Is preoperative hypoalbuminemia or hypoproteinemia a reliable marker for anastomotic leakage risk in patients undergoing elective colorectal surgery in an enhanced recovery after surgery (ERAS) program?

PURPOSE: Preoperative hypoalbuminemia has traditionally been used as a marker of nutritional status and is considered a significant risk factor for anastomotic leak (AL). METHODS: The Westmead Enhanced Recovery After Surgery (WERAS) prospectively collected database, consisting of 361 patients who underwent colorectal surgery with primary anastomosis, was interrogated. Preoperative serum albumin and protein levels (measured within 1 week of surgery) were plotted on receiver operating characteristic curves (ROC curves) and statistically analyzed for cutoff values, sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). RESULTS: The incidence of AL was 4.4% (16/361). Overall mortality was 1.4% (5/361), 6.3% (1/16) in the AL group, and 1.2% (4/345) in the no AL group. The median preoperative albumin and protein level in the AL group were 39 g/L and 75 g/L, respectively. The median preoperative albumin and protein level in the no AL group were 38 g/L and 74 g/L, respectively. The Mann-Whitney U test showed no statistically significant difference in albumin levels (p = 0.4457) nor protein levels (p = 0.6245) in the AL and no AL groups. ROC curves demonstrated that preoperative albumin and protein levels were not good predictors of anastomotic leak. Cutoff values for albumin (38 g/L) and protein (75 g/L) both had poor PPV for AL (4.8% and 3.8% respectively). CONCLUSION: In patients undergoing elective colorectal surgery as part of an ERAS program, preoperative serum albumin and protein levels are not reliable in predicting AL. This may be because of nutritional supplementation provided as part of an ERAS program may correct nutritional deficits to protect against AL or that low albumin/protein is not as robust a marker of AL as previously reported.

A rare case of ruptured appendiceal diverticulitis: A significant surgical pathology.

Appendiceal diverticulitis is a rare pathology which is distinctly different to acute appendicitis and associated with higher rates of morbidity and mortality. Furthermore, diagnosis is often retrospective on histopathological analysis of appendicectomy specimens due to the atypical clinical and radiological features. Herein, we present a case of ruptured appendiceal diverticulitis in a young patient with atypical clinical features and a radiologically normal appearing appendix in close proximity to an inflammatory phlegmon. This case highlights the importance of maintaining a high clinical suspicion of surgical pathology and considering atypical diagnosis in patients with inflammatory changes in the right iliac fossa.

A rare case of intestinal internal hernia beneath the external iliac artery following radical cystectomy.

Gastrointestinal complications following radical cystectomy (RC) are a common occurrence, with small bowel obstruction (SBO) a known complication. Limited cases have been reported of SBO following RC due to internal herniation of the small intestine around the ureter, ileal conduit, obturator nerve and, as a consequence of retroperitoneal lymphadenectomy, even the abdominal vasculature. We present a rare case in which intestinal herniation beneath the external iliac artery (EIA) resulted in a closed-loop SBO with ischaemia and necrosis. Intra-operative transection of the unrecognised EIA occurred, necessitating primary arterial repair. This case highlights the importance of maintaining a high index of suspicion for complex pathology and anatomical variations in patients following RC and other operations involving retroperitoneal lymphadenectomy.