Serum nutritional predictive biomarkers and risk assessment for anastomotic leakage after laparoscopic surgery in rectal cancer patients

BACKGROUND Anastomotic leakage(AL)is one of the severest complications after laparoscopic surgery for middle/low rectal cancer,significantly impacting patient outcomes.Identifying reliable predictive factors for AL remains a clinical challenge.Serum nutritional biomarkers have been implicated in surgical outcomes but are un-derexplored as predictive tools for AL in this setting.Our study hypothesizes that preoperative serum levels of prealbumin(PA),albumin(ALB),and transferrin(TRF),along with surgical factors,can accurately predict AL risk.AIM To determine the predictive value of preoperative serum nutritional biomarkers for rectal cancer AL following laparoscopic surgery.METHODS In the retrospective cohort study carried out at a tertiary cancer center,we examined 560 individuals who underwent laparoscopic procedures for rectal cancer from 2018 to 2022.Preoperative serum levels of PA,ALB,and TRF were measured.We employed multivariate logistic regression to determine the independent risk factors for AL,and a predictive model was constructed and evaluated using receiver operating characteristic curve analysis.RESULTS AL occurred in 11.96%of cases,affecting 67 out of 560 patients.Multivariate analysis identified PA,ALB,and TRF as the independent risk factor,each with an odds ratio of 2.621[95%confidence interval(CI):1.582-3.812,P=0.012],3.982(95%CI:1.927-4.887,P=0.024),and 2.109(95%CI:1.162-2.981,P=0.031),respectively.Tumor location(<7 cm from anal verge)and intraoperative bleeding≥300 mL also increased AL risk.The predictive model demonstrated an excellent accuracy,achieving an area under the receiver operating characteristic curve of 0.942,a sensitivity of 0.844,and a specificity of 0.922,demonstrating an excellent ability to discriminate.CONCLUSION Preoperative serum nutritional biomarkers,combined with surgical factors,reliably predict anastomotic leakage risk after rectal cancer surgery,highlighting their importance in preoperative assessment.

Peritoneal fluid indocyanine green test for diagnosis of gut leakage in anastomotic leakage rats and colorectal surgery patients

BACKGROUND Application of indocyanine green(ICG)fluorescence has led to new developments in gastrointestinal surgery.However,little is known about the use of ICG for the diagnosis of postoperative gut leakage(GL).In addition,there is a lack of rapid and intuitive methods to definitively diagnose postoperative GL.AIM To investigate the effect of ICG in the diagnosis of anastomotic leakage in a surgical rat GL model and evaluate its diagnostic value in colorectal surgery patients.METHODS Sixteen rats were divided into two groups:GL group(n=8)and sham group(n=8).Approximately 0.5 mL of ICG(2.5 mg/mL)was intravenously injected postoperatively.The peritoneal fluid was collected for the fluorescence test at 24 and 48 h.Six patients with rectal cancer who had undergone laparoscopic rectal cancer resection plus enterostomies were injected with 10 mL of ICG(2.5 mg/mL)on postoperative day 1.Their ostomy fluids were collected 24 h after ICG injection to identify the possibility of the ICG excreting from the peripheral veins to the enterostomy stoma.Participants who had undergone colectomy or rectal cancer resection were enrolled in the diagnostic test.The peritoneal fluids from drainage were collected 24 h after ICG injection.The ICG fluorescence test was conducted using OptoMedic endoscopy along with a near-infrared fluorescent imaging system.RESULTS The peritoneal fluids from the GL group showed ICG-dependent green fluorescence in contrast to the sham group.Six samples of ostomy fluids showed green fluorescence,indicating the possibility of ICG excreting from the peripheral veins to the enterostomy stoma in patients.The peritoneal fluid ICG test exhibited a sensitivity of 100%and a specificity of 83.3%for the diagnosis of GL.The positive predictive value was 71.4%,while the negative predictive value was 100%.The likelihood ratios were 6.0 for a positive test result and 0 for a negative result.CONCLUSION The postoperative ICG test in a drainage tube is a valuable and simple technique for the diagnosis of GL.Hence,it should be employed in clinical settings in patients with suspected GL.

