Diagnosis and treatment of anastomotic leak after low anterior resection for rectal cancer: current status and future prospect / 中华胃肠外科杂志

Anastomotic leak is one of inevitable postoperative complications of rectal cancer. With the improvement of surgical techniques, the enhancement of the cognization of rectal cancer, and the development of surgical instruments, surgical procedures of rectal cancer are getting more sophisticated. The anastomosis is performed lower and lower, however the incidence of anastomotic leak is not significantly decreased. In addition, different from intraperitoneal anastomotic leak, the low rectal anastomotic leak after low anterior resection has many special issues in the diagnosis and treatment in clinic. The incidence of peritonitis caused by low anastomotic leak is low, the onset time is late, and symptoms of peritonitis are mild. So most low anastomotic leak is treated conservatively, second surgical repair or resection of anastomotic site is rarely performed, and proximal intestinal diversion is commonly performed. In the prevention of low anastomotic leak, some techniques and precautions during the perioperative period and identification of high risk factors might play important roles. Combined our clinical experiences, we introduced the diagnosis, treatment, prevention and research progression of low anastomotic leak after anterior resection of low rectal cancer, we hope it would be helpful.

Procalcitonin as an early marker in the detection of anastomotic intestinal leak in a Universitary Hospital of Bogotá / Procalcitonina como um marcador precoce na detecção de vazamento anastomótico intestinal em um Hospital Universitário de Bogotá

ABSTRACT Introduction: Anastomotic leakage is a complication of intestinal anastomosis, with an incidence of 2%-7% in centers of experience. To be able to achieve an early detection, serological markers such as Procalcitonin were included. Methods: Descriptive retrospective cohort study of patients taken to colorectal surgery with intestinal anastomosis, the objective is to estimate association between procalcitonin (≥2 ng/dl) as an early inflammatory marker and anastomotic leakage in a Coloproctological Service of a highest level of health care hospital, between September 2017 and January 2019. Results: Cohort of 237 patients, 51% women (18-89 years), with multiple comorbidities in 81% of patients, colon cancer was the most operated pathology (53.1%). Laparoscopic approach was the most applied 60.34%, colorectal anastomosis was the most frequently performed (47.26%). Ileocolic anastomosis presented a higher frequency (43.75%-n:7) of dehiscence. Anastomotic leakage was associated with a serum procalcitonin positive 3 days postoperatively (p-value <0.05). Patients with a positive result had 4.28 times higher risk of presenting an anastomotic leak, compared to this risk in those patients with negative results 3 days postoperatively, this association was statistically significant 95% CI (1.34-14.16); p value <0.05. Conclusion: Anastomotic leakage is a source of morbidity in patients taken to intestinal anastomosis. It's necessary to guarantee an early diagnosis of this complication, prevent abscesses and secondary peritonitis, providing adequate treatment and even reducing the associated mortality. We recommend including the procalcitonin in the assessment protocol on the third day of postoperative follow-up.

RESUMO Introdução: O vazamento anastomótico é uma complicação da anastomose intestinal, com uma incidência de 2% a 7% em centros com experiência. Para conseguir uma detecção precoce, foram incluídos marcadores sorológicos como a Procalcitonina. Métodos: Estudo de coorte descritivo e retrospectivo de pacientes submetidos à cirurgia colorretal com anastomose intestinal, cujo objetivo é estimar a associação entre os níveis de procalcitonina (≥ 2 ng/dL) como marcador inflamatório precoce e vazamento anastomótico em um Serviço de Coloproctologia de alto nível de atenção à saúde hospitalar, entre setembro de 2017 a janeiro de 2019. Resultados: Coorte de 237 pacientes, 51% mulheres (18−9 anos), com múltiplas comorbidades em 81% dos pacientes, sendo o câncer de cólon a patologia mais operada (53,1%). A abordagem laparoscópica foi a mais utilizada, em 60,34%, e a anastomose colorretal foi a mais frequentemente realizada (47,26%). A anastomose ileocólica apresentou a maior frequência (43,75%, n = 7) de deiscências. O vazamento anastomótico foi associado a procalcitonina sérica positiva 3 dias após a cirurgia (p < 0,05). Pacientes com resultado positivo tinham um risco 4,28 vezes maior de apresentar vazamento anastomótico, em comparação com esse mesmo risco nos pacientes com resultado negativo 3 dias após a cirurgia, sendo essa associação estatisticamente significativa, (IC95%:1,34−14,16); p < 0,05. Conclusão: O vazamento anastomótico é fonte de morbidade em pacientes encaminhados para anastomose intestinal. É necessário garantir o diagnóstico precoce desta complicação, prevenir abscessos e peritonites secundárias, proporcionando tratamento adequado e até mesmo reduzindo a mortalidade associada. Recomendamos incluir a procalcitonina no protocolo de avaliação no terceiro dia de seguimento pós-operatório.

