Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM: Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. METHOD: This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage. RESULTS: A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001). CONCLUSION: In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Prognostic implications of circumferential location of distal rectal cancer.

AIM: This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. METHOD: All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. RESULTS: Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty-three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. CONCLUSION: Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy.

OBJECTIVE: To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence. METHOD: A total of 140 consecutive patients undergoing lateral internal sphincterotomy (LIS) for idiopathic chronic anal fissure were prospectively studied. Preoperative clinical assessment was performed together with a postoperative clinical and endosonographic examination. Three zones of the internal sphincter, identifiable by endosonography, were used to describe the uppermost extent of LIS. Primary end-points were fissure persistence/recurrence and faecal incontinence. RESULTS: A total of 140 patients, median age 49.5 years (IQR: 38-56 years) were included. Seventy-five (53.6%) and 65(46.4%) patients underwent percutaneous LIS (PLIS) and open LIS (OLIS) respectively. Median follow-up was 21 months (IQR: 14-29 months). Persistence and recurrence rates were 2.9% (4/140) and 5.7% (8/140) respectively. 7.9% (11/140) patients scored > 3 on the Jorge and Wexner Faecal Incontinence scale. PLIS was associated with a trend towards higher fissure persistence/recurrence rates than OLIS (12.0%vs 4.6%, P = 0.141). OLIS was significantly associated with a higher proportion of complete sphincterotomies (CS) than PLIS (56/65 vs 48/75, P = 0.003). A CS was associated with a lower fissure persistence or recurrence rate (1/104 vs 11/36, P < 0.001) but higher incontinence scores (11/104 vs 0/36 cases with Wexner scores > 3, P = 0.042) than following incomplete sphincterotomy. There was a strongly significant increase in incontinence scores (P < 0.001) and decrease in recurrence rates (P < 0.001) with increasing length of sphincterotomy. CONCLUSION: We recommend a short and CS using either PLIS or OLIS for the treatment of idiopathic anal fissure.

Management of intersphincteric abscesses.

OBJECTIVE: Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses. METHODS: Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied. RESULTS: Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were anterolateral. Twelve patients had low intersphincteric abscesses and were treated by laying open the abscess and dividing the internal sphincter. Nine were found to have high extensions into the intermuscular planes and were treated by staged procedures: a temporary transanal mushroom catheter was used in seven patients. Endoanal ultrasound was used initially in seven patients (33.3%) and for the evaluation of definitive treatment in 11 (52%). CONCLUSIONS: Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.

Simple technique for the intraoperative detection of Crohn's strictures with a calibration sphere.

Several methods have been used to detect and evaluate small-bowel strictures in Crohn's disease. We describe a simple technique for the calibration of strictures using a 2.5-cm medical plastic sphere. This method provides an aseptic, safe, and effective calibration of the entire small bowel.

Impact of surgeon organization and specialization in rectal cancer outcome.

PURPOSE: The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery. METHODS: Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used. RESULTS: The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03). CONCLUSION: Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.

Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy.

PURPOSE: The present study was undertaken to evaluate anal endosonographic results of the transverse and longitudinal extent of internal anal sphincter division after closed lateral subcutaneous sphincterotomy and its relationship to outcome with respect to anal fissure recurrence and postoperative anal incontinence. METHODS: Ten patients selected for symptomatic anal fissure recurrence (mean follow-up, 10.9 months) and 41 asymptomatic control patients (mean follow-up, 15.5 months) were reviewed by anal endosonography after closed lateral subcutaneous sphincterotomy. Clinical evaluation was focused on anal fissure recurrence and postoperative anal incontinence. The anal endosonographic study involves serial radial images of the distal, proximal, and midanal canal. RESULTS: In 32 patients in whom a complete internal sphincter defect was identified, 31 (75.6 percent) were from the control group and only 1 patient (10 percent) was from the recurrence group (P < 0.001). In 19 patients, an incomplete internal sphincter defect was identified; 10 (24.4 percent) were from the control group (residual median size, 1.8 mm; contralateral, 2.5 mm) and 9 patients (90 percent) were from the recurrence group (P = 0.001; residual median size, 1.4 mm; contralateral, 2.2 mm). Ten patients (19.6 percent) were incontinent for gas and three patients (5.9 percent) for liquid feces, without significant differences between groups. CONCLUSIONS: Anal endosonography is a useful method for evaluating the anatomic effectiveness of closed lateral subcutaneous sphincterotomy. An incomplete sphincterotomy is associated with significant symptomatic anal fissure recurrence.

Fistulectomía tipo core out modificada. Abordaje personal / Modified core fistulectomy. A personal approach

Objetivo. Presentar los resultados de una técnica de fistulectomía modificada con preservación del esfínter interno y cierre de los orificios esfinterianos por planos en fístulas transesfinterianas altas y en las bajas anteriores de mujeres. Pacientes y método. Estudio prospectivo de esta técnica en 9 pacientes. Ninguno fue operado previamente de fístula y todos presentaron fístulas transesfinterianas según la clasificación de Parks. Se realizó un cuestionario de incontinencia según la escala de Pescatori en el preoperatorio y en el postoperatorio, así como a los 3 y 6 meses y anualmente. Además, se realizó ecografía postoperatoria. La técnica quirúrgica consiste en una disección del tracto fistuloso desde el orificio externo hasta el interno atravesando los planos esfinterianos. Tras la exéresis se cierra primero el esfínter interno con sutura reabsorbible y después el externo con el mismo material. Si la mucosa anal no queda tensa se opta por un cierre vertical (n = 5) hasta el margen anal; en caso contrario se emplea un colgajo mucoso/ submucoso de avance (n = 4) que se fija sobre el esfínter interno íntegro. Resultados. Se han intervenido 9 pacientes (6 varones y 3 mujeres) con una edad media de 39 años (rango, 24-55). El tiempo medio de cicatrización de las heridas fue de 28-50 días. Hubo una dehiscencia de sutura con el colgajo de avance (sin consecuencias) y dos con el cierre vertical, que se manifestaron en un caso por rectorragias defecatorias (n = 1) que cedieron espontáneamente tras cicatrizar la herida. En el otro caso se evidenció una cicatrización tórpida que obligó a una esfinterotomía superficial. El control postoperatorio mínimo de 3 meses y máximo de 24 meses no ha evidenciado recidivas fistulosas ni ningún caso de incontinencia. En 3 casos se realizó una ecografía endoanal de control en el postoperatorio que puso de manifiesto en dos casos una imagen de esfinterotomía superficial. Conclusiones. La fistulectomía tipo core out modificada permite extirpar el trayecto fistuloso entero respetando al máximo la integridad del aparato esfinteriano, y puede ser una técnica alternativa frente al uso tradicional del Seton en las fístulas transesfinterianas altas (AU)