Analysis of risk factors related to anastomotic leakage after rectal cancer surgery / 中国现代医生

Objective To investigate the risk factors related to postoperative anastomotic leakage(AL)of rectal cancer.Methods The clinical data of 392 patients with rectal cancer diagnosed and treated in Linyi People's Hospital from January 2019 to December 2021 were retrospectively analyzed.They were divided into AL group(n=17)and non-AL group(n=375)according to whether AL occurred.The relevant clinical data of patients were collected,and the risk factors of postoperative AL in rectal cancer patients were analyzed by binary Logistic regression.Results The proportion of body mass index(BMI)≥25kg/m2,preoperative intestinal obstruction,perioperative blood transfusion history,operation duration≥3h and postoperative white blood cell count≥10×109/L in AL group were significantly higher than those in non-AL group(P<0.05).Binary Logistic regression analysis showed that BMI≥25kg/m2,preoperative intestinal obstruction,and operation duration≥3h were all independent risk factors for postoperative AL in rectal cancer patients(P<0.05).Conclusion Patients with rectal cancer who are obese,have preoperative intestinal obstruction,and have long operation duration have a higher risk of postoperative AL.Corresponding preventive measures should be taken according to the above risk factors to reduce the incidence of AL and improve the quality of life of patients.

Different intrathoracic anastomotic strategies for proximal esophageal dilatation in 654 patients with esophageal: A retrospective cohort study / 中国胸心血管外科临床杂志

@#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.

Risk factors and outcomes of occurrence of anastomotic leakage and reoperations for its management after colorectal surgery

Background: Anastomotic leakage (AL) is still the most annoying postsurgery complication after colorectal resection due to its serious complications up to death. Limited data were available regarding differences in AL incidence, management, and consequences for different types of colorectal resection. The aim of the present work was to evaluate differences in incidence of AL, incidence of postoperative complications, and length of hospital stay in a large number of patients who underwent elective colorectal resection for management of colorectal lesions. In addition to detect when and what type of reoperation for management of AL occur after colorectal resection. Patients: All 250 included patients underwent elective surgeries for colorectal resection with performance of primary anastomosis for management of colorectal neoplastic and non-neoplastic diseases in the period between May 2016 and July 31, 2021. We followed the patients for 90 days; we registered the follow-up findings. Results: the rates of AL occurrence were variable after the different procedures. The lowest rate of AL occurrence was found in patients who underwent right hemicolectomy, then in patients who underwent sigmoidectomy, left hemicolectomy, transversectomy and anterior resection (p= 0.004). A stoma was frequently performed during reoperation (79.5%) which was significantly different between different procedures: 65.5% in right hemicolectomy, 75.0% in transversectomy, 85.7% in left hemicolectomy, and 93.0% in sigmoid resection (p< 0.001). Conclusion Rates, types, time of occurrence and severity of AL vary according to the type of colectomy performed and selective construction of stoma during AL reoperation is currently safely applied with comparable mortality rates for patients who did and who did not have a stoma after reoperation. (AU)

Diagnostic value of ultrasound contrast agent enema in patients with anastomotic leakage after rectal cancer resection / 中华超声影像学杂志

Objective:To investigate the diagnostic value of ultrasound contrast agent enema (UCAE) for anastomotic leakage (AL) after rectal cancer surgery.Methods:From January 2020 to December 2022, a total of 95 patients with presacral fluid collection after rectal cancer surgery in the Sixth Affiliated Hospital of Sun Yat-sen University who received perineal ultrasound (PNUS) and UCAE were retrospectively selected. Among them, 70 patients (73.3%) were diagnosed with AL.After PNUS scanning, all patients received a diluted ultrasound contrast agent administered through the rectum. Receiver operating characteristic (ROC) curve were used to compare the accuracies of PNUS, UCAE, CT, MRI and water-soluble contrast enema in the diagnosis of AL. Factors that may have impacts on the sensitivity of UCAE were thoroughly analyzed.Results:UCAE improved the consistency (Kappa value: 0.757 vs 0.292, P<0.001) and accuracy (AUC: 0.893 vs 0.693, P<0.001) of PNUS in the diagnosis of AL, and its diagnostic accuracy was comparable to that of CT (AUC 0.807), MRI (AUC 0.811) and water-soluble contrast enema (AUC 0.923) (all P>0.05). For mid-to-high AL (anastomotic stoma distance ≥70 mm) and tiny AL (≤3 mm), the sensitivity of UCAE decreased significantly (anastomotic stoma position: 25.0% vs 85.5%, P=0.001; anastomotic leak diameter: 42.9% vs 87.5%, P=0.002). Conclusions:UCAE can significantly improve the diagnostic accuracy and consistency of PNUS for AL after rectal cancer surgery, and its diagnostic sensitivity is affected by the anastomotic stoma distance and the diameter of the leak.