Characteristics of gut microbiota in anastomotic leakage patients in cold zones post-colorectal cancer surgery: A high-throughput sequencing and propensity-score matching study

Objective:The study aimed to explore the association between gut microbiota and anastomotic leakage(AL)after surgery in colorectal cancer(CRC)patients from a frigid zone,based on high-throughput sequencing.Methods:A total of 98 CRC patients admitted to the Second Affiliated Hospital of Harbin Medical University from July 2018 to February 2019,who met the inclusion criteria,were included.Among these,10 patients were diagnosed as AL.After propensity-score matching of baseline characteristics,10 patients from the anastomotic leakage group(AG)and 10 patients from the normal group(NG)were finally included in this study.Fecal samples were collected,and total DNA was extracted for high-throughput sequencing and bioinformatic analysis.Results:Alpha diversity analysis showed no significant difference between the two groups,while beta diversity analysis revealed significant differences in principal components.Differential microbiota were classified as Proteobacteria at the phylum level(P=0.021).At the genus level,the abundances of Streptococcus(P=0.045),Citrobacter(P=0.008)and Klebsiella(P=0.002)were significantly different between the two groups.LEfSe analysis indicated that these genera contributed most to the differences between the groups.Conclusion:The characteristics of the gut microbiota in the AG and NG were significantly different,and these differences might be associated with AL in CRC patients from frigid zones.

Establishment and application of three predictive models of anastomotic leakage after rectal cancer sphincter-preserving surgery

BACKGROUND Anastomotic leakage(AL)occurs frequently after sphincter-preserving surgery for rectal cancer and has a significant mortality rate.There are many factors that influence the incidence of AL,and each patient’s unique circumstances add to this diversity.The early identification and prediction of AL after sphincter-preserving surgery are of great significance for the application of clinically targeted preventive measures.Developing an AL predictive model coincides with the aim of personalised healthcare,enhances clinical management techniques,and advances the medical industry along a more precise and intelligent path.AIM To develop nomogram,decision tree,and random forest prediction models for AL following sphincter-preserving surgery for rectal cancer and to evaluate the predictive efficacy of the three models.METHODS The clinical information of 497 patients with rectal cancer who underwent sphincter-preserving surgery at Jincheng People’s Hospital of Shanxi Province between January 2017 and September 2022 was analyzed in this study.Patients were divided into two groups:AL and no AL.Using univariate and multivariate analyses,we identified factors influencing postoperative AL.These factors were used to establish nomogram,decision tree,and random forest models.The sensitivity,specificity,recall,accuracy,and area under the receiver operating characteristic curve(AUC)were compared between the three models.RESULTS AL occurred in 10.26%of the 497 patients with rectal cancer.The nomogram model had an AUC of 0.922,sensitivity of 0.745,specificity of 0.966,accuracy of 0.936,recall of 0.987,and accuracy of 0.946.The above indices in the decision tree model were 0.919,0.833,0.862,0.951,0.994,and 0.955,respectively and in the random forest model were 1.000,1.000,1.000,0.951,0.994,and 0.955,respectively.The DeLong test revealed that the AUC value of the decision-tree model was lower than that of the random forest model(P<0.05).CONCLUSION The random forest model may be used to identify patients at high risk of AL after sphincter-preserving surgery for rectal cancer owing to its strong predictive effect and stability.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer(CRC)is one of the most common malignancies in the world.Despite significant improvements in surgical technique,postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery.The most feared complication is anastomotic leakage.It negatively affects shortterm prognosis,with increased post-operative morbidity and mortality,higher hospitalization time and costs.Moreover,it may require further surgery with the creation of a permanent or temporary stoma.While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC,still under discussion is its impact on the long-term prognosis.Some authors have described an association between leakage and reduced overall survival,disease-free survival,and increased recurrence,while other Authors have found no real impact of dehiscence on long term prognosis.The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery.The main risk factors of leakage and early detection markers are also summarized.

Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis

BACKGROUND Anastomotic leakage(AL)following rectal cancer surgery is an important cause of mortality and recurrence.Although transanal drainage tubes(TDTs)are expected to reduce the rate of AL,their preventive effects are controversial.AIM To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery.METHODS A systematic literature search was performed using the PubMed,Embase,and Cochrane Library databases.We included randomized controlled trials(RCTs)and prospective cohort studies(PCSs)in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated.The results of the studies were synthesized using the Mantel-Haenszel randomeffects model,and a two-tailed P value>0.05 was considered statistically significant.RESULTS Three RCTs and two PCSs were included in this study.Symptomatic AL was examined in all 1417 patients(712 with TDT),and TDTs did not reduce the symptomatic AL rate.In a subgroup analysis of 955 patients without a diverting stoma,TDT reduced the symptomatic AL rate(odds ratio=0.50,95%confidence interval:0.29–0.86,P=0.012).CONCLUSION TDT may not reduce AL overall among patients undergoing rectal cancer surgery.However,patients without a diverting stoma may benefit from TDT placement.

Can intraluminal devices prevent or reduce colorectal anastomotic leakage:A review

Colorectal anastomotic leakage is a serious complication of colorectal surgery, leading to high morbidity and mortality rates. In recent decades, many strategies aimed at lowering the incidence of anastomotic leakage have been examined. The focus of this review will be on mechanical aids protecting the colonic anastomosis against leakage. A literature search was performed using MEDLINE, EMBASE, and The Cochrane Collaborative library for all papers related to prevention of anastomotic leakage by placement of a device in the colon. Devices were categorised as decompression devices, intracolonic devices, and biodegradable devices. A decompression device functions by keeping the anal sphincter open, thereby lowering the intraluminal pressure and lowering the pressure on the anastomosis. Intracolonic devices do not prevent the formation of dehiscence. However, they prevent the faecal load from contacting the anastomotic site, thereby preventing leakage of faeces into the peritoneal cavity. Many attempts have been made to find a device that decreases the incidence of AL;however, to date, none of the devices have been widely accepted.

Low ligation has a lower anastomotic leakage rate after rectal cancer surgery

BACKGROUND For laparoscopic rectal cancer surgery,the inferior mesenteric artery(IMA)can be ligated at its origin from the aorta[high ligation(HL)]or distally to the origin of the left colic artery[low ligation(LL)].Whether different ligation levels are related to different postoperative complications,operation time,and lymph node yield remains controversial.Therefore,we designed this study to determine the effects of different ligation levels in rectal cancer surgery.AIM To investigate the operative results following HL and LL of the IMA in rectal cancer patients.METHODS From January 2017 to July 2019,this retrospective cohort study collected information from 462 consecutive rectal cancer patients.According to the ligation level,235 patients were assigned to the HL group while 227 patients were assigned to the LL group.Data regarding the clinical characteristics,surgical characteristics and complications,pathological outcomes and postoperative recovery were obtained and compared between the two groups.A multivariate logistic regression analysis was performed to evaluate the possible risk factors for anastomotic leakage(AL).RESULTS Compared to the HL group,the LL group had a significantly lower AL rate,with 6(2.8%)cases in the LL group and 24(11.0%)cases in the HL group(P=0.001).The HL group also had a higher diverting stoma rate(16.5%vs 7.5%,P=0.003).A multivariate logistic regression analysis was subsequently performed to adjust for the confounding factors and confirmed that HL(OR=3.599;95%CI:1.374-9.425;P=0.009),tumor located below the peritoneal reflection(OR=2.751;95%CI:0.772-3.985;P=0.031)and age(≥65 years)(OR=2.494;95%CI:1.080-5.760;P=0.032)were risk factors for AL.There were no differences in terms of patient demographics,pathological outcomes,lymph nodes harvested,blood loss,hospital stay and urinary function(P>0.05).CONCLUSION In rectal cancer surgery,LL should be the preferred method,as it has a lower AL and diverting stoma rate.

Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons

AIM To determine the level of consensus on the definition of colorectal anastomotic leakage(CAL) among Dutch and Chinese colorectal surgeons.METHODS Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as > 80% agreement between respondents on various statements regarding a general definition of CAL,and regarding clinical and radiological diagnosis of the complication.RESULTS Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan'. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation',and ‘a radiological collection treated with percutaneous drainage'. No consensus was found for all other proposed elements that may be included in a general definition.CONCLUSION There is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical' leaks as CAL,which partly explains the higher reported Dutch CAL rates.

Narrow pelvic inlet plane area and obesity as risk factors for anastomotic leakage after intersphincteric resection

BACKGROUND Intersphincteric resection(ISR)has been increasingly used as the ultimate sphincter-preserving procedure in extremely low rectal cancer.The most critical complication of this technique is anastomotic leakage.The incidence rate of anastomotic leakage after ISR has been reported to range from 5.1%to 20%.AIM To investigate risk factors for anastomotic leakage after ISR based on clinicopathological variables and pelvimetry.METHODS This study was conducted at Department of Colorectal Surgery,Japanese Red Cross Medical Center,Tokyo,Japan,with a total of 117 patients.We enrolled 117 patients with extremely low rectal cancer who underwent laparotomic and laparoscopic ISRs at our hospital.We conducted retrospective univariate and multivariate regression analyses on 33 items to elucidate the risk factors for anastomotic leakage after ISR.Pelvic dimensions were measured using threedimensional reconstruction of computed tomography images.The optimal cutoff value of the pelvic inlet plane area that predicts anastomotic leakage was determined using a receiver operating characteristic(ROC)curve.RESULTS We observed anastomotic leakage in 10(8.5%)of the 117 patients.In the multivariate analysis,we identified high body mass index(odds ratio 1.674;95%confidence interval:1.087-2.58;P=0.019)and smaller pelvic inlet plane area(odds ratio 0.998;95%confidence interval:0.997-0.999;P=0.012)as statistically significant risk factors for anastomotic leakage.According to the receiver operating characteristic curves,the optimal cutoff value of the pelvic inlet plane area was 10074 mm2.Narrow pelvic inlet plane area(≤10074 mm2)predicted anastomotic leakage with a sensitivity of 90%,a specificity of 85.9%,and an accuracy of 86.3%.CONCLUSION Narrow pelvic inlet and obesity were independent risk factors for anastomotic leakage after ISR.Anastomotic leakage after ISR may be predicted from a narrow pelvic inlet plane area(≤10074 mm2).

Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis

AIM: To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.

Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage:A prospective observational study

