Timing and outcome of right- vs left-sided colonic anastomotic leaks: Is there a difference?

BACKGROUND: Anastomotic leaks (AL) contribute to postoperative mortality, prolonged hospitalization, and increased health care costs. While left-sided AL (LAL) are well described in the literature, there is a paucity of studies on outcomes and management of right-sided AL (RAL). This study aimed to compare the timing of RAL versus LAL, and the variable diagnosis, management and outcomes of RAL versus LAL. We hypothesized that the timing of RAL may be later compared to LAL and may result in worse overall outcomes. METHODS: Patients who underwent curative intent surgery for neoplastic disease from January 1995 to December 2015 were included. Patients that underwent an anastomosis below the peritoneal reflection, neoadjuvant treatment, fecal diversion, previous colectomy/anastomosis, multiple anastomoses, and patients with inflammatory bowel disease or hereditary colorectal cancer syndromes were excluded. Patient demographics, neoplastic data, operative data, time to AL, methods utilized for diagnosis of AL, and management of AL were collected. The primary endpoint was timing of AL, and secondary endpoints were management and outcome based on RAL versus LAL. RAL and LAL were analyzed and compared using Chi-squared and categorical variables were expressed as number (percentage) and continuous variables expressed as median (interquartile range). RESULTS: A total of 2223 patients underwent oncologic resection for colonic neoplasia (1457 right sided and 766 left sided anastomoses). 67% of patients were male and median age was 69 years (range, 34-91). There were 48 total AL events (2.16%): 26 RAL (1.78%) and 22 LAL (2.87%). There was no statistical difference in leak rates between RAL and LAL and no difference in time to diagnosis or management (Table 1). RAL had significantly decreased operative time (p = 0.016), decreased intraoperative blood loss (p = 0.002), and increased diagnosis by CT/plain radiograph (p = 0.04). All patients that underwent surgery for leak had some form of fecal diversion performed. Morbidity and mortality were comparable between groups (p = 0.70; p = 1.0). CONCLUSIONS: This study found overall very low AL rates with comparable timing of RAL and LAL, and no difference in management or outcome of RAL vs. LAL. These findings are informative for patient and surgeon expectations before and after surgery and when AL is suspected.

Defunctioning stoma- a prognosticator for leaks in low rectal restorative cancer resection: A retrospective analysis of stoma database.

AIMS: Low anterior resection (LAR) has higher risk of anastomotic leak with its attendant morbidity -mortality. De-functioning loop ileostomy (DLI), claimed to mitigate the consequences of anastomotic leak, has been questioned in recent years. This study aims to evaluate the impact of ileostomy on LAR. METHODS: A retrospective analysis of stoma database. 136 patients with stoma (March 2011-July 2015) were assessed. Data was analysed in respect to LAR anastomotic leak rate, impact on morbidity-mortality, short and long-term stoma complications, rate of ileostomy reversal and reasons for non-reversal. RESULTS: 45 patients had loop ileostomy for LAR. Male (28) to female (17) ratio was 1.65:1 with median age of 69 (IQR: 56-75.5). Only 3 anastomotic leaks (3/45, 6.5%) occurred, all treated conservatively with no mortality. 29 had reversal, average reversal time is 10 months (3-24) and 5 awaiting. Reasons for non-reversal included patients' choice (7), death from cardiac cause (1), chemotherapy (1), unfit for surgery (1) and failed reversal (1). Acute complications included high output & reversible AKI (1), bleeding (3) and minor complications (6) as skin excoriation, separation and appliance issues. Parastomal hernia was repaired during reversal (12/15). CONCLUSIONS: De-functioning ileostomy for LAR is a safe procedure with low morbidity. Most stomas are reversible. Series highlights a late reversal contrary to the nationally recommended guidelines. Most interestingly, the study demonstrated de-functioning mitigated clinical consequences of anastomotic leak to an extent that reoperation was avoidable, in keeping with recent meta-analysis indicating a significantly low anastomotic leakage rates and reoperation. Larger study is invaluable to substantiate findings.

THD and mucopexy: Efficacy and controversy.

AIMS: Transanal haemorrhoidal dearterialisation and mucopexy has evolved in recent years as a popular minimally invasive non-excisional surgery for symptomatic prolapsing haemorrhoids. The long-term outcome of this procedure however, remains to be established. We aim to analyse the long-term outcome of THD-mucopexy in the management of prolapsing haemorrhoids based on the evidence of a prospective data from a single institution. METHODS: A prospective data was collected on 100 consecutive cases of grade 3 and 4 symptomatic haemorrhoids between the period 03/2010 and 06/2015 who underwent the procedure as a day case under general anaesthetic. Overall median follow up was for two years with average age of 54.4 ranges from 34 to 79 and gender ratio of 61% Male and 39% Female. Pre-and postoperative symptoms were assessed with a view to evaluate the nature of complications and long-term recurrence rate. RESULTS: [Table: see text]. CONCLUSION: THD mucopexy is a safe and effective minimally invasive modality for prolapsing symptomatic haemorrhoids with acceptable complication rates and a recurrence rate of 13% majority of which could be dealt with a repeat procedure. Long terms follow up and randomised (THD VS Haemorrhoidectomy) multicentre trials are warranted to compare its efficacy with that of conventional excisional surgery.

Mid-term results of thoracoscopic thymectomy for myasthenia gravis.

CONTEXT: Video-assisted thoracic surgery (VATS) has been proposed as a less invasive technique for treatment of myasthenia gravis. MATERIALS AND METHODS: A total of 31 patients underwent a right-sided VATS to remove all anterior mediastinal fat and thymic tissue during a 4-year period in our institution. None of the patients had associated thymoma. RESULTS: All procedures were performed successfully with no conversion to sternotomy. The mean operating time was 190 minutes. The median intubation time and assisted ventilation were 24 and 18 hours, respectively. The median ICU and hospital stays were 3 and 7 days, respectively. The median time for post-operative chest drainage was 48 hours. There was no perioperative mortality. Eight significant complications occurred. One patient had atelectasis, 1 patient had aspiration pneumonia, and 3 patients had postoperative myasthenic crisis and required prolonged mechanical ventilation. Other complications were granuloma of the vocal cord, right recurrent laryngeal nerve palsy, and temporary brachial plexus injury due to poor intraoperative positioning. The mean length of follow-up was 20 months (range: 3-42 months). Overall, 27 patients (87%) had improved clinically and 11 patients (35%) had complete remission. The resulting scars were cosmetically acceptable for all patients. CONCLUSION: VATS provides an effective alternative approach to thymectomy and has several advantages over open techniques. VATS causes minimal postoperative complications, shortens hospital stay, and gives better cosmetic results.