Impact of Clostridium difficile Infection Versus Colonization on Postoperative Outcomes After Oncological Colorectal Surgery: An Observational Single-Center Study With Propensity Score Analysis.

BACKGROUND: There is limited research available concerning the risk anastomotic leakage in the context of Clostridium difficile infection (CDI). Herein, we aim to elucidate the correlation between CDI, encompassing both preoperative asymptomatic C. difficile carriers (CDC) and postoperative hospital acquired C. difficile infections (HA-CDI), and the occurrence of anastomotic leakage in patients undergoing oncological colorectal surgery. METHODS: This is an observational, single-center study. Data were sourced from surgical logs between 2018 and 2023, via the hospital's electronic system. Patients were split into three subgroups: CDC, HA-CDI, and control group (CG). Groups were compared in terms of patient characteristics, morbidity, and mortality via Fisher's exact test and Kruskal-Wallis test. One-to-one propensity score matching was performed to reduce selection bias. RESULTS: A total of 522 patients were analyzed, split into three subgroups: CDC, n = 35; HA-CDI, n = 27; CG, n = 460. One-to-one propensity score matching reduced the CG to 62 patients. Patients in the HA-CDI group had higher rates of overall morbidity (p < 0.0001), higher rates of anastomotic leaks (p = 0.002), more surgical site infections (SSI) (p = 0.001), and a longer length of stay (26 vs. 11.2 vs. 9.3 days, p < 0.001), while patients in the CDC group had comparable rates of complications with the CG. CONCLUSION: HA-CDI is associated with a higher risk of anastomotic leak after oncological colorectal surgery, while asymptomatic CDC do not have higher morbidity and may be operated electively, under standard CD treatment.

Single-stapled colorectal anastomotic techniques: Do not cross the line.

The double-stapled technique is the most common method of colorectal anastomosis. Despite its widespread use, emerging data suggests that this technique may be a risk factor for anastomotic complications, as it is believed that crossing staple lines and resultant dog-ears are potentially weak points that are prone to ischemia and anastomotic leak. Herein, we describe technical variations of single-stapled colorectal anastomoses which surgeons can readily adopt and integrate into their armamentarium of anastomotic techniques.

Conduit Ischemia After Esophagectomy: A Spectrum of Clinical Manifestations, Prevention, and Management.

This article outlines the anatomic and physiologic basis for gastric conduit ischemia and the range of its possible manifestations, from superficial mucosal ischemia to gross conduit necrosis. Methods by which these complications are suspected and ultimately diagnosed are discussed, focusing on clinical and laboratory signs as the harbingers and the use of imaging and endoscopy for confirmation. From there, management options are detailed based on the Esophagectomy Complications Consensus Group classification of esophageal leak and gastric necrosis. Finally, the short- and long-term implications of these complications are reviewed.

PROFUGO study protocol: Predictive model for the early diagnosis of anastomotic leak after esophagectomy and gastrectomy.

In esophagogastric surgery, the appearance of an anastomotic leak is the most feared complication. Early diagnosis is important for optimal management and successful resolution. For this reason, different studies have investigated the value of the use of markers to predict possible postoperative complications. Because of this, research and the creation of predictive models that identify patients at high risk of developing complications are mandatory in order to obtain an early diagnosis. The PROFUGO study (PRedictivO Model for Early Diagnosis of anastomotic LEAK after esophagectomy and gastrectomy) is proposed as a prospective and multicenter national study that aims to develop, with the help of artificial intelligence methods, a predictive model that allows for the identification of high-risk cases. of anastomotic leakage and/or major complications by analyzing different clinical and analytical variables collected during the postoperative period of patients undergoing esophagectomy or gastrectomy.

Ileoanal Pouch Salvage Rates with Endoluminal Vacuum Therapy for Early vs. Late Anastomotic Leaks.

