The role of preoperative mechanical bowel preparation and oral antibiotics in prevention of anastomotic leakage following restorative resection for primary rectal cancer - a systematic review and meta-analysis.

PURPOSE: Anastomotic leakage after colorectal cancer resection is a feared postoperative complication seen among up till 10-20% of patients, with a higher risk following rectal resection than colon resection. Recent studies suggest that the combined use of preoperative mechanical bowel preparation and oral antibiotics may have a preventive effect on anastomotic leakage. This systematic review aims to explore the association between preoperative mechanical bowel preparation combined with oral antibiotics and the risk of anastomotic leakage following restorative resection for primary rectal cancer. METHODS: Three databases were systematically searched in February 2022. Studies reporting anastomotic leakage rate in patients, who received mechanical bowel preparation and oral antibiotics before elective restorative resection for primary rectal cancer, were included. A meta-analysis was conducted based on the risk ratios of anastomotic leakage. RESULTS: Among 839 studies, 5 studies met the eligibility criteria. The median number of patients were 6111 (80-29,739). The combination of preoperative mechanical bowel preparation and oral antibiotics was associated with a decreased risk of anastomotic leakage (risk ratio = 0.52 (95% confidence interval 0.39-0.69), p-value < 0.001). Limitations included a low number of studies, small sample sizes and the studies being rather heterogenous. CONCLUSION: This systematic review and meta-analysis found that the use of mechanical bowel preparation and oral antibiotics is associated with a decreased risk of anastomotic leakage among patients undergoing restorative resection for primary rectal cancer. The limitations of the review should be taken into consideration when interpreting the results.

Preoperative combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery.

