Anastomotic dehiscence (AD) in colorectal cancer surgery: mechanical anastomosis versus manual anastomosis.

INTRODUCTION: Anastomotic dehiscence (AD) is the "Achilles heel" for resectional colorectal pathology and is the most common cause of postoperative morbidity and mortality. AD incidence is 3-8%; mortality rate due to AD two decades ago was around 60% and at present is 10%. This paper analyzes the incidence of AD after colorectal resection performed both in emergency and elective situations, depending on the way it is done: manually or mechanically. METHODS: Retrospective, single-center, observational study of patients operated in the period from 1st of January 2009 to 31th of December 2011 for malignant colorectal pathology in the Emergency Clinical Hospital of Bucharest. We evaluated the incidence of digestive fistulas according to the segment of digestive tract and time from hospital admission, to the way the anastomosis was achieved (mechanical vs. Manual), to the complexity of intervention, to the transfusion requirements pre/intra or postoperative, to the past medical history of patients (presence of colorectal inflammatory diseases: ulcerative colitis and Crohn's disease), to the average length of hospital stay and time of postoperative resumption of bowel transit. RESULTS: We included 714 patients who had surgery between 1st of January 2009 and 31th of December 2011. 15.26% (109/714) of the cases were operated in emergency conditions. Of the 112 cases of medium and lower rectum, 76 have "benefited" from preoperative radiotherapy with a fistula rate of 22.36% (17/76). The incidence of anastomotic dehiscence in the group with preoperative radiotherapy and mechanical anastomosis was 64.7% (11/17) versus 35.3% (6/17) incidence recorded in the group with manual anastomosis. Colorectal inflammatory diseases have been found as a history of pathology in 41 patients--incidence of fistulas in this group was of 12.2% (5/41), compared to only 6.83% (46/673) incidence seen in patients without a history of such disease. For the group with bowel inflammatory disease, anastomotic dehiscence incidence was of 13.8% (4/29) when using mechanical suture and 8.3% (1/12) when using manual suturing. The period required for postoperative resumption of intestinal transit was of 3.12 days for mechanical suturing and 3.93 days in case of manual suture. The mean time (MT) to perform the ileocolic and colocolic mechanical anastomosis is 9 ± 2 minutes. If anastomosis is "cured" with surjet wire or separate threads, MT is 11 ± 5 minutes. MT to perform the ileocolic and colocolic manual anastomosis is 9 ± 3 minutes for surjet wire and 18 ± 5 minutes for separate threads. MT to perform the colorectal mechanical anastomosis is 15 ± 4 minutes. MT to perform the colorectal manual anastomosis is 30 ± 7 minutes (using separate threads). Detailing the nature of the surgical reinterventions, we have found: 7 reinterventions for AD post mechanical anastomoses (1 case of suture defect, 2 cases of resection and re-anastomoses, 4 cases with external branching stoma); 5 reinterventions for AD post manual anastomoses (0 cases of suture defect, 1 case of resection with re-anastomosis, 4 cases of external shunt stoma). In the analyzed group, we recorded a total of 57 deaths from a total of 714 cases resulting in a mortality rate of 7.98%. CONCLUSIONS: Mechanical suture technique is not ideal for making digestive sutures. With the exception of low colorectal anastomoses where mechanical sutures are preferable, we cannot claim the superiority of mechanical anastomoses over those manually made, for colorectal neoplasia.

[Stapled vs. hand-sewn colorectal anastomosis in complicated colorectal cancer--a retrospective study]. / Anastomozele manuale versus anastomozele mecanice in cancerul colorectal complicat--studiu retrospectiv.

UNLABELLED: Emergens in colorectal pathology are in most cases by complications of cancer. The prognosis for colorectal cancer is poor when this pathology is addressed in emergency situations because, on one hand, of the organ specific structure, blood supply, septic content and, on the other hand, because of the special group of patients with this pathology: aged, immunosuppressed and with various comorbidities. The high rate of postoperative complications of these patients requires a specific management. The development and improvement of medical devices has brought to the surgeons new products among which mechanice devices for anastomoses. In this study we compared two groups of operated patients (with hand sutured and stapled anastomoses) who presented as emergences with complications of colorectal cancer. MATERIAL AND METHOD: Retrospective clinical study with a total of 72 patients who underwent a colorectal resection procedure in emergency in our clinic (Emergency Hospital Bucharest) over a period of 2 years (2007-2008). RESULTS: The 72 patients who required emergency surgery were randomly assigned to 2 categories according to the type of anastomosis: hand sutured (group 1, n = 34) and stapled (group 2, n = 38). Age, sex, comorbidities, and tumor staging were comparable in both groups. The emergency was represented by obstruction (56.94%), hemorrhage (8.33%) and perforation (34.72%). The mortality (10.5% vs. 8.8%) and orbidity rate (20.83% vs. 15.27%) was higher in the stapled anastomosis group. The average duration of the surgical procedure performed in emergency was also quantified and was 118 min. (group 2) vs. 236 min. (group 1) respectively. CONCLUSION: Comparison did not disclose any significant difference in the number of complications in these two groups. Anastomosis is safe in emergency colorectal surgery and the reduction of the operative time may also improve the outcome of these patients.

[Splenic angioembolization--a safe, efficient and rational approach]. / Angioembolizarea terapeutica în trauma splenica--eficienta, sigura si rationala.

The authors present a case of postraumatic splenic rupture grade III (AAST-OIS), with injury severity score 10, revised trauma score 7841 managed nonoperatively, by angioembolization, with successful outcome. The indications and different types of splenic angioembolization in trauma are discussed, together with the role of this procedure in increasing the success rate of nonoperative management. Up to our knowledge, this is the first reported case of therapeutic splenic angioembolization in the Romanian medical literature.

[Köhlmeier-Degos disease (Malignant Atrophic Papulosis): a cause of recurrent multiple intestinal perforations]. / Boala köhlmeier-Degos (Papuloza Atrofianta Maligna): cauza de perforatii intestinale multiple iterative--prezentare de caz.

Malignant Atrophic Papulosis (MAP) or Degos disease is a very rare vasculopathy affecting multiple systems. When associated with gastrointestinal tract or central nervous system involvment, patients with Degos disease have a poor prognosis and a high mortality. We report a case of Degos disease with systemic involvement, which ultimately caused peritonitis, sepsis, and death, despite all treatment. A 29-year-old man was admitted in June 2007 on the surgical ward of our hospital with acute generalized abdominal pain and multiple skin lesions. The patient had an appendectomy at another hospital 6 weeks before the current presentation. The exploratory laparotomy showed 2 perforations of the ileum. After the initial procedure, the patient developed spontaneous recurrent perforations of the small bowel and suffered another 3 reoperations. Neuroradiologic reports described central and peripheral nervous system involvement with progressive clinical deterioration and a meningovascular pattern at cerebral MRI. Despite aggressive treatment the patient died 3 months after the first surgical intervention.