BACKGROUND: Anastomotic leaks post-ileoanal pouch-anal anastomosis (IPAA) significantly compromise patient outcomes and increase healthcare resource utilization. The aim of this study was to evaluate outcomes of Endoluminal Vacuum Therapy (EndoVac) for pouch leaks. We hypothesized that EndoVac for early compared with late leaks was associated with a higher pouch survival rate. METHODS: We retrospectively reviewed consecutive pouch anastomotic leaks treated with EndoVac therapy at our institution between 2013-2023. Patients were stratified into early (≤30 days) and late (>30 days) leaks. Anastomotic healing was defined as complete closure of the leak site and resolution of symptoms. Pouch failure was defined as a permanent ileostomy or pouch excision. The probability of pouch survival was estimated using the Kaplan-Meier method. RESULTS: A total of 14 IPAA patients were included: median age 34 years, 71% were male, and median body mass index 23.46kg/m2. DIAGNOSES: ulcerative colitis (n=12) and familial adenomatous polyposis (n=2). The median (IQR) time from pouch construction to leak was 44.5 (12-192) days; of these, 6 (43%) early and 8 (57%) late. All (100%) leaks were at the anastomosis; all (100%) were diverted at the time of EndoVac therapy: 10 (71%) still diverted and 4 (29%) re-diverted. Patients underwent a median of 5.5 EndoVac changes (3-7) over a duration of 13.5 (6-21) days from initiation of treatment to cessation of therapy. After EndoVac therapy, healing was observed in 10 (71%) patients, 2 of whom required a minor handsewn anastomotic revision but healed completely, and 4 did not heal: 3 had pouch excision and 1 underwent redo pouch surgery. Anastomotic healing (66.7% vs. 75%, p=0.7) and pouch survival (83.3% vs. 75%, p=0.73) were not significantly different between the early and late leak groups. The overall pouch salvage rate was 78.5%. CONCLUSIONS: EndoVac therapy was effective in achieving high rates of pouch salvage and anastomotic healing in patients with ileoanal pouch leaks, irrespective of the timing of intervention postoperatively. This supports the use of EndoVac as a viable treatment option for both early and late anastomotic leaks.

Worth the Wait? The Impact of Timing of Repair of Esophageal Atresia With Tracheoesophageal Fistula on Outcomes.

INTRODUCTION: Infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) are at increased risk for respiratory compromise and gastric perforation until fistula ligation. We sought to describe current practice regarding the timing of EA/TEF repair and hypothesized that age at repair is a predictor of adverse outcomes. METHODS: The Pediatric Health Information System (PHIS) database was used to identify patients with EA/TEF who underwent fistula ligation and esophago-esophagostomy at US children's hospitals from July 2016-June 2021. Patients with a repair >10 days of age, a long-gap atresia, or H-type fistula were excluded. Comorbidities including prematurity and operative congenital heart disease were noted. Outcomes including anastomotic leak, gastric perforation, and post-operative respiratory failure were assessed for association with age and day of the week of operation. RESULTS: Among 863 patients that were evaluated, the plurality of operations was on DOL 2 (36%) and 83% were on a weekday (random rate = 71%). Later operations had shorter LOS (p = 0.04) and more recurrent nerve injuries (p = 0.01). Weekend repairs were associated with equivalent outcomes. Gastric perforations occurred in 18 (2.0%) patients; 11 (61%) of these occurred after DOL 2. CONCLUSIONS: We found no significant differences in outcomes other than more recurrent nerve injury and decreased LOS with EA/TEF repair at older ages. Although repair beyond DOL 2 was safe from a respiratory standpoint, most gastric perforations occurred after this point. In the absence of contraindications or significantly reduced weekend capabilities, we recommend repair of EA/TEF by DOL 2. LEVEL OF EVIDENCE: III.

Venous Supercharging Relieves Venous Congestion and Salvages Gastric Conduit Post-esophagectomy.