Influencing factors of anastomotic leakage after laparoscopic intersphincter resection for extremely low rectal cancer and construction of nomogram prediction model / 中华消化外科杂志

Objective:To investigate the influencing factors of anastomotic leakage after laparoscopic intersphincter resection (ISR) for extremely low rectal cancer and construction of nomogram prediction model.Methods:The retrospective case-control study was conducted. The clinicopathological data of 812 patients who underwent laparoscopic ISR for extremely low rectal cancer in the Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital) from February 2012 to February 2022 were collected. There were 459 males and 353 females, aged (51±11)years. Observation indicators: (1) surgical situations; (2) follow-up; (3) influencing factors of postoperative anastomotic leakage; (4) construction and evaluation of nomogram prediction model for postoperative anastomotic leakage. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. The COX proportional hazard model was used for univariate and multivariate analyses. The R software(3.5.1 version) was used to construct nomogram prediction model. The receiver operating characteristic (ROC) curve was drawn and the area under curve (AUC) was used to evaluate the efficacy of the nomogram prediction model. The Bootstrap method was used for internal verification and to calculate the average consistency index (C-index). Results:(1) Surgical situations. All 812 patients underwent laparoscopic ISR for extremely low rectal cancer, including 388 cases undergoing partial ISR, 218 cases undergoing subtotal ISR and 206 cases undergoing complete ISR. All 812 patients underwent ileal protective ostomy, and there were 306 cases with double anastomosis and 203 cases with left colic artery preserved, respectively. The operation time and volume of intraoperative blood loss of 812 patients was (179±33)minutes and (33±13)mL, respectively. (2) Follow-up. All 812 patients were followed up for (13.5±0.9)months. Of the 812 patients, there were 62 cases with postoperative anastomotic leakage and the healing time of these cases was (33±6)days. (3) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that male, neoadjuvant chemoradiotherapy, failure of reser-ving left colic artery were independent risk factors of anastomotic leakage after laparoscopic ISR for extremely low rectal cancer ( hazard ratio=5.98, 4.00, 16.26, 95% confidence interval as 1.66-24.12, 1.30-12.42, 3.00-90.89, P<0.05). (4) Construction and evaluation of nomogram prediction model for postoperative anastomotic leakage. According to the results of multivariate analysis, male, neoadju-vant chemoradiotherapy and failure of reserving left colic artery were used to construct the nomogram prediction model for anastomotic leakage after laparoscopic ISR for extremely low rectal cancer, and the score of these indexes in the nomogram prediction model was 50, 49, 93, respectively. The total score of these index corresponded to the incidence rate of anastomotic leakage. Results of ROC curve showed that the AUC of nomogram prediction model of anastomotic leakage after laparoscopic ISR for extremely low rectal cancer was 0.87 (95% confidence interval as 0.80-0.93, P<0.05), with sensi-tivity and specificity 0.96 and 0.60, respectively. Results of internal verification showed that the C-index of nomogram prediction model was 0.87. Conclusion:Male, neoadjuvant chemoradiotherapy, failure of reserving left colic artery are independent risk factors of anastomotic leakage after laparo-scopic ISR for extremely low rectal cancer, and the nomogram prediction model based on these indexes can predict the incidence rate of postoperative anastomotic leakage.

Health economic evaluation of patients with postoperative complications after colorectal surgery / 中华消化外科杂志

Postoperative complications of colorectal surgery are one of the most important reasons affecting patients' postoperative health and also an important factor increasing the burden of medical care. It can give policymakers a basis to the optimization of medical resources by clarifying the health economic burden of different postoperative complications through health economic evalua-tion. Through a detailed search of domestic and foreign literatures, the authors summarize and analyze the increased medical costs and prolonged hospital stays associated with postoperative anastomotic leak, surgical site infection, and postoperative ileus. Furthermore, the authors identify shortcomings in existing clinical studies of different mediacal centers for colorectal postoperative complications, in order to better guide future clinical researches related to colorectal postoperative complications.

Incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer / 中华消化外科杂志

Objective:To investigate the incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer.Methods:The retrospective case-control study was conducted. The clinicopathological data of 804 patients with rectal cancer who were admitted to Peking Union Medical College Hospital of Chinese Academy of Medical Sciences from January 2017 to December 2019 were collected. There were 521 male and 283 female, aged 63(range, 27-94)years. All 804 patients underwent laparoscopic anterior resection for rectal cancer. Observation indicators: (1) surgical situations; (2) incidence of postoperative anastomotic leakage; (3) follow-up; (4) influencing factors of postoperative anastomotic leakage; (5) subgroup analysis. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribu-tion were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Univariate analysis was conducted using the chi-square test or independent sample t test. Factors with P≤0.2 in univariate analysis were included in multivariate Logistic regression analysis. Results:(1) Surgical situations. All 804 patients underwent laparoscopic radical resection of upper and middle rectal cancer successfully, with the operation time and volume of intraoperative blood loss as 135(range, 118-256)minutes and 30(range, 5-350)mL. All 804 patients completed end-to-end colon rectal anastomosis, including 287 patients with reinforced sutures at the anastomotic site, and 517 patients with routine anastomosis. (2) Incidence of postoperative anastomotic leakage. Of the 804 patients, 40 patients had postoperative anastomotic leakage, with the incidence rate as 4.98%(40/804). (3) Follow-up. All 804 patients were followed up for 32(range, 6-49)months. None of patient died during the perioperative period. (4) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that unreinforced suture at the anastomotic site was an independent risk factor for postoperative anastomotic leakage ( odds ratio=2.78, 95% confidence interval as 1.21-6.37, P<0.05). (5) Subgroup analysis. Of the 804 patients, 202 patients received neoadjuvant therapy and 602 patients did not receive neoadjuvant therapy. Of the 602 patients who did not receive neo-adjuvant therapy, cases with postoperative anastomotic leakage was 6 in the 253 patients with reinforced sutures, versus 21 in the 349 patients with routine sutures, showing a significant difference between them ( χ2=4.56, P<0.05). Conclusion:Unreinforced anastomosis at the anasto-motic site is an independent risk factor for anastomotic leakage after laparoscopic anterior rectal resection, especially for rectal cancer patients without neoadjuvant radiochemotherapy.

Identification of risk factors for urethrovesical anastomotic leakage following laparoscopic radical prostatectomy / 中华泌尿外科杂志

Objective:To investigate the risk factors of urethrovesical anastomotic leakage after laparoscopic radical prostatectomy.Methods:The clinical data of 292 patients who underwent laparoscopic radical prostatectomy in the Tenth People's Hospital Affiliated to Tongji University from January to December 2021 were retrospectively analyzed. According to whether there was anastomotic leakage, the patients were divided into leakage group (27 cases) and non-leakage group (265 cases). There were no significant differences in age [(71.5±6.5) years vs. (70.2±6.4) years], body mass index [(24.5±3.6) kg/m 2 vs. (24.2±3.0) kg/m 2], prostate volume[40(27.3, 63.2)ml vs. 38(28.1, 56.2)ml], Gleason score, clinical stage, and risk classification between the leakage group and the non-leakage group ( P>0.05), but the total prostate-specific antigen in the leakage group was significantly higher than that in the non-leakage group[20.0 (9.6, 79.0) ng/ml vs. 13.7 (8.5, 25.0) ng/ml, P=0.049]. Propensity score matching (PSM) was used to match the above indicators between the leakage group and the non-leakage group as 1∶1, so that the baseline of the two groups was balanced. The perioperative indicators of the matched two groups of patients were compared and analyzed. Statistically significant indicators were selected and included in univariate and multivariate logistic regression to analyze the risk factors of anastomotic leakage after radical prostatectomy. Finally, the receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was calculated. The accuracy of each factor in predicting urine leakage was obtained. Results:After PSM, 24 cases were successfully matched. The leakage group had shorter membranous urethral length (MUL) [(15.5±2.2)mm vs. (17.5±1.5)mm, P<0.001], thinner membranous urethral wall thickness (UWT) [(9.5±1.9)mm vs. (10.6±1.5)mm, P=0.024], longer anastomotic time of urethrovesical neck[(21.6±4.1)min vs. (16.9±2.9)min, P<0.001] and higher failure rate of water injection test [16.7% (4/24) vs. 4.2% (1/24), P=0.045] than the non-leakage group. There was no significant difference in other indicators between the two groups. The results of multivariate logistic regression analysis showed that short MUL ( OR=0.544, 95% CI 0.335-0.884, P=0.014), narrow UWT ( OR=0.538, 95% CI 0.313-0.924, P=0.025) and long anastomotic time of urethrovesical neck ( OR=1.519, 95% CI 1.122-2.110, P=0.009) were independent risk factors for anastomotic urine leakage. ROC curve analysis showed that the AUC of MUL, UWT, and anastomotic time were 0.789 (95% CI 0.651-0.927), 0.715 (95% CI 0.562-0.868), and 0.842 (95% CI 0.731-0.953), respectively. Conclusions:Narrow and short membranous urethra and long anastomosis time in patients with laparoscopic radical prostatectomy may be independent risk factors for postoperative anastomotic leakage, which may predict the occurrence of anastomotic leakage.