BACKGROUND: The success of elective colorectal surgery is mainly influenced by the surgical procedure and postoperative complications. The most serious complications include anastomotic leakages and surgical site infections (SSI)s, which can lead to prolonged recovery with impaired long-term health.  Compared with other abdominal procedures, colorectal resections have an increased risk of adverse events due to the physiological bacterial colonisation of the large bowel. Preoperative bowel preparation is used to remove faeces from the bowel lumen and reduce bacterial colonisation. This bowel preparation can be performed mechanically and/or with oral antibiotics. While mechanical bowel preparation alone is not beneficial, the benefits and harms of combined mechanical and oral antibiotic bowel preparation is still unclear. OBJECTIVES: To assess the evidence for the use of combined mechanical and oral antibiotic bowel preparation for preventing complications in elective colorectal surgery. SEARCH METHODS: We searched MEDLINE, Embase, CENTRAL and trial registries on 15 December 2021. In addition, we searched reference lists and contacted colorectal surgery organisations. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of adult participants undergoing elective colorectal surgery comparing combined mechanical and oral antibiotic bowel preparation (MBP+oAB) with either MBP alone, oAB alone, or no bowel preparation (nBP). We excluded studies in which no perioperative intravenous antibiotic prophylaxis was given. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as recommended by Cochrane. Pooled results were reported as mean difference (MD) or risk ratio (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel method. The certainty of the evidence was assessed with GRADE. MAIN RESULTS: We included 21 RCTs analysing 5264 participants who underwent elective colorectal surgery. None of the included studies had a high risk of bias, but two-thirds of the included studies raised some concerns. This was mainly due to the lack of a predefined analysis plan or missing information about the randomisation process. Most included studies investigated both colon and rectal resections due to malignant and benign surgical indications. For MBP as well as oAB, the included studies used different regimens in terms of agent(s), dosage and timing.  Data for all predefined outcomes could be extracted from the included studies. However, only four studies reported on side effects of bowel preparation, and none recorded the occurrence of adverse effects such as dehydration, electrolyte imbalances or the need to discontinue the intervention due to side effects. Seventeen trials compared MBP+oAB with sole MBP. The incidence of SSI could be reduced through MBP+oAB by 44% (RR 0.56, 95% CI 0.42 to 0.74; 3917 participants from 16 studies; moderate-certainty evidence) and the risk of anastomotic leakage could be reduced by 40% (RR 0.60, 95% CI 0.36 to 0.99; 2356 participants from 10 studies; moderate-certainty evidence). No difference between the two comparison groups was found with regard to mortality (RR 0.87, 95% CI 0.27 to 2.82; 639 participants from 3 studies; moderate-certainty evidence), the incidence of postoperative ileus (RR 0.89, 95% CI 0.59 to 1.32; 2013 participants from 6 studies, low-certainty of evidence) and length of hospital stay (MD -0.19, 95% CI -1.81 to 1.44; 621 participants from 3 studies; moderate-certainty evidence). Three trials compared MBP+oAB with sole oAB. No difference was demonstrated between the two treatment alternatives in terms of SSI (RR 0.87, 95% CI 0.34 to 2.21; 960 participants from 3 studies; very low-certainty evidence), anastomotic leakage (RR 0.84, 95% CI 0.21 to 3.45; 960 participants from 3 studies; low-certainty evidence), mortality (RR 1.02, 95% CI 0.30 to 3.50; 709 participants from 2 studies; low-certainty evidence), incidence of postoperative ileus (RR 1.25, 95% CI 0.68 to 2.33; 709 participants from 2 studies; low-certainty evidence) or length of hospital stay (MD 0.1 respectively 0.2, 95% CI -0.68 to 1.08; data from 2 studies; moderate-certainty evidence). One trial (396 participants) compared MBP+oAB versus nBP. The evidence is uncertain about the effect of MBP+oAB on the incidence of SSI as well as mortality (RR 0.63, 95% CI 0.33 to 1.23 respectively RR 0.20, 95% CI 0.01 to 4.22; low-certainty evidence), while no effect on the risk of anastomotic leakages (RR 0.89, 95% CI 0.33 to 2.42; low-certainty evidence), the incidence of postoperative ileus (RR 1.18, 95% CI 0.77 to 1.81; low-certainty evidence) or the length of hospital stay (MD 0.1, 95% CI -0.8 to 1; low-certainty evidence) could be demonstrated. AUTHORS' CONCLUSIONS: Based on moderate-certainty evidence, our results suggest that MBP+oAB is probably more effective than MBP alone in preventing postoperative complications. In particular, with respect to our primary outcomes, SSI and anastomotic leakage, a lower incidence was demonstrated using MBP+oAB. Whether oAB alone is actually equivalent to MBP+oAB, or leads to a reduction or increase in the risk of postoperative complications, cannot be clarified in light of the low- to very low-certainty evidence. Similarly, it remains unclear whether omitting preoperative bowel preparation leads to an increase in the risk of postoperative complications due to limited evidence. Additional RCTs, particularly on the comparisons of MBP+oAB versus oAB alone or nBP, are needed to assess the impact of oAB alone or nBP compared with MBP+oAB on postoperative complications and to improve confidence in the estimated effect. In addition, RCTs focusing on subgroups (e.g. in relation to type and location of colon resections) or reporting side effects of the intervention are needed to determine the most effective approach of preoperative bowel preparation.

Perioperative Low-Dose Prednisolone Treatment Has Beneficial Effects on Postoperative Recovery and Anastomotic Healing in a Murine Colitis Model.