BACKGROUND Colorectal anastomotic leakage(CAL)is one of the most dreaded complications after colorectal surgery,with an incidence that can be as high as 27%.This event is associated with increased morbidity and mortality;therefore,its early diagnosis is crucial to reduce clinical consequences and costs.Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL.AIM To assess the usefulness of plasma C-reactive protein(CRP)and calprotectin(CLP)as early predictors of CAL.METHODS A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis,from March 2017 to August 2019.Patients were divided into three groups:G1–no complications;G2–complications not related to CAL;and G3–CAL.Five biomarkers were measured and analyzed in the first 5 postoperative days(PODs),namely white blood cell(WBC)count,eosinophil cell count(ECC),CRP,CLP,and procalcitonin(PCT).Clinical criteria,such as abdominal pain and clinical condition,were also assessed.The correlation between biomarkers and CAL was evaluated.Receiver operating characteristic(ROC)curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL,and the area under the ROC curve(AUROC),specificity,sensitivity,positive predictive value,and negative predictive value(NPV)during this period were estimated.RESULTS In total,25 of 396 patients developed CAL(6.3%),and the mean time for this diagnosis was 9.0±6.8 d.Some operative characteristics,such as surgical approach,blood loss,intraoperative complications,and duration of the procedure,were notably related to the development of CAL.The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications(median of 21 d vs 13 d and 7 d respectively;P<0.001).For abdominal pain,the best predictive performance was on POD4 and POD5,with the largest AUROC of 0.84 on POD4.Worsening of the clinical condition was associated with the diagnosis of CAL,presenting a higher predictive effect on POD5,with an AUROC of 0.9.WBC and ECC showed better predictive effects on POD5(AUROC=0.62 and 0.7,respectively).Those markers also presented a high NPV(94%-98%).PCT had the best predictive effect on POD5(AUROC=0.61),although it presented low accuracy.However,this biomarker revealed a high NPV on POD3,POD4,and POD5(96%,95%,and 96%,respectively).The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications(195.5±139.9 mg/L vs 59.5±43.4 mg/L;P<0.00001).On POD5,CRP had a NPV of 98%.The mean CLP value on POD3 was significantly higher in G3 compared with G1(5.26±3.58μg/mL vs 11.52±6.81μg/mL;P<0.00005).On POD3,the combination of CLP and CRP values showed a high diagnostic accuracy(AUROC=0.82),providing a 5.2 d reduction in the time to CAL diagnosis.CONCLUSION CRP and CLP are moderate predictors of CAL.However,the combination of these biomarkers presents an increased diagnostic accuracy,potentially decreasing the time to CAL diagnosis.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage(AL)has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure.An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication.Despite AL continues to be a dreadful complication after colorectal surgery,there has been no consensus on its management.However,based on patient’s presentation and timing of the AL,there has been a gradual shift to a more conservative management,keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak.A nonoperative management is usually preferred in these patients.There are several treatment options,also for patients without a stoma who do not require a reoperation for a contained pelvic leak,including recently developed endoscopic procedures,such as clip placement or endoluminal vacuum-assisted therapy.More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage:A critical analysis

Endoluminal vacuum-assisted therapy(EVT)has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients.Its application has been mainly reserved to low colorectal and colo-anal anastomoses.The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity,to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity.The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement,percutaneous drainage,endoscopic clipping of the anastomotic defect or stent placement.Nevertheless,despite this procedure is gaining acceptance among the surgical community,indications,inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous,making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure.Moreover,long-term and functional results are poorly reported.The present review is focused on critically analyzing the theoretical benefits and risks of the procedure,short-and long-term functional results and future direction in the application of EVT.

Risk Factors of Anastomotic Leakage After Anterior Resection for Rectal Cancer Patients

Objective Anastomotic leakage(AL)is one of the serious complications after anterior resection for rectal cancer.Defunctioning stoma(DS)is one of the most widely used approaches to prevent it;however,the effect of DS on the occurrence of AL remains controversial.This study aimed to investigate risk factors of AL and assess the effect of DS after anterior resection for rectal cancer patients.Methods A retrospective analysis was conducted for the data of 1840 patients who underwent anterior resection for rectal cancer from January 2014 to December 2019.Results The results showed the overall AL incidence was 7.5%.Multivariate analyses revealed that males[odds ratio(OR)1.562]and T3–T4 stage(OR 1.729)were independent risk factors for all patients.After propensity score matching analysis,the AL incidence was 14.1%in the group with no DS and 6.4%in the DS group(P<0.001).The clinical AL(grade B+grade C)incidence was 12.4%in no DS group and 4.6%in the DS group(P<0.001).Conclusion The study suggested that males and T3–T4 stage were independent risk factors of AL.In addition,DS could reduce the rate of symptomatic AL.