Early diagnosis of anastomotic leakage after anterior resection for rectal carcinoma / 中华普通外科杂志

Objective:To search for valuable laboratory indexes of early diagnosis of anastomotic leakage after anterior resection for rectal carcinoma.Methods:From Sep 2017 to Jan 2019, 128 patients with colorectal cancer underwent anterior rectal resection at the Department of Colorectal & Anal Surgery, the 940 Hospital of the Joint Logistics Support Force.Results:Anastomotic leakage occurred in 16 of 128 patients (12.5%). Definite diagnosis of anastomotic leakage was made on between 2nd and 9th day, postopera tively averagign (6.13±2.00) days. Tumor location was a risk factor for anastomotic leakage with the incidence significantly lower when the distance from the lower edge of the tumor to the anal margin >7 cm than when the distance ≤7 cm ( χ 2=6.022, P=0.014). The percentage of increase in peripheral blood leukocytes, neutrophils, serum interleukin-6, C-reactive protein and procalcitonin in patients 3-5 days after surgery significantly related to the occurrence of anastomotic leakage (all P<0.05). The area under the working characteristic curve of the subjects with the percentage of C-reactive protein, procalcitonin, interleukin-6, leukocytes and neutrophils from the 3rd to the 5th day after operation was greater than 0.5. Conclusion:C-reactive protein, procalcitonin, interleukin-6, leukocyte and neutrophil percentage are risk factors predicting anastomotic leakage after anterior resection of rectal cancer.

Risk factors and prediction model of perioperative esophagogastric anastomotic leakage after esophageal cancer surgery / 中国胸心血管外科临床杂志

@#Objective    To analyze the risk factors for esophagogastric anastomotic leakage (EGAL) after esophageal cancer surgery, and to establish a risk prediction model for early prevention and treatment. Methods    Clinical data of patients undergoing esophagectomy in our hospital from January 2013 to October 2020 were retrospectively analyzed. The independent risk factors for postoperative EGAL were analyzed by univariate and multivariate logistic regression analyses, and a clinical nomogram prediction model was established. According to whether EGAL occurred after operation, the patients were divided into an anastomotic fistula group and a non-anastomotic fistula group. Results    A total of 303 patiens were enrolled, including 267 males and 36 females with a mean age of 62.30±7.36 years. The incidence rate of postoperative EGAL was 15.2% (46/303). The multivariate logistic regression analysis showed that high blood pressure, chronic bronchitis, peptic ulcer, operation way, the number of lymph node dissected, anastomotic way, the number of intraoperative chest drainage tube, tumor location, no-supplementing albumin in the first three days after operation, postoperative pulmonary infection, postoperative use of bronchoscope were the independent risk factors for EGAL after esophageal cancer surgery (P<0.05). A prognostic nomogram model was established based on these factors with the area under the receiver operating characteristic curve of 0.954 (95%CI 0.924-0.975), indicating a high predictive  value. Conclusion    The clinical prediction model based on 11 perioperative risk factors in the study has a good evaluation efficacy and can promote the early detection, diagnosis and treatment of EGAL.

Nomogram prediction model of cervical anastomotic leakage after esophageal cancer surgery / 中华肿瘤杂志

Objective: To retrospectively analyze the risk factors of anastomotic leakage in the neck after esophageal cancer and establish a nomogram prediction model that can accurately predict the occurrence of anastomotic leakage in the neck of the patient. Methods: The study retrospectively analyzed 702 patients who underwent radical esophageal cancer surgery between January 2010 and May 2015 at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. A multivariate logistic regression model was used to determine the risk factors for neck anastomotic leak, and a nomogram model was constructed, internal validation methods were used to evaluate and verify the predictive effectiveness of the nomogram. Results: There were 702 patients in the whole group, 492 in the training group and 210 in the validation group. The incidence of postoperative cervical anastomotic leak was 16.1% (79/492) in 492 patients with esophageal cancer in the training group. Multifactorial analysis revealed calcification of the descending aorta (OR=2.12, 95% CI: 1.14, 3.94, P=0.018), calcification of the celiac artery (OR=2.29, 95% CI: 1.13, 4.64, P=0.022), peripheral vascular disease (OR=5.50, 95% CI: 1.64, 18.40, P=0.006), postoperative ventilator-assisted breathing (OR=5.33, 95% CI: 1.83, 15.56, P=0.002), pleural effusion or septic chest (OR=3.08, 95% CI: 1.11, 8.55, P=0.031), incisional fat liquefaction and infection (OR=3.49, 95% CI: 1.68, 7.27, P=0.001) were independent risk factors for the development of cervical anastomotic leak after esophageal cancer surgery. The results of the nomogram prediction model showed that the consistency indices of the training and external validation groups were 0.73 and 0.74, respectively (P<0.001), suggesting that the prediction model has good predictive efficacy. Conclusion: The nomogram prediction model can intuitively predict the incidence of postoperative cervical anastomotic leakage in patients with high prediction accuracy, which can help provide a clinical basis for preventing cervical anastomotic leak and individualized treatment of patients.

