI 1.37-6.72], p = 0.006 and OR = 2.70 [95% CI 0.89-8.23], p = 0.08, respectively. Postoperative ileus occurred in 15% of patients after colorectal surgery within enhanced recovery programs. For 60% of patients, this was considered severe. The physiopathology of these two entities could be different, severe POI being linked to intraabdominal complication, while non-severe POI being linked with risk factors for "primary" POI. The physician should pay attention to male patients having POI after colorectal surgery and look for features evocating intraabdominal complications.

Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers. This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated. Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity). Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.