Computer tomography-guided negative pressure drainage treatment of intrathoracic esophagojejunal anastomotic leakage:A case report

BACKGROUND Esophagojejunal anastomotic leakage(EJAL)is a serious and potentially crucial complication of total gastrectomy and represents the major cause of postoperative death,with a mortality rate of up to 50%.However,treatment remains challenging and controversial.We report here the case of a patient whose intrathoracic EJAL was successfully treated with computer tomography(CT)-guided negative pressure drainage treatment.CASE SUMMARY A 69-year-old male patient complained of difficulty swallowing within the last six months.He was diagnosed with esophagogastric junction carcinoma,Siewert II,cT3N0M0 stage II.Total gastrectomy and Roux-en-Y esophagojejunostomy were performed.High fever,left chest pain and dyspnea appeared on postoperative day 5,and EJAL was confirmed by CT,gastroscopy and oral blue-dimethylene tests.Conservative treatment measures were applied immediately,including antibiotics,nasojejunal tubes,and repeated thoracic puncture and drainage under ultrasound guidance.However,without sufficient and effective drainage,the thoracic infection and systemic condition continued to deteriorate.With the cooperation of multiple departments,percutaneous CT-guided drainage(24 Fr 7 mm)in the thoracic cavity was successfully placed near the anastomotic leakage.Because of continuous negative pressure suction,the infection symptoms were effectively controlled and the general situation gradually recovered.Subsequent follow-up examination showed that the patient was in good condition.CONCLUSION Negative pressure drainage via CT may represent an effective minimally invasive approach to treating intrathoracic EJAL.

Development of a warning score for early detection of colorectal anastomotic leakage:Hype or hope?

BACKGROUND Colorectal anastomotic leakage(CAL),a severe postoperative complication,is associated with high morbidity,hospital readmission,and overall healthcare costs.Early detection of CAL remains a challenge in clinical practice.However,some decision models have been developed to increase the diagnostic accuracy of this event.AIM To develop a score based on easily accessible variables to detect CAL early.METHODS Based on the least absolute shrinkage and selection operator method,a predictive classification system was developed[Early ColoRectAL Leakage(E-CRALL)score]from a prospective observational,single center cohort,carried out in a colorectal division from a non-academic hospital.The score performance and CAL threshold from postoperative day(POD)3 to POD5 were estimated.Based on a precise analytical decision model,the standard clinical practice was compared with the E-CRALL adoption on POD3,POD4,or POD5.A cost-minimization analysis was conducted,on the assumption that all alternatives delivered similar health-related effects.RESULTS In this study,396 patients who underwent colorectal resection surgery with anastomosis,and 6.3%(n=25)developed CAL.Most of the patients who developed CAL(n=23;92%)were diagnosed during the first hospital admission,with a median time of diagnosis of 9.0±6.8 d.From POD3 to POD5,the area under the receiver operating characteristic curve of the E-CRALL score was 0.82,0.84,and 0.95,respectively.On POD5,if a threshold of 8.29 was chosen,87.4%of anastomotic failures were identified with E-CRALL adoption.Additionally,score usage could anticipate CAL diagnosis in an average of 5.2 d and 4.1 d,if used on POD3 and POD5,respectively.Regardless of score adoption,episode comprehensive costs were markedly greater(up to four times)in patients who developed CAL in comparison with patients who did not develop CAL.Nonetheless,the use of the E-CRALL warning score was associated with cost savings of€421442.20,with most(92.9%)of the savings from patients who did not develop CAL.CONCLUSION The E-CRALL score is an accessible tool to predict CAL at an early timepoint.Additionally,ECRALL can reduce overall healthcare costs,mainly in the reduction of hospital costs,independent of whether a patient developed CAL.

Efficacy of staple line reinforcement by barbed suture for preventing anastomotic leakage in laparoscopic rectal cancer surgery