Nomogram prediction model of cervical anastomotic leakage after esophageal cancer surgery / 中华肿瘤杂志

Objective: To retrospectively analyze the risk factors of anastomotic leakage in the neck after esophageal cancer and establish a nomogram prediction model that can accurately predict the occurrence of anastomotic leakage in the neck of the patient. Methods: The study retrospectively analyzed 702 patients who underwent radical esophageal cancer surgery between January 2010 and May 2015 at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. A multivariate logistic regression model was used to determine the risk factors for neck anastomotic leak, and a nomogram model was constructed, internal validation methods were used to evaluate and verify the predictive effectiveness of the nomogram. Results: There were 702 patients in the whole group, 492 in the training group and 210 in the validation group. The incidence of postoperative cervical anastomotic leak was 16.1% (79/492) in 492 patients with esophageal cancer in the training group. Multifactorial analysis revealed calcification of the descending aorta (OR=2.12, 95% CI: 1.14, 3.94, P=0.018), calcification of the celiac artery (OR=2.29, 95% CI: 1.13, 4.64, P=0.022), peripheral vascular disease (OR=5.50, 95% CI: 1.64, 18.40, P=0.006), postoperative ventilator-assisted breathing (OR=5.33, 95% CI: 1.83, 15.56, P=0.002), pleural effusion or septic chest (OR=3.08, 95% CI: 1.11, 8.55, P=0.031), incisional fat liquefaction and infection (OR=3.49, 95% CI: 1.68, 7.27, P=0.001) were independent risk factors for the development of cervical anastomotic leak after esophageal cancer surgery. The results of the nomogram prediction model showed that the consistency indices of the training and external validation groups were 0.73 and 0.74, respectively (P<0.001), suggesting that the prediction model has good predictive efficacy. Conclusion: The nomogram prediction model can intuitively predict the incidence of postoperative cervical anastomotic leakage in patients with high prediction accuracy, which can help provide a clinical basis for preventing cervical anastomotic leak and individualized treatment of patients.

Risk factors for anastomotic leakage following total or subtotal colectomy

Introduction: A higher rate of anastomotic leakage (AL) is reported after ileosigmoid anastomosis (ISA) or ileorectal anastomosis (IRA) in total or subtotal colectomy (TSC) compared with colonic or colorectal anastomosis. Themain aimof the present studywas to assess potential risk factors for AL after ISA or IRA and to investigate determinants of morbidity. Methods: We identified 180 consecutive patients in a prospective referral, single center database, in which 83 of the patients underwent TSC with ISA or IRA. Data regarding the clinical characteristics, surgical treatment, and outcome were assessed to determine their association with the cumulative incidence of AL and surgical morbidity. Results: Ileosigmoid anastomosis was performed in 51 of the patients (61.5%) and IRA in 32 patients (38.6%). The cumulative incidence of ALwas 15.6% (13 of 83 patients). A higher AL rate was found in patients under 50 years-old (p=0.038), in the electivelaparoscopic approach subgroup (p=0.049), and patients in the inflammatory bowel disease (IBD) subgroup (p=0.009). Furthermore, 14 patients (16.9%) had morbidity classified as Clavien-Dindo ≥ IIIA. Discussion: A relatively high incidence of AL after TSC was observed in a relatively safe surgical procedure. Our findings suggest that the risk of AL may be higher in IBD patients. According to our results, identifying risk factors prior to surgerymay improve short-term outcomes. (AU)

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap / Tratamento da fístula anastomótica cervical refratária após esofagectomia utilizando retalho miocutâneo do músculo peitoral maior

Abstract Introduction A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. Objective This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. Methods Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. Results All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months. Conclusion The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