BACKGROUND AND AIMS: High-dose glucocorticoid treatment has been identified as a risk factor for anastomotic leakage in patients with inflammatory bowel disease [IBD] undergoing bowel resection surgery. By contrast, active disease during surgery is also associated with elevated morbidity. Perioperative low-dose treatment might be beneficial regarding postoperative outcomes by controlling disease activity. The present study is the first to investigate the dose-dependent effect of perioperative prednisolone therapy in a murine IBD model combining dextran sodium sulphate [DSS] colitis with intestinal anastomosis surgery. METHODS: In 84 10-week-old wild-type mice, a colorectal anastomosis was performed using a microsurgical technique. Half the animals received induction of chemical colitis with 2% DSS via drinking water prior to surgery. In both groups, one-third of the animals received daily oral administration of high-dose [0.533 mg/kg] and one-third low-dose [0.133 mg/kg] prednisolone. Evaluation was performed on postoperative days 3 and 7. RESULTS: While high-dose prednisolone treatment led to an increased anastomotic leakage rate in mice under colitis, low-dose prednisolone treatment limited preoperative disease activity and did not influence the leakage rate. Histological examination showed a beneficial effect of low-dose prednisolone treatment on microscopic abscess formation at the anastomotic site in DSS mice as well as an increased anastomotic healing score. CONCLUSIONS: We demonstrate a beneficial effect of perioperative short-term low-dose prednisolone treatment on intestinal anastomotic healing in the context of colitis. Perioperative use of short-term low-dose prednisolone treatment might be beneficial in IBD patients who need to undergo surgery during active disease.

Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis.

OBJECTIVE: A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection. METHODS: Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation. RESULTS: The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI. CONCLUSION: MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.

Comparative effectiveness of oral antibiotics, probiotics, prebiotics, and synbiotics in the prevention of postoperative infections in patients undergoing colorectal surgery: A network meta-analysis.

Oral antibiotics (OAB), probiotics, prebiotics, and synbiotics are reported to be effective for preventing postoperative infection following colorectal surgery, but the comparative effectiveness between them has not been studied. To compare these interventions through a network meta-analysis. Ovid Medline, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) were searched from inception to January 1, 2022 without any language restriction. Two reviewers independently screened the retrieved articles, assessed risk of bias, and extracted information from the included randomised controlled trials (RCTs). The primary outcome was infection rate, and the secondary outcome was anastomotic leakage rate. 4322 records were retrieved after literature search, and 20 RCTs recruiting 3726 participants were finally included. The analysis showed that usual care (UC) + Synbiotics ranked the most effective treatment (SUCRA = 0.968), UC + OAB ranked the second (SUCRA = 0.797), and UC + IAB ranked the third (SUCRA = 0.678) for preventing postoperative infection rate, but only UC + OAB achieved statistical significance. UC + OAB was the most effective treatment (SUCRA = 0.927) for preventing anastomotic leakage rate. Our study confirmed that preoperative administration of OAB was associated with lower infection rate and anastomotic leakage rate than placebo and UC alone. However, the beneficial effect of probiotics and synbiotics should still be investigated by large-scale randomised controlled trials.

Cyanoacrylate injection treatment for postoperative leakage of Boerhaave's syndrome: A case report.

RATIONALE: Surgical treatment remains the most effective option for treating Boerhaave's syndrome. However, in cases of postoperative anastomotic leakage of Boerhaave's syndrome, endoscopic interventions such as over-the-scope clip, stenting, or cyanoacrylate injection have emerged over reoperation. PATIENT CONCERNS: We report the case of a 50-year-old male patient who presented with vomiting and abdominal pain after alcohol consumption. Laparoscopic surgery was performed for primary closure of a laceration at the lower esophagus, and for the closure of a Boerhaave's syndrome, which was detected by abdominal computed tomography. However, postoperative anastomotic leakage was confirmed through esophagography after the operation. In our case, endoscopic treatment with an over-the-scope clip and stenting were not effective for the repair of the anastomotic leakage, but cyanoacrylate injection successfully healed the anastomotic leakage. DIAGNOSES: Boerhaave's syndrome was initially detected by abdominal computed tomography, but postoperative anastomotic leakage after the operation was confirmed with esophagography. INTERVENTIONS: A total of 2.0 cc of N-butyl-2-cyanoacrylate and lipiodol mixture (at 1:1) was injected into the leakage tract through the perforation entrance. OUTCOMES: Complete healing of the anastomotic leakage was confirmed with a follow-up esophagoscopy. LESSONS: N-butyl-2-cyanocrylate injection treatment can be used as a rescue option for postoperative leakage when over-the-scope clips and stenting fail for this indication.

Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial.

PURPOSE: Anastomotic leak and other infectious complications are septic complications of rectal cancer surgery caused by bacteria. Data from registry analysis show a beneficial effect of local antimicrobial administration on anastomotic leaks, but data are inconsistent in recent clinical trials. Therefore, our aim was to study the efficacy of topical antibiotic treatment on the incidence of anastomotic leaks in rectal cancer surgery. METHODS: A prospective, randomized, double-blind and placebo-controlled, single center trial was conducted. Patients received either placebo and amphotericin B or decontamination with polymyxin B, tobramycin, vancomycin, and amphotericin B four times per day starting the day before surgery until postoperative day 7. If a protective ileostomy was created, a catheter was placed transanally and the medication was administered locally to the anastomotic site. All patients received an intravenous perioperative antibiotic prophylaxis. RESULTS: The trial had to be stopped for ethical reasons after first interim analysis with 80 patients instead of the initially planned 280 patients. Of the 40 patients randomized to receive placebo, eight (20%) developed anastomotic leak compared to only 2 (5%) in the treatment group of 40 patients (decontamination) with significant difference in the χ2 test (p = 0.0425). Twenty percent of the placebo group and 12.5% in the treatment group developed infectious complications not associated with anastomotic leak (p = 0.5312). One patient (2.5%) in the placebo group died (p = 0.3141). CONCLUSION: Local decontamination with polymyxin, tobramycin, vancomycin, and amphotericin B is safe and effective in the prevention of anastomotic leak in rectal cancer surgery.

Comparison of the effects of two different marine-derived omega-3 fatty acid sources, krill oil, and fish oil, on the healing of primary colonic anastomoses after colectomy applied Wistar albino rat model.

BACKGROUND: Oils from marine organisms have a different fatty acid composition. Fish oil (FO) has a high content of eicosapentaenoic and docosahexaenoic acids esterified to triacylglycerols; while in krill oil (KO), fatty acids are primarily esterified to phospholipids. This study aimed to compare the efficacy of two different, marine-derived omega-3 fatty acid sources in the wound healing of colon anastomoses rat model. METHODS: For the study, we used 42 male Wistar albino rats. The rats were divided into six groups with seven rats in each group-CO3: left colonic anastomosis (control group), sacrificed on the third day; KO3: left colonic anastomosis + oral KO, sacrificed on the third day; FO3: left colonic anastomosis + oral FO, sacrificed on the third day; CO7: left colonic anastomosis (control group), sacrificed on the seventh day; KO7: left colonic anastomosis + oral KO, sacrificed on the seventh day; FO7: left colonic anastomosis + oral FO, sacrificed on the seventh day. Peritoneal adhesions, anastomotic bursting pressures, hydroxyproline levels, and histological examination of the anastomotic tissue were evaluated. RESULTS: On day 7, bursting pressure and hydroxyproline measurements of the KO group was significantly higher than the FO group (p=0.012; p=0.002, respectively). Also, on day 7, a statistically significant difference was observed between the groups according to inflammatory cell infiltration, fibroblast activity, neoangiogenesis, and collagen deposition in favor of the KO group (p=0.023; p=0.028; p=0.016; p=0.012, respectively). CONCLUSION: Both KO and FO supplementation in patients before colorectal surgery may reduce some risk of anastomotic leakage; and KO might be a better alternative and excellent omega-3 source.

Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery.

PURPOSE: Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. METHODS: To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8 h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. RESULTS: Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. CONCLUSION: Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.

Does the application of Ankaferd Blood Stopper rectally have positive effects on the healing of colorectal anastomosis and prevention of anastomotic leakage? An experimental study.