Utilização dos níveis de amilase no dreno abdominal para diagnóstico de fístulas anastomóticas após o bypass gástrico em Y de Roux / Drain amylase levels may indicate gastrojejunostomy leaks after roux-en-y gastric bypass

ABSTRACT BACKGROUND: Although the incidence of leaks after Roux-en-Y gastric bypass (RYGB) significantly decreased over time, their detection still remains challenging. OBJECTIVE: This study aimed to determine the usefulness of drain amylase levels to detect leaks after RYGB. METHODS: This is a population-based study which enrolled 170 individuals who underwent RYGB. Drain amylase levels were determined on the first and fourth postoperative days. Two thresholds were evaluated: three times higher than the serum levels (parameter I) and higher than 250 IU/L (parameter II). The main outcomes evaluated were perioperative morbidity, the occurrence of leaks, 30-day readmissions and reoperations, hospital stay, and mortality. RESULTS: Considering the parameter I, high drain amylase levels were significantly associated with leaks (12.5% vs 0; P<0.00001). Considering the parameter II, high drain amylase levels were significantly associated with longer hospital stay (8±5.7 vs 4.5±1.3 days; P=0.00032), 30-day reoperations (50% vs 3%; P=0.000285), and leaks (50% vs 0; P<0.00001). The parameter I presented a sensitivity of 100% and specificity of 95.9%, whereas the parameter II presented a sensitivity of 100% and a specificity of 99.4%. CONCLUSION: The determination of drain amylase levels after RYGB was a significant indicator of leaks, hospital stay, and 30-day reoperations. This finding reinforces the importance of abdominal drainage in the RYGB within this context.

RESUMO CONTEÚDO: Embora a incidência de fistulas após o bypass gástrico em Y de Roux (BGRY) tenha diminuído significativamente com a evolução da técnica, sua detecção continua desafiadora. OBJETIVO: Determinar a acurácia dos níveis de amilase no dreno abdominal para detector fístulas após o BGYR. MÉTODOS: Este é um estudo populacional que avaliou 170 indivíduos submetidos ao BGYR. Os níveis de amilase no dreno foram determinados no primeiro e quarto dias de pós-operatório. Dois pontos de corte foram avaliados: três vezes maior que os níveis séricos (parâmetro I) e acima de 250 UI/L (parâmetro II). Os principais desfechos estudados foram: morbidade perioperatória, ocorrência de fístulas, reinternações e reoperações nos primeiros 30 dias, permanência hospitalar e mortalidade. RESULTADOS: Considerando o parâmetro I, altos níveis de amilase do dreno foram indicadores significativos de fístulas (12,5% vs 0; P<0,00001). Considerando o parâmetro II, altos níveis de amilse no dreno estiveram significativamente associados a maior permanência hospitalar (8±5,7 vs 4,5±1,3 dias; P=0,00032), frequência de reoperações (50% vs 3%; P=0,000285) e ocorrência de fístulas (50% vs 0; P<0,00001). O parâmetro I apresentou sensibilidade de 100% e especificidade de 95,9%, enquanto o parâmetro II apresentou sensibilidade de 100% e especificidade de 99,4%. CONCLUSÃO: A determinação dos níveis de amilase no dreno após o BGYR foi um indicador significativo de fístulas, permanência hospitalar e reoperações. Este achado reforça a importância da drenagem abdominal no BGYR dentro deste contexto.

Aplicabilidad del Colon Leakage Score como predictor de filtración anastomótica en cirugía de cáncer colorrectal / Applicability of the Colon Leakage Score as an anastomotic leakage predictor in colorectal cancer surgery

Introducción: La filtración anastomótica (FA) en cirugía colorrectal aumenta la morbimortalidad. La identificación de factores de riesgo y la creación de un modelo predictivo ayudaría en la decisión de crear un ostoma desfuncionalizante, hecho que, actualmente, recae en el criterio del cirujano. Dekker creó el Colon Leakage Score (CLS) estableciendo criterios objetivos. Objetivo: Establecer el CLS en pacientes intervenidos por cáncer de colon izquierdo y recto en Clínica INDISA, estableciendo valores de corte locales, su sensibilidad y especificidad. Pacientes y Método: Corresponde a un estudio de pruebas diagnósticas, cuya intervención es la aplicación del CLS comparándolo con la presencia de filtración anastomótica (gold standard), definida por criterios clínicos y radiológicos. Se utilizó análisis de curvas ROC, índice de Youden y regresión logística. Resultados: De 180 pacientes, hubo FA en 12 (6,6%). La media de CLS en quienes hubo FA fue de 11,5 y en quienes no hubo FA de 6,9 (p = 0,0001). El área bajo la curva para predicción de FA con el CLS fue de 0,829 (IC 95% 0,69-0,96), con un valor de corte de 11, sensibilidad de 67% y especificidad de 89%. En el análisis de regresión logística, el OR para la predicción de FA utilizando el CLS fue de 1,48 (IC 95% 1,22-1,79 p < 0,001). Conclusión: El CLS es una herramienta que permite predecir el riesgo de FA en pacientes intervenidos por cáncer de colon izquierdo y recto. Ante un valor mayor o igual a 11 se debería crear un ostoma protector, generando un cambio en la práctica clínica.