Resumo Introdução Uma fístula anastomótica cervical refratária, que permanece sem cicatrização por mais de 2 meses sob cuidados conservadores, afeta gravemente a qualidade de vida do paciente e potencialmente causa estenose anastomótica após a cicatrização da fístula. É amplamente aceito que as fístulas anastomóticas cervicais refratárias devem ser submetidas a tratamentos mais agressivos. No entanto, quando e qual intervenção cirúrgica deve ser considerada ainda é incerto. Objetivo Avaliar o papel do retalho miocutâneo do peitoral maior no manejo de fístula anastomótica cervical refratárias com base em nossa experiência de 6 casos e uma revisão da literatura. Métodos Foram incluídos no estudo seis pacientes diagnosticados com fístula anastomótica cervical refratária após esofagectomia tratados com transferência de retalho miocutâneo do peitoral maior. Os dados clínicos, detalhes cirúrgicos e resultado do tratamento foram analisados retrospectivamente. Resultados Todos os pacientes sobreviveram às cirurgias. Um paciente com defeito anastomótico circunferencial, resultante da exploração cirúrgica, desenvolveu uma fístula leve no sítio neoanastomótico no 5° dia de pós-operatório, que foi resolvida após 7 dias de tratamento conservador. Esse paciente desenvolveu uma estenose anastomótica parcialmente aliviada por uma dilatação endoscópica anastomótica. Todos os outros 5 pacientes tiveram recuperações sem intercorrências após as cirurgias, restabeleceram a ingestão oral 10 ou 15 dias após a operação e toleraram dietas normais sem sequelas subsequentes no seguimento. Um paciente desenvolveu recorrência local e pulmonar e morreu 15 meses após a cirurgia, enquanto os outros 5 pacientes sobreviveram com bom controle tumoral durante o seguimento de 25 a 53 meses. Conclusão O resultado satisfatório do tratamento em nosso estudo demonstra que a reconstrução com o retalho miocutâneo do peitoral maior é uma modalidade de manejo confiável para as fístula anastomótica cervical refratárias após a esofagectomia, particularmente nos pacientes que apresentaram falha após o tratamento conservador das feridas cirúrgicas e com fechamento repetido delas.

Clinical outcomes of redo median sternotomy on proximal aortic repair / 中华胸心血管外科杂志

Objective:To summarize the clinical outcomes and experience of redo median sternotomy on proximal aortic repair. Investigate the relationship between first operation and reoperation, reoperation indications, cardiopulmonary bypass strategy, intraoperative technical details, early and mid-term postoperative results.Methods:There were 28 patients underwent 29 times of redo median sternotomy on proximal aorta from April 2017 to December 2019. There were 23 males (79.3%) with an average age of (45.1±12.7) years (26-79 years), 15 Marfan syndrome (15/29, 51.7%) and 3 Behcet's disease (3/29, 10.3%). The primary operation included aortic valve or mitral valve replacement, Bentall procedure, ascending aortic replacement, simultaneous abdominal aortic replacement, Sun's procedure and coronary artery bypass grafting. The indications for reoperation were: aortic root aneurysm or coronary artery aneurysm, anastomotic leakage, perivalvular leakage due to inflammatory aortic disease, acute or chronic type A aortic dissection and aortic root abscess, aortic arch aneurysm. The surgical methods were Bentall, Cabrol, wheat, aortic valve sparing root replacement with replantation, anastomotic leakage repair, CABG, total arch replacement + stent elephant trunk implantation (Sun's procedure), ascending aorta to abdominal aorta bypass, abdominal aortic replacement.Results:One patient (3.4%) died in hospital because of severe postoperative pulmonary complications, consolidation of both lungs, ARDS and hypoxia. Postoperative low cardiac output was occurred in 2 cases (6.9%), 1 case was cured by ECMO, and 1 case died half a year after operation during follow up period. Re-exploration for postoperative hemorrhage was occurred in three cases (10.3%). Renal failure requires dialysis was 3 cases (10.3%), and transient paresis was 1 cases (3.4%), respectively. All of them were recovered before discharge. During the follow-up period, one patient died of multiple organ failure due to low cardiac output, and one patient underwent total thoracoabdominal aortic replacement. One patient underwent Cabrol for aneurysm of the coronary artery after Bentall procedure. One year later, type A dissection occurred again and Sun's procedure was performed through a median sternotomy.Conclusion:Reoperation of proximal aorta after cardiac and aortic surgery is safe and effective, with good short-term and medium-term results. Comprehensive preoperative evaluation, successful sternotomy, establishment of cardiopulmonary bypass and effective organ protection are the key to successful operation. Patients with aortic diseases, especially Marfan syndrome, are more likely to undergo reoperation. Close follow-up and timely reoperation are necessary to avoid aortic rupture. Sun's procedure is suitable for redo complex arch operation.