The purpose of this study was to evaluate the effectiveness of incorporating additional venous anastomoses (venous super charging) in improving gastric conduit congestion and preventing complications such as conduit loss and anastomotic leakage following esophagectomy. We included two consecutive patients, one undergoing esophagectomy and the other undergoing laryngo-pharyngo-esophagectomy. Additional venous anastomoses were performed to alleviate venous congestion at the oral end of the gastric conduit. The perfusion assessment of the anastomosis was evaluated using indocyanine green fluorescence angiography (ICG FA) by Stryker's SPY PHI device. Both patients experienced anastomotic leakage, with one having a grade 2 leak and the other a grade 1 leak. Fortunately, conservative measures proved successful in managing these complications and there was no conduit loss. The incorporation of additional venous anastomoses effectively relieves venous congestion in the gastric conduit after esophagectomy and prevent conduit loss, indicating its potential in improving patient outcomes.

Evaluation of the gastric conduit perfusion using indocyanine green in thoracoscopic esophagectomy for esophageal cancer.

Objective: Indocyanine green has been used in the assessment of the gastric conduit perfusion in thoracoscopic esophagectomy to prevent malperfusion-associated anastomotic leak. This study aims to evaluate the initial results of investigating the gastric conduit perfusion with indocyanine green in the surgical treatment of esophageal cancer. Patients and methods: This cross-sectional descriptive study was carried out on 54 esophageal cancer patients undergoing thoracoscopic esophagectomy and gastric conduit reconstruction. The blood flow in the gastric conduit was observed using an infrared camera and indocyanine green after completion of the conduit and after tunneling the conduit through the mediastinum to the neck. Results: The gastric conduit width and length were 5.2 ± 0.3 cm, and 31.5 ± 1.6 cm, respectively. The length of the gastric conduit from the junction between the right and left gastroepiploic to the point where the distal end of the gastric conduit still has a vascular pulse was 11.9 ± 4.3 cm. Seventeen patients (31.5%) had poor blood supply at the distal end of the gastric conduit, with indocyanine green appearance time ⩾ 60 s, in whom anastomotic leaks occurred in five patients (9.3%). The lack of connection between the right and left gastroepiploic vessels was associated with poor blood supply of the distal gastric conduit (p = 0.04). Multivariable logistic regression analysis showed association between the time of indocyanine green appearance at the distal gastric conduit and the risk of anastomotic leak (OR = 1.99, 95% CI = 1.10-3.60, p = 0.02). Conclusion: Investigation of gastric conduit perfusion using indocyanine green in gastric conduit reconstruction detected 31.5% of patients with poor blood supply at the distal end of the conduit, in whom 9.3% had anastomotic leak. The longer indocyanine green appearance time in the distal gastric conduit (segment BC), was associated with the higher rate of the anastomotic leak.

Quadruple Assessment of Colorectal Anastomosis after Laparoscopic Rectal Resection: A Retrospective Analysis of a Propensity-Matched Cohort.

Background: Anastomotic leakage (AL) is one of the most feared complications in colorectal surgery, with an incidence of 12-39% and associated risk of mortality of 2-24%. The causes of AL and the ways to prevent it are currently under investigation. This study aims to verify if a quadruple assessment of colorectal anastomosis could reduce AL incidence. Methods: A retrospective analysis of prospectively collected data on rectal cancer surgery performed from January 2015 to December 2017 and from January 2021 to December 2023 at a tertiary referral cancer centre was performed. Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. Results: A total of 293 patients were enrolled. AL incidence was lower in the quadruple assessment group than in the control group, reaching a statistically significant result (7.7% vs. 16%; p = 0.001). This result was also confirmed after a propensity score match analysis (PSM), in which the AL rate was lower in the quadruple assessment group (5.4% vs. 12.3%; p = 0.01). Conclusions: This study shows how the systematic implementation of a quadruple assessment when performing a colorectal anastomosis could increase awareness on anastomotic success and reduce the incidence of AL.