ObjectiveTo study feasibility of sheath technique with seromuscular sleeve of pedicled colon in preventing anastomotic leakage following laparoscopic anterior resection of rectal cancer.MethodsThe clinical data of patients who underwent laparoscopic anterior resection of rectal cancer in our hospital from January 2017 to March 2020 were retrospectively collected. According to different surgical methods, they were divided into two groups: pedicled seromuscular sleeve sheath group (referred to as sleeve sheath operation group) and traditional operation group. The intraoperative and postoperative statuses were compared between these two groups.ResultsIn this study, 87 patients with rectal cancer were included, 37 in the sleeve sheath operation group and 50 in the traditional operation group. There were no significant differences in the baseline data such as the gender, age, body mass index (BMI), complicating disease, distance from lower tumor margin to anal verge, histological classification, neoadjuvant radio- chemotherapy, and TNM stage between the two groups (P>0.05). There were no significant differences in the volumes of intraoperative blood loss, the number of lymph node dissection, the first postoperative anal exhaust time and the hospitalization expense between the two groups (P>0.05). Compared with the traditional operation group, the operative time of the sleeve sheath operation group was longer (P<0.05), the postoperative hospitalization time of the sleeve sheath operation group was shorter (P<0.05). The incidence of postoperative anastomotic leakage in the sleeve sheath operation group and the traditional group were 0.0% (0/37) and 12.0% (6/50), respectively, and the difference was statistically significant (P<0.05). There were no significant differences in the anastomotic stenosis, the lymphatic fistula and the incision infection between the two groups (P>0.05). All patients were followed-up for 6 to 36 months, with a median time of 21 months. No recurrence or death occurred.ConclusionThe sheath technique with seromuscular sleeve of pedicled colon can increase the anti tension ability of anastomotic stoma and reduce the incidence of anastomotic leakage, which is a safe and effective surgical method.
Objective To understand the changes of intestinal flora during perioperative period of colorectal cancer and the mechanism affecting the occurrence of postoperative anastomotic leakage, so as to improve perioperative management of patients and find possible measures to decrease the incidence rate of anastomotic leakage. Method The literature related to perioperative intestinal flora assessment, anastomotic healing, and anastomotic leakage of colorectal cancer in recent years was comprehensively searched in the CNKI, PubMed, and Embase databases and made an review. ResultsDue to the various perioperative interventions, the diversity and abundance of intestinal flora had changed after colorectal cancer surgery, and some conditional pathogenic bacteria such as Enterococcus faecalis, Pseudomonas aeruginosa, etc. increased obviously, which led to collagen degradation through the expression of bacterial collagenase or the excessive activation of matrix metalloproteinases in the host intestine, then might lead to the poor anastomotic healing and even the anastomotic leakage. ConclusionAlthough the evidence of effect of intestinal flora on anastomotic leakage mainly comes from animal experiments, it still shows the potential role of intestinal flora in the occurrence of anastomotic leakage after colorectal cancer surgery, and can be regulated by perioperative intervention, which suggests that it may provide a new strategy for prevention of anastomotic leakage.
ObjectiveTo summarize the experience in the treatment of anastomotic leakage after laparoscopic D2 radical gastrectomy.MethodThe clinicopathologic data of 11 patients with anastomotic leakage after the laparoscopic D2 radical gastrectomy in the Nanchong Central Hospital from May 2016 to January 2018 were analyzed retrospectively.ResultsAmong the 11 patients with anastomotic leakage, 3 were grade Ⅱ leakages and 8 were grade Ⅲa leakages. There were no symptoms in the 3 cases of anastomotic leakage, which were confirmed only by the gastrointestinal radiography and were healed after 7 d of conservative treatment. Among the 8 patients with the clinical symptoms, 5 cases were treated by the endoscopic drainage and negative pressure suction for 60–90 d, 3 cases were treated by the endoscopic covered stent, 2 cases were cured after 30–60 d, and 1 case died of massive bleeding after 45 d.ConclusionsDue to differences of location, time, limitation, and size of anastomotic leakage after laparoscopic D2 radical gastrectomy, individualized treatment should be performed according to specific situation of patients in local treatment. Endoluminal covered stent has certain clinical application value.