Risk factors for esophagogastric anastomotic leakage after esophageal cancer surgery: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To systematically review risk factors for esophagogastric anastomotic leakage (EGAL) after  esophageal cancer surgery for adults to provide theoretical basis for clinical prevention and treatment. Methods    PubMed, Web of Science, The Cochrane Library, WanFang Data, VIP, CNKI and CBM were searched from inception to January 2020 to collect case control studies and cohort studies about risk factors for EGAL after esophageal cancer surgery. Two reviewers independently screened literature, extracted data and assessed risk of bias of included studies, and then, meta-analysis was performed by using RevMan 5.3 software. Results    A total of 33 studies were included, including 19 case-control studies and 14 cohort studies, all of which had a Newcastle-Ottawa Scale (NOS)≥6. There were 26 636 patients, including 20 283 males and 6 353 females, and there were 9 587 patients in China and 17 049 patients abroad. The results of meta-analysis showed that the following factors could increase the risk for EGAL (P≤0.05), including patient factors (18): age, sex, body mass index (BMI), smoking history, smoking index (≥400), alcohol history, digestive tract ulcer, respiratory disease, lower ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC), chronic obstructive pulmonary disease (COPD), coronary atherosclerosis, peripheral vascular disease, arrhythmia, diabetes, hypertension, cerebrovascular disease, celiac trunk calcification and descending aortic calcification; preoperative factors (6): abnormal liver function, renal insufficiency, American Society of Anesthesiologists (ASA) grading, neoadjuvant radiotherapy and preoperative albumin<35 g/L, preoperative lower albumin; intraoperative factors (7): retrosternal route, cervical anastomosis, thoracoscopic surgery, operation time≥4.5 h, tubular stomach, upper segment tumor, splenectomy; postoperative factors (5): respiratory failure, postoperative arrhythmia, use of fiberoptic bronchoscopy, pulmonary infection, deep venous thrombosis. Neoadjuvant chemotherapy could reduce the risk for postoperative EGAL (P<0.05). However, age≥60 years, upper gastrointestinal inflammation, diffusing capacity for carbon monoxide (DLCO%), thoracic surgery history, abdominal surgery history, glucocorticoid drugs history, neoadjuvant chemoradiotherapy, anastomotic embedding, end-to-end anastomosis, hand anastomosis, intraoperative blood loss and other factors were not significantly correlated with EGAL. Conclusion    Current evidence suggests that the risk factors for postoperative EGAL include age, sex, BMI, smoking index, alcohol history, peptic ulcer, FEV1/FVC, COPD, diabetes, ASA grading, neoadjuvant radiotherapy, preoperative albumin<35 g/L, cervical anastomosis, thoracoscopic surgery, operation time≥4.5 h, tubular stomach, upper segment tumor, intraoperative splenectomy, postoperative respiratory failure, postoperative arrhythmia and other risk factors. Neoadjuvant chemotherapy may be the protection factor for EGAL. Due to limited study quality, more high quality studies are needed to verify the conclusion.

Management of anastomotic leakage after laparoscopic surgery for adenocarcinoma of esophagogastric junction / 中华胃肠外科杂志

The incidence of adenocarcinoma of esophagogastric junction (AEG) is increasing at home and abroad. Laparoscopic surgery has gradually become the main means of surgical treatment of this kind of tumor. However, due to the special anatomical position of the tumor, the high position away from the broken esophagus and the narrow space in the mediastinum, laparoscopic anastomosis has the characteristics of difficult anastomosis and high anastomosis position. There is a high risk of anastomotic leakage after operation, which may cause serious consequences. Early identification of anastomotic leakage and unobstructed drainage by various means are the key to treatment. With the development of endoscopic technology, endoscopic methods such as covered stent and vacuum-assisted closure further improve the treatment efficacy. As a salvage measure, surgical treatment can achieve good treatment outcome, while accompanied by risk of complications and mortality, so we must strictly grasp the indications.

Risk factors for anastomotic leakage after laparoscopic lower anterior resection of rectal cancer and application value of risk assessment scoring model: a multicenter retrospective study / 中华消化外科杂志