Introduction: Anastomotic filtration increases morbidity and mortality in colorrectal surgery. Identification of risk factors and creation of a predictive model would help the decision of creating a defunctionalizing ostoma, that currently is taken by the surgeon. Dekker created de Colon Leakege Score (CLS) with objective criteria. Objective: Establish CLS in patients that underwent left colon and rectum surgery with cancer diagnosis in Clinica INDISA, define the local cutting value, it's specificity and sensibility. Patients and Methods: Corresponds to a diagnostic test's study, that intervention is CLS application, comparing with the presence of anastomotic filtration (gold standard), defined by clinical and radiologic criteria. For the analysis, ROC curves, Youden's index and logistic regression. Results: From 180 patients, anastomotic filtration was present in 12 (6.6%). Average CLS score in patients with anastomotic filtration was 11.5 and in those without anastomotic filtration was 6.9 (p = 0.0001). Area under the curve for anastomotic filtration prediction using CLS was 0.829 (CI 95% 0.69-0.96) with a cutting value of 11, 67% of sensibility and 89% of specificity. Logistic regression analysis, OR for anastomotic filtration prediction using CLS was 1.48 (CI 95% 1.22-1.79 p < 0.001). Conclusion: CLS is a tool that permits predicting anastomotic filtration risk in patients that underwent left colon and rectum surgery. With a CLS value equal or more than 11, we should create a protective ostoma, generating a clinical practice local change.

Técnica con indocianina verde (ICG) como predictor de la falla de sutura: inicio de la experiencia en nuestro medio / Technical indocyanine green (ICG) as a predictor of suture failure

Objetivo: Valorar en el intraoperatorio en tiempo real, el flujo sanguíneo de los cabos anastomóticos y la anastomosis. El objetivo final de este trabajo busca que este sea el inicio de un estudio prospectivo, con el fin de auditar las anastomosis colónicas de forma intraoperatoria buscando así disminuir el número de fallas de suturas. Material y método: Se realizó un estudio prospectivo, observacional y descriptivo, desarrollado en el Hospital de Clínicas en el período comprendido entre enero de 2014 y julio 2015. Se incluyeron en el mismo pacientes sometidos a resección de colon y reconstrucción primaria del tránsito intestinal de coordinación. El indocianina verde (ICG) se empleó como colorante vital fluorescente para la valoración in situ de la anastomosis colónica. La presencia de falla de sutura en el postoperatorio en relación con la perfusión anastomótica objetivada con ICG constituye un parámetro de importancia en nuestro estudio. Resultados: En lo referente a la perfusión de la anastomosis, destacamos que en el primer caso la misma fue sensiblemente inferior en el cabo colónico, en tanto que en los 2 casos restantes la vascularización de los cabos fue óptima. Conclusiones: La técnica con ICG constituye una herramienta apropiada para poder auditar la calidad de las anastomosis intestinales realizadas de coordinación. Se trata de una técnica segura, aplicable en nuestro medio. Siendo un predictor de falla de sutura, permite un descenso de la morbimortalidad postoperatoria por esta causa.

Aim: Rate intraoperatively in real time, blood flow and ends anastomotic and anastomosis. The ultimate goal of this work seeks to make this the beginning of a prospective study in order to audit the colonic anastomosis intraoperatively and seeking to reduce the number of sutures failure. Material and method: A prospective, observational and descriptive study, to be held in the Clinics Hospital in the period between January 2014 and July 2015. They were included in the same patients undergoing resection of colon and intestinal transit reconstruction on primary coordination. Indocyanine green (ICG) was used as a fluorescent vital dye for in situ evaluation of colonic anastomosis. The presence of failure postoperative suture relative to the anastomotic objectified perfusion with ICG, is an important parameter in our study.Results:Regarding the perfusion of the anastomosis, in the first case it was significantly lower than in the colonic out. While in the remaining two cases the vascularization of the ends was optimal. Conclusions: The technique with indocyanine green is an appropriate tool to audit the quality of intestinal anastomoses performed coordination.