The purpose of this experimental study was to evaluate the potential effects on the healing of colorectal anastomoses of the rectal administration of Ankaferd Blood Stopper (ABS). Thirty Wistar-Albino male rats were randomly separated into 3 groups. In the sham group, only laparotomy and colonic mobilization was performed. In the other 2 groups, colon transection and anastomosis were carried out. Saline (2 mL, 0.9% NaCl) was given rectally via a feeding tube for 10 days after the surgical procedure in the sham and control groups. In Group 3 (ABS group), the rats were treated with rectally administered ABS (2 mL/day) for 10 days. In all groups, after the measurement of bursting pressures, tissue samples were collected for the measurement of tissue hydroxyproline and prolidase levels, and for histopathological evaluation on postoperative day 11. The rectal administration of ABS showed positive effects on bursting pressures, tissue prolidase and hydroxyproline levels, and the histopathological findings of colonic anastomosis. The rectal application of ABS had positive effects on the healing of colorectal anastomosis. As a natural product, it may be used effectively and safely to achieve better healing results after colorectal anastomosis.

Impact of tissue adhesives on the prevention of anastomotic leakage of colonic anastomoses: an in vivo study.

BACKGROUND: Tissue adhesives (TA) may be useful to strengthen colorectal anastomoses, thereby preventing anastomotic leakage (AL). Previous studies have identified cyanoacrylate (CA) TAs as the most promising colonic anastomotic sealants. This study investigates the protective effects of sealing colonic anastomoses with various CAs. MATERIALS AND METHODS: Fifty-five Wistar rats underwent laparotomy and transection of the proximal colon. An anastomosis was created with 4 interrupted sutures followed by either application of Histoacryl Flexible, Omnex, Glubran 2, or no TA seal. An additional control group was included with a 12-suture anastomosis and no TA seal. After 7 days, the rats were sacrificed and scored for the presence of AL as the main outcome. Secondary outcomes were the occurrence of bowel obstruction, adhesions, and anastomotic bursting pressure. Histological evaluation was performed. RESULTS: The highest AL rate was found in the Glubran 2 group (7/11), followed by the 4-sutures group without TA (5/11), and the Omnex group (5/11). Histoacryl Flexible showed the lowest AL rate (2/11). In the control group, only one rat showed signs of AL. Histologically, the highest influx of inflammatory cells was found in the 4-suture group without TA and for Omnex and Glubran 2. Histoacryl Flexible caused more mature collagen deposition when compared to the other TA groups. CONCLUSIONS: Histoacryl Flexible showed the lowest leakage rate compared to the other TA groups and to the 4-suture control group. Glubran 2 showed the highest AL rate and a high inflammatory response. Histoacryl Flexible was associated with the presence of more mature collagen and seems to promote anastomotic healing.

Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model?

PURPOSE: Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis. MATERIALS AND METHODS: Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied. RESULTS: The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups. CONCLUSIONS: Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.

Role of glycopyrrolate in healing of anastomotic dehiscence after primary repair of esophageal atresia in a low resource setting-A randomized controlled study.

AIMS: To investigate the role of glycopyrrolate in decreasing oral secretions in patients of esophageal atresia (EA) with anastomotic leak and evaluate its effect on healing of anastomotic dehiscence. METHODS: The study comprised consecutive neonates of esophageal atresia, who had undergone primary surgery and developed anastomotic leak. The patients were randomized into two groups with the observer blinded to the group. The patients in the treatment group were administered glycopyrrolate in the dose of 8 µg/kg 8 hourly, whereas placebo group patients were injected normal saline only. Neonates, in both the groups, were managed conservatively based on the clinical and radiological parameters. The end points of the study were either resolution or progression of the leak. The study was approved by the institute ethics committee. RESULTS: There were 21 patients each in two groups with comparable preoperative characteristics. All the cases had anastomotic leaks clinically detectable in the chest tube. Saliva alone constituted the leak material in 18 cases in the treatment group and 10 in the placebo group. Cumulative total of mean chest tube output per patient for all patients in the treatment group was 124.15ml as compared to 370.27ml in the placebo group (p=0.001). Anastomotic leak stopped in 16 cases (76%) in the treatment group, as compared to 6 cases (29%) in the placebo group (p=0.004). The postoperative ventilation was required in 8 cases (8/21, 38%) in the treatment group and 17 cases (17/21, 81%) in the placebo group (p=0.010). In the treatment group, the diversion procedures were carried out in 2 out of 21 cases (10%), whereas in the placebo group, 52% of the patients (11/21) required such an intervention (p=0.003). At the time of discharge, the oral feeds could be started in 15 cases (15/21, 71%) in the treatment group, as compared to 3 (3/21, 14%) in the placebo group (p=0.0004). CONCLUSIONS: Administration of glycopyrrolate in patients of anastomotic leak after primary repair of esophageal atresia resulted in reduced oral secretions, which helped in healing of the anastomotic dehiscence in a significant number of patients.