Objective:To investigate the risk factors for anastomotic leakage after laparo-scopic lower anterior resection (LAR) of rectal cancer, and the application value of its risk assess-ment scoring model.Methods:The retrospective case-control study was conducted. The clinico-pathological data of 539 patients who underwent laparoscopic LAR of rectal cancer in 13 medical centers, including 248 cases in Renji Hospital of Shanghai Jiaotong University School of Medicine, 35 cases in Ningbo First Hospital, 35 cases in Changzhou Second People's Hospital, 32 cases in the First People's Hospital of Nantong, 32 cases in Linyi People's Hospital, 31 cases in Changzhou Wujin People's Hospital, 28 cases in Jiading District Hospital of Traditional Chinese Medicine, 27 cases in the First Hospital of Taizhou, 26 cases in Shanghai Pudong Gongli Hospital, 21 cases in the People's Hospital of Rugao, 11 cases in Central Hospital of Fengxian District, 7 cases in Ningbo Hangzhou Bay Hospital and 6 cases in Jiangsu jianhu People's Hospital, from January 2016 to November 2020 were collected. There were 157 males and 382 females, aged (62.7±0.5)years. Observation indicators: (1) follow-up; (2) risk factors for anastomotic leakage after laparoscopic LAR; (3) establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. Follow-up was conducted by outpatient examination or telephone interview. Patients were followed up at 1 week after discharge or 1 month after the operation to detect the anastomotic leakage. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the chi-square test and multivariate analysis was conducted usong the Logistic regression model. The area under curve of receiver operating characteristic curve was used to estimate the efficiency of detecton methods. The maximum value of the Youden index was defined as the best cut-off value. Results:(1) Follow-up: 539 patients were followed up at postoperative 1 week and 1 month. During the follow-up, 79 patient had anastomotic leakage, with an incidence of 14.66%(79/539). Of the 79 patients, 39 cases were cured after conservative treatment, 40 cases were cured after reoperation (ileostomy or colostomy). (2) Risk factors for anastomotic leakage after laparoscopic LAR. Results of univariate analysis showed that sex, age, body mass index, smoking and/or drinking, tumor diameter, diabetes mellitus, hemoglobin, albumin, grade of American Society of Anesthesio-logists (ASA), neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line, the number of pelvic stapler, reinforced anastomosis, volume of intraoperative blood loss, placement of decompression tube, preservation of left colic artery, operation time and professional doctors were related factors for anastomotic leakage after laparoscopic LAR ( χ2=14.060, 4.387, 5.039, 4.094, 17.488, 33.485, 25.066, 28.959, 34.973, 34.207, 22.076, 13.208, 16.440, 17.708, 17.260, 4.573, 5.919, 5.389, P<0.05). Results of multivariate analysis showed that male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decom-pression tube were independent risk factors for anastomotic leakage after laparoscopic LAR ( odds ratio=2.864,3.043,12.556,7.178,8.425,12.895,8.987,4.002,3.084,4.393,3.266,3.224,95% confidence interval as 1.279?6.411, 1.404?6.594, 4.469?35.274, 2.648?19.459, 2.471?28.733, 4.027?41.289, 3.702?21.777, 1.746?9.171, 1.365?6.966, 1.914?10.083, 1.434?7.441, 1.321?7.867, P<0.05). (3) Establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. based on the results of univariate analysis, clinicopathological factors with χ2>20, χ2>10 and ≤20 or χ2≤10 were defined as scoring of 3, 2, 1, respectively. The cumulative clinicopatho-logical factors scoring ≥6 was defined as an effective evaluating indicator for postoperative anastomotic leakage. The risk assessment scoring model (6-321) for anastomotic leakage after laparoscopic LAR was established. The cumulative value ≥6 indicated high incidence of anastomotic leakage, and the cumulative value <6 indicated low incidence of anastomotic leakage. Conclusions:Male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neo-adjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decompression tube are independent risk factors for anastomotic leakage after laparoscopic LAR. The risk assessment scoring model (6-321) is established according to the above results.The cumulative value ≥6 indicates high incidence of anastomotic leakage and the cumulative value <6 indicates low incidence of anastomotic leakage.

Chinese expert consensus on radical resection of rectal cancer with preservation of left colonic artery (2021 edition) / 中华胃肠外科杂志

The preservation of left colonic artery (LCA) has been accepted by more and more surgeons in the radical resection of rectal cancer, but whether it can reduce anastomotic complications and affect the oncology efficacy remains controversial. This consensus elaborates the significance, anatomical structure, key points of operation techniques, indications and contraindications, and surgical approaches of LCA preservation. Each statement and recommendation was recognized by most experts in the field of colorectal surgery. The purpose of this consensus is to improve the cognitive level of Chinese colorectal surgeons on LCA preservation, so as to standardize the surgical strategies and methods of LCA preservation and furthermore practice, and promote it. The pending issues in this consensus need further high-quality clinical studies.

Application of electric tube stapler in laparoscopic colorectal tumor surgery / 中华胃肠外科杂志

Objective: To investigate the application of electric tube stapler in laparoscopic colorectal tumor surgery. Methods: A descriptive case series study was conducted. Clinical data of patients who underwent laparoscopic colorectal surgery in Peking Union Medical College Hospital in August 2021 using domestic electric tube stapler were collected to analyze the occurrence of postoperative anastomotic leakage, anastomotic bleeding and other complications as well as postoperative intestinal function recovery. Results: A total of 11 patients with colorectal tumor were enrolled in this study, including 8 males and 3 females. Eight patients underwent laparoscopic low anterior resection (1 patient underwent protective ileostomy), and three patients underwent laparoscopic sigmoid carcinoma radical resection. During operation, power system failure of stapler occurred in 1 patient, and the replacement manual device was used to complete the anastomosis. No anastomotic leakage or bleeding occurred in the cohort of patients. There was no conversion to laparotomy or conventional anastomosis. One patient developed acute myocardial infarction 2 days after surgery. The average time to the first flatus after surgery was (2.4±0.8) days and the average length of hospital stay was (10.0±6.1) days. Conclusions: The application of electric tube stapler in laparoscopic colorectal tumor surgery has many advantages, such as safe and effective anastomosis, low morbidity of postoperative complications, and rapid recovery of intestinal function. Domestic electric tube stapler can be applied in minimally invasive surgery for colorectal tumor.