Abstract： Objective To investigate diagnosis and treatment of concealed intrathoracic anastomotic leak of the esophagus. Methods We retrospectively analyzed the clinical data of 32 patients who presented with unexplained sepsis （temperature＞38 ℃ and elevated white blood cell count） after esophagectomy and intrathoracic anastomosis for esophageal carcinoma or gastric cardia carcinoma in Affiliated Hospital, Medical College of Qingdao University from January 2006 to December 2010. All the patients underwent oral water-soluble contrast esophagogram and oral water-soluble contrast computerized tomography of the chest. None of the patients had any sign of contrast leak in these diagnostic examinations, but their chest computerized tomography all showed peri-anastomotic bubble and encapsulated effusion. Fifteen patients were treated as concealed intrathoracic anastomotic leak of the esophagus, including fasting, broad spectrum antibiotic treatment, prolonged gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube. The other 17 patients were not treated as anastomotic leak of the esophagus and only received broad spectrum antibiotic treatment. Results None of the 15 patients who were treated as concealed intrathoracic anastomotic leak finally developed anastomotic leak proved by oral water-soluble contrast esophagogram and computerized tomography of the chest （0%, 0/15）. Among the 17 patients who were not treated as anastomotic leak, fourteen patients developed anastomotic leak later （82.4%, 14/17）, 2 patients died of aorto-esophageal fistula and 3 patients died of multiple organ dysfunction syndrome. Conclusion Peri-anastomotic bubble and irregular encapsulated effusion in oral water-soluble contrast esophagogram and computerized tomography of the chest should be considered as specific signs of concealed intrathoracic anastomotic leak of esophagus after esophagectomy and intrathoracic anastomosis. Patients with such signs should be treated as anastomotic leak.
ObjectiveTo explore the predictive value of systemic immune-inflammation index (SII) combined with neutrophil-monocyte ratio (NMR) on postoperative anastomotic leakage in elderly colon cancer. MethodsThe clinical data of 493 elderly colon cancer patients who attended the Department of General Surgery of the First Hospital of Lanzhou University from January 2018 to October 2023 were retrospectively analysed, and divided into an anastomotic leakage group (n=29) and a non-anastomotic leakage group (n=464) according to the occurrence of anastomotic leakage or not, and the differences between the two groups in terms of SII and NMR at different time points were compared. Area under the curve (AUC) of receiver operating characteristic (ROC) was used to compare the predictive value of SII, NMR and the combination of the two on the occurrence of anastomotic leakage after surgery in elderly colon cancer patients. Logistic regression was used to analyse the independent risk factors for postoperative anastomotic leakage in elderly colon cancer patients. ResultsThe SII and NMR in the anastomotic leakage group were higher than those in the non-anastomotic leakage group on the 3 rd and 5 th day after operation (P<0.05). ROC curve analysis showed that the AUC values for SII on postoperative day 3, NMR on postoperative day 5, and the combination of the two to predict anastomotic leakage were 0.613, 0.743, and 0.750, respectively. The results of DeLong’s test suggested that the difference between the AUC values of NMR on postoperative day 5 combined with SII on postoperative day 3 and SII on postoperative day 3 was statistically significant (P=0.047). Multifactorial logistic regression analysis showed that age, male, diabetes, preoperative radiotherapy and chemotherapy, tumor located in the left colon, SII on postoperative day 3, and NMR on postoperative day 5 were independent risk factors for postoperative anastomotic leakage in elderly patients with colorectal cancer (all P<0.05). ConclusionsPostoperative day 3 SII combined with postoperative day 5 NMR, postoperative day 3 SII, and postoperative day 5 NMR all have predictive value for postoperative anastomotic leakage in elderly patients with colorectal cancer. Both have the potential to serve as important predictors of postoperative anastomotic leakage in elderly patients with colon cancer.