Novel approach to pleurodesis with 50 % glucose for air leakage after lung resection or pneumothorax.

PURPOSE: Pleurodesis is performed in patients demonstrating air leakage after lung resection and in those with pneumothorax who must avoid surgery. However, there have so far been very few reports of pleurodesis with 50 % glucose. We herein examined the feasibility and effectiveness of this novel pleurodesis technique. METHODS: Thirty-five patients after lung resection and 11 pneumothorax patients without surgery were treated with pleurodesis using 50 % glucose. Approximately, 200 mL of 50 % glucose solution was injected into the pleural space and repeated until the air leakage stopped. Cases in which the air leakage did not stop after three injections were considered to be unsuccessful and subsequently treated with conventional pleurodesis using OK-432. RESULTS: Thirty-nine patients were successfully treated with 50 % glucose, although 7 patients required further treatment with OK-432. The unsuccessful group had some pulmonary comorbidities (P < 0.001), and the pleural effusion volume after pleurodesis was less than that in the successful group (P < 0.001). Although the air leakage did not stop in unsuccessful patients, the amount of air leakage markedly decreased. A temporary elevation of the blood sugar level was observed in 20 patients, but no other side effects had appeared. CONCLUSIONS: Pleurodesis with 50 % glucose is an easy, safe, and effective treatment modality. It is therefore considered to be a useful alternative method for pleurodesis.

Surgical site infections following short-term radiotherapy and total mesorectal excision: results of a randomized study examining the role of gentamicin collagen implant in rectal cancer surgery.

BACKGROUND: Despite the findings of several randomized clinical studies, the role of gentamicin collagen implant (GCI) in rectal cancer surgery is unclear. Local pelvic application of GCI following preoperative radiotherapy and total mesorectal excision (TME) was evaluated to determine the risk of surgical site infections (SSI). METHODS: In this single-center trial, 176 patients with rectal cancer after preoperative, short-term radiotherapy (5 × 5 Gy) were randomized either to the study group in which GCI was used or in the control group without GCI. Prior to surgery and intraoperatively five patients were excluded from the study. The remaining 171 patients were analyzed; 86 were in the study group and 85 in the control group. RESULTS: There were no statistically significant differences in the overall rate of early postoperative complications between the study and control group: 25.6 and 34.1 % respectively; p = 0.245, relative risk (RR) 0.750 [95 % confidence interval (CI) 0.471-1.195]. The reoperation rate was similar in both groups: 12.8 versus 9.4 %; p = 0.628; RR 1.359; (95 % CI 0.575-3.212). The total rate of SSI and organ space SSI were 22.2 and 15.8 % without differences between the study and control group. In patients without anastomotic leakage, the risk of organ space SSI was significantly reduced in patients who received GCI: 2.6 versus 13.0 %; p = 0.018. CONCLUSIONS: Application of GCI in the pelvic cavity after short-term preoperative radiotherapy and TME may reduce the risk of organ space SSI but only in the absence of anastomotic leakage.

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift.