Filtraciones en bypass gástrico resectivo por laparotomía en obesidad mórbida / Anastomotic leaks after roux-en Y gastric bypass for morbid obesity

Background: Obesity is a severe disease whose prevalence continues to increase. Resective gastric bypass is one of the surgical procedures used in our center in patients with obesity, but like other techniques is not without complications, and the leak is one of the most serious. Aim: To determine by a prospective study the incidence, clinical presentation, postoperative course and treatment of obese patients with leaks after open resective gastric bypass. Material and Methods: From August 1999 to December 2009, 900 morbidly obese patients underwent open resective Roux-en-Y gastric bypass at the Hospital of the University of Chile. The use of drains and leak test with methylene blue during surgery, such as barium x-ray were performed in all patients as part of a protocol. Clinical signs, development, testing and treatment were recorded. Results: 36 patients (4 percent developed leaks. Of the 900 patients died 3 (0.33 percent). Fever and tachycardia were the predominant symptoms. The diagnosis was made by imaging studies in 19 cases (52.7 percent). The leaks were mostly between 5 th and 9 th postoperative day. The most frequent location of the leak was at the gastrojejunal anastomosis (58.3 percent). Treatment was medical in 24 patients (66.7 percent), requiring re-operation only in 12 cases. The average time of closure of the leak was 35.5 days and the patients were hospitalized a total of 33.7 days on average. Conclusions: In the series studied after resective gastric bypass the leak is presented in 4 percent of patients. Fever and tachycardia are useful signs to suspect a leak. The early detection of leaks is determinant to reach the best evolution of the patient and success in the treatment.

Introducción: La obesidad es una enfermedad severa cuya prevalencia continúa en incremento. El bypass gástrico resectivo, es una intervención quirúrgica realizada en nuestro centro, para obesidad; al igual que otras técnicas no está exenta de complicaciones, siendo la filtración una de las más graves. Objetivos: Determinar mediante estudio prospectivo la incidencia, presentación clínica, evolución y tratamiento de pacientes obesos con filtraciones después de bypass gástrico resectivo vía abierta. Material y Método: Desde agosto de 1999 a diciembre de 2009, 900 obesos mórbidos fueron sometidos a bypass gástrico resectivo en Y de Roux vía abierta en el Hospital Clínico de la Universidad de Chile. Se realizó a los pacientes por protocolo, prueba con azul de metileno intraoperatoria y control radiológico con bario postoperatorio. Fue registrada la evolución, exámenes y tratamiento realizado. Resultados: 36 pacientes (4 por ciento) desarrollaron filtraciones. De 900 pacientes fallecieron 3 (0,33 por ciento). Fiebre y taquicardia fueron síntomas predominantes. El diagnóstico fue realizado por estudios radiológicos en 19 casos (52,7 por ciento). Las filtraciones se produjeron mayormente entre el 5° y 9° día postoperatorio. Localización más frecuente de filtración fue la anastomosis gastroyeyunal (58,3 por ciento). Tratamiento médico en 24 pacientes (66,7 por ciento) y reoperación en 12 casos. Tiempo promedio de cierre de filtración 35,5 días y hospitalización 33,7 días. Conclusiones: En la serie, la filtración post bypass gástrico resectivo se presentó en 4 por ciento de pacientes. Fiebre y taquicardia son signos útiles para sospechar filtración. El diagnóstico precoz de las filtraciones es determinante en la mejor evolución del paciente y éxito en el tratamiento.

Aspectos atuais na propedêutica e tratamento dos tumores do colo, reto e ânus / Current aspects in the diagnosis and treatment of tumors of the colon, rectum and anus

Este trabalho tem como objetivo a apresentação atualizada da propedêutica e tratamento dos tumores do colo e reto, realizada por levantamento bibliográfico amplo e complementado pela experiência do autor quando em visita a grandes centros de pesquisa e tratamento deste tipo de patologia, no Brasil e no Exterior. Evidencia-se a crescente e preocupante incidência desta patologia no mundo moderno e ressalta-se pontos de importância para a obtenção de melhores resultados terapêuticos, baseados fundamentalmente no diagnóstico precoce da doença. Apresentam-se as principais técnicas e procedimentos cirúrgicos para o tratamento da patologia tumoral do intestino grosso, procurando a luz da ciência e tecnologia ressaltar as opiniões e conceitos que partilhamos, sem contudo deixar de apresentar o assunto em sua totalidade, com seu valor histórico e evolutivo dentro da prática médica. Observou-se que novos métodos e exames assumem gradativamente maior importância no controle da doença. As alterações da dosagem do antígeno carcino-embrionário tem sido úteis, para o controle das metástases e recidivas tumorais, sendo que muitos autores, baseando-se somente nestas alterações têm realizado uma segunda laparotomia e surpreendido recidivas em face inicial.