Objective To determine the risk factors of anastomotic leakage after elective colectomy in elderly patients with colon cancer, and to establish a model for predicting the risk of postoperative anastomotic leakage based on these factors. Methods The clinical data of 122 over 65 years old elderly patients who underwent colon cancer surgery in the First Hospital of Lanzhou University from January 2018 to December 2021 were analyzed retrospectively. Single factor analysis and multivariate logistic regression were used to analyze the potential risk factors for anastomotic leakage. A nomogram predictive model was established based on the determined independent risk factors, and the predictive performance of the model was evaluated by the receiver operating characteristic curve. Results Among the 122 patients included in this study, 10 had postoperative anastomotic leakage and 112 had no anastomotic leakage. Single factor analysis results showed that the occurrence of anastomotic leakage was associated with body mass index, smoking, combined diabetes, age-adjusted Charlson comorbidity index, intraoperative and postoperative blood transfusion within 2 days, preoperative hemoglobin, preoperative albumin, and preoperative prognostic nutritional index (P＜0.05). The results of multivariate logistic regression analysis showed that smoking [OR=15.529, 95%CI (1.529, 157.690), P=0.020], age-adjusted Charlson comorbidity index [OR=1.742, 95%CI (1.024, 2.966), P=0.041], and intraoperative and postoperative blood transfusion within 2 days [OR=82.223, 95%CI (1.265, 5 343.025), P=0.038] were independent risk factors for anastomotic leakage. A nomogram predictive model was established based on three independent risk factors. The area under the receiver operating characteristic curve of the model was 0.897 [95%CI (0.804, 0.990)], and its corrected C-index value was 0.881, indicating that the model had good predictive ability for the risk of anastomotic leakage. Conclusions Smoking, higher age-adjusted Charlson comorbidity index, and intraoperative and postoperative blood transfusion within 2 days are important risk factors for anastomotic leak in elderly patients undergoing elective colon cancer resection. This nomogram predictive model based on the combination of the three factors is helpful for surgeons to optimize treatment decisions and postoperative monitoring.
ObjectiveTo investigate the diagnostic value of intra-intestinal angiography CT in patients with anastomotic leakage (AL) after rectal cancer resection.MethodsPatients who admitted to The Department of General Surgery of The No. 900 Hospital of The Joint Logistic Team from January 2013 to October 2018, who were diagnosed with rectal cancer and underwent rectal cancer resection with sphincter preserving surgery, were retrospectively collected in the study. All patients underwent routine imaging examination on the 7th day after rectal cancer operation. The retrograde contrast enema (RCE) was performed to obtain the abdominal X-ray film, then the pelvic CT scan was performed to get the CT image of the intestinal lumen. The films were reviewed by 2 senior radiologists, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RCE and intra-intestinal angiography CT in the diagnosis of AL after rectal cancer resection were evaluated. Evaluated the sensitivity of the CT image feature to predict AL after rectal cancer resection.ResultsThe sensitivity, specificity, PPV, and NPV of RCE in the diagnosis of AL after the rectal cancer resection were 69.23% (18/26), 98.64% (218/221), 85.71% (18/21), and 96.46% (218/226) respectively. The sensitivity, specificity, PPV, and NPV of intra-intestinal angiography CT were 96.15% (25/26), 99.09% (219/221), 92.59% (25/27), and 99.54% (219/220) respectively. The sensitivity and NPV of intra-intestinal angiography CT in diagnosis of AL were significantly higher than those of RCE (P<0.05). The sensitivity of contrast agent leakage to diagnosis of AL was the highest, reaching 96.15% (25/26).ConclusionsThe sensitivity of intra-intestinal angiography CT in the diagnosis of AL is high and the overall diagnostic efficiency is better than RCE, and the leakage of contrast agent is the main imaging feature of AL. It is significant to guide the clinical practice.