BACKGROUND: During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals. METHODS: We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded. RESULTS: There were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient. CONCLUSION: EIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.

The effect of erythropoietin on anastomotic healing of irradiated rats.

AIM: The aim of the present study is to evaluate the possible protective effects of erythropoietin (EPO) on anastomotic wound healing after preoperative radiotherapy according to its pleiotropic mechanism of action. METHODS: Thirty-two male Wistar albino rats were randomized into four groups containing eight rats each: ANAS group, standard resection plus anastomosis; RT+ANAS group, radiation plus standard resection plus anastomosis; ANAS+EPO group, standard resection plus anastomosis plus EPO; RT+ANAS+EPO, radiation plus standard resection plus anastomosis plus EPO. All animals were sacrificed by cardiac puncture, and anastomotic healing was measured by bursting pressure, hydroxyproline (OHP) levels, myeloperoxidase (MPO) activity and histopathological evaluations. Malondialdehyde (MDA), tumor necrosis factor-alpha (TNF-α), and matrix metalloproteinase-9 (MMP-9) were also measured in serum specimens. RESULTS: OHP levels in the RT+ANAS + EPO group were significantly increased compared with other groups (p < .05). In contrast, MPO activity in the RT+ANAS+EPO group was significantly decreased compared with other groups (p < .05). Serum MDA levels were found to be decreased in the ANAS+EPO and RT+ANAS+EPO groups (p < .05). Group comparisons demonstrated that bursting pressure was significantly higher in EPO treated rats (p < .05). The histopathology results revealed that EPO treatment improves anastomotic wound healing though decreased necrosis and inflammatory cell infiltration and increased fibroblast activity. CONCLUSION: The findings of the present study indicate that EPO contributes to wound healing and the strength of colon anastomosis following radiation due to its antioxidant and anti-inflammatory effects, but further studies are needed to explore the significance of these effects.

Adrenomedulline improves ischemic left colonic anastomotic healing in an experimental rodent model.

BACKGROUND: Leakage from colonic anastomosis is a major complication causing increased mortality and morbidity. Ischemia is a well-known cause of this event. This study was designed to investigate the effects of adrenomedullin on the healing of ischemic colon anastomosis in a rat model. METHODS: Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats that were divided into four groups. To mimic ischemia, the mesocolon was ligated 2 cm from either side of the anastomosis in all of the groups. The control groups (1 and 2) received no further treatment. The experimental groups (3 and 4) received adrenomedullin treatment. Adrenomedullin therapy was started in the perioperative period in group 3 and 4 rats (the therapeutic groups). Group 1 and group 3 rats were sacrificed on postoperative day 3. Group 2 and group 4 rats were sacrificed on postoperative day 7. After careful relaparotomy, bursting pressure, hydroxyproline, malondialdehyde, interleukin 6, nitric oxide, vascular endothelial growth factor, and tumor necrosis factor alpha levels were measured. Histopathological characteristics of the anastomosis were analyzed. RESULTS: The group 3 animals had a significantly higher bursting pressure than group 1 (p<0.05). Hydroxyproline levels in group 1 were significantly lower than in group 3 (p<0.05). The mean bursting pressure was significantly different between group 2 and group 4 (p<0.05). Hydroxyproline levels in groups 3 and 4 were significantly increased by adrenomedullin therapy relative to the control groups (p<0.05). When all groups were compared, malondialdehyde and nitric oxide were significantly lower in the control groups (p<0.05). When vascular endothelial growth factor levels were compared, no statistically significant difference between groups was observed. Interleukin 6 and tumor necrosis factor alpha were significantly decreased by adrenomedullin therapy (p<0.05). The healing parameters and inflammatory changes (e.g., granulocytic cell infiltration, necrosis, and exudate) were significantly different among all groups (p<0.05). CONCLUSION: Adrenomedullin had positive effects on histopathologic anastomotic healing in this experimental model of ischemic colon anastomosis.