Objective To analyze the influencing factors for postoperative anastomotic leak (AL) in carcinoma of the esophagus and gastroesophageal junction and construct a nomogram predictive model. Methods The patients who underwent radical esophagectomy at Jinling Hospital Affiliated to Nanjing University School of Medicine from January 2018 to June 2020 were included in this study. Relevant variables were screened using univariate and multivariate logistic regression analyses. A nomogram was then developed to predict the risk factors associated with postoperative AL. The predictive performance of the nomogram was validated using the receiver operating characteristic (ROC) curve. Results A total of 468 patients with carcinoma of the esophagus and gastroesophageal junction were included in the study, comprising 354 males and 114 females, with a mean age of (62.8±7.2) years. The tumors were predominantly located in the middle or lower esophagus, and 51 (10.90%) patients experienced postoperative AL. Univariate logistic regression analysis indicated that age, body mass index (BMI), tumor location, preoperative albumin levels, diabetes mellitus, anastomosis technique, anastomosis site, and C-reactive protein (CRP) levels were potentially associated with AL (P<0.05). Multivariate logistic regression analysis identified age, BMI, tumor location, diabetes mellitus, anastomosis technique, and CRP levels as independent risk factors for AL (P<0.05). A nomogram was developed based on the findings from the multivariate logistic regression analysis. The area under the receiver operating characteristic (ROC) curve was 0.803, indicating a strong concordance between the actual observations and the predicted outcomes. Furthermore, decision curve analysis demonstrated that the newly established nomogram holds significant value for clinical decision-making. Conclusion The predictive model for postoperative AL in patients with carcinoma of the esophagus and gastroesophageal junction demonstrates strong predictive validity and is essential for guiding clinical monitoring, early detection, and preventive strategies.
Objective To compare the safety of manual anastomosis and mechanical anastomosis after esophagectomy by meta-analysis. MethodsThe randomized controlled trials (RCTs) about manual anastomosis and mechanical anastomosis after esophagectomy were searched from PubMed, EMbase and The Cochrane Library from inception to January 2018 by computer, without language restrictions. Two authors according to the inclusion and exclusion criteria independently researched literature, extracted data, evaluated bias risk and used R software meta package for meta-analysis. Results Seventeen RCTs were enrolled, including 2 159 patients (1 230 by manual anastomosis and 1 289 by mechanical anastomosis). The results of meta-analysis showed that: (1) there was no significant difference in the incidence of anastomotic leakage between mechanical and manual anastomosis (RR=1.00, 95%CI 0.67–1.48, P=0.181); (2) no significant difference was found in the 30-day mortality (RR=0.95, 95%CI 0.61–1.49, P=0.631); (3) compared with manual anastomosis, the mechanical anastomosis group may increase the risk of anastomotic stenosis (RR=0.74, 95%CI 0.48-1.14, P<0.001). Conclusion Esophageal cancer surgery using a linear or circular stapler can increase the incidence of anastomotic stenosis after surgery. There is no significant difference in the anastomotic leakage and 30-day mortality between manual anastomosis, linear stapler and circular stapler.
Objective To explore the strategy of intrathoracic anastomosis in patients with esophageal squamous cell carcinoma when the proximal esophagus is dilated to different degrees and explore its mechanism. Methods We retrospectively reviewed the clinical data of patients who underwent esophagectomy between 2014 and 2017 in West China Hospital. The patients were divided into two groups including a significant dilatation group with inner mucosal phase diameter (IMPD)≥17.9 mm and a non-significant dilatation group with IMPD<17.9 mm. And the patients were divided into two groups (a layered manual anastomosis group and a stapled anastomosis group) according to anastomosis method and propensity score matching was applied to adjust for potential confounders. Results We finally included 654 patients. There were 206 patients with 158 males and 48 females at average age of 62.21±7.72 years in the layerd manual analstomosis group and 448 patietns with 377 males and 71 females at average age of 62.57±8.42 years in the stapled anastomosis group. We also used Masson trichrome staining to assess the collagen fiber content in the esophagus. Compared with layered manual anastomosis, the incidence of anastomotic leakage was higher in the significant dilatation group than that in the stapled anastomosis group (original cohort: 3.8% vs. 10.7%, P=0.093; propensity score-matched cohort: 1.4% vs. 15.3%, P=0.004). And there was no significant difference in anastomotic leakage b etween layered manual anastomosis and stapled anastomosis in the non-significant dilatation group (original cohort: 4.7% vs. 4.2%, P=0.830; propensity score-matched cohort: 4.8% vs. 4.0%, P=0.206). Moreover, the average collagen fiber area ratio was significantly lower in the significant dilation group than that in the non-significant dilatation group (P=0.045). Conclusion There is a significant reduction in collagen fibers in the proximal esophageal wall tissue of esophageal squamous cell carcinoma patients with a IMPD≥17.9 mm. Intrathoracic layered manual anastomosis effectively reduces postoperative anastomotic leakage in these patients.