BACKGROUND Anastomotic leakage(AL) is a severe complication in rectal cancer surgery.Various methods, including intracorporeal reinforcing suturing, have been used to reduce the incidence of AL. However, little is known about the efficacy of staple-line reinforcement by barbed suture for preventing AL.AIM To evaluate the efficacy of staple-line reinforcement using barbed suture for preventing AL in laparoscopic surgery for rectal cancer.METHODS We retrospectively reviewed the clinical datum of 319 patients undergoing laparoscopic low anterior resection combined with double stapling technique between May 1, 2017 and January 31, 2021. All surgeries were performed by the same surgical team specializing in colorectal surgery. Patients were divided into two groups depending on whether they received reinforcing sutures. Patients’ baseline characteristics did not show any significant difference between the two groups. We analyzed patient-, tumor-, as well as surgery-related variables using univariate and multivariate logistic analyses.RESULTS There were 168 patients in the reinforcing suture group and 151 patients in the non-reinforcing suture group. AL occurred in 25 cases(7.8%). Its incidence was significantly higher in the non-reinforcing suture group than in the reinforcing suture group(4.8% vs 11.3%, P = 0.031). The multivariate analyses demonstrated that the tumor site, tumor size and presence of staple-line reinforcement were independent risk factors for AL. We divided these patients into two risk groups based on the combination of tumor site and tumor size. Patients without any risk factor were assigned to the low-risk group(n = 177), whereas those having one or two risk factors were assigned to the high-risk group(n = 142). In the high-risk group, the AL incidence considerably decreased in the reinforcing suture group compared with that in the non-reinforcing suture group(P = 0.038). Nonetheless, no significant difference was found in the low-risk group between the two groups.CONCLUSION Staple-line reinforcement by barbed suture may decrease the incidence of AL. A large-scale prospective randomized controlled trial is needed for evaluating the efficacy of staple-line reinforcement for preventing AL.

Application of endoscopic mucosal advancement in the treatment of chronic anastomotic leakage:A case report

Anastomotic leakage is one of the most serious postoperative complications after colorectal surgery.A fistula or chronic sinus formation is one kind of anastomotic leakage.Most fistulas may heal after conservative treatment,but some patients will develop a chronic anastomotic leakage,which definitely requires elective surgery due to the formation of a sinus tract or an internal fistula.This study reports a case of an 88-year-old man with sigmoid colon cancer who developed a chronic anastomotic leakage after colorectal surgery.Endoscopic mucosal advancement combined with titanium clips was success-fully performed to close the fistula.The patient was discharged 12 days after the operation and resumed a normal diet 1 week after discharge.Endoscopic mucosal advancement could be an alternative choice for the treatment of chronic anastomotic leakage and can prevent a secondary surgery;however,good bowel preparation and strict inclusion criteria are required.

Comprehensive abdominal composition evaluation of rectal cancer patients with anastomotic leakage compared with body mass indexmatched controls

BACKGROUND Anastomotic leakage(AL)is a fatal complication in patients with rectal cancer after undergoing anterior resection.However,the role of abdominal composition in the development of AL has not been studied.AIM To investigate the relationship between abdominal composition and AL in rectal cancer patients after undergoing anterior resection.METHODS A retrospective case-matched cohort study was conducted.Complete data for 78 patients with AL were acquired and this cohort was defined as the AL group.The controls were matched for the same sex and body mass index(±1 kg/m^(2)).Parameters related to abdominal composition including visceral fat area(VFA),subcutaneous fat area(SFA),subcutaneous fat thickness(SFT),skeletal muscle area(SMA),skeletal muscle index(SMI),abdominal circumference(AC),anterior to posterior diameter of abdominal cavity(APD),and transverse diameter of abdominal cavity(TD)were evaluated based on computed tomography(CT)images using the following Hounsfield Unit(HU)thresholds:SFA:-190 to-30,SMA:-29 to 150,and VFA:-150 to-20.The significance of abdominal compositionrelated parameters was quantified using feature importance analysis;an artificial intelligence method was used to evaluate the contribution of each included variable.RESULTS Two thousand two hundred and thirty-eight rectal cancer patients who underwent anterior resection from 2010 to 2020 in a large academic hospital were investigated.Finally,156 cases were enrolled in the study.Patients in the AL group showed longer operative time(225.03±55.29 vs 207.17±40.80,P=0.023),lower levels of preoperative hemoglobin(123.32±21.17 vs 132.60±16.31,P=0.003)and albumin(38.34±4.01 vs 40.52±3.97,P=0.001),larger tumor size(4.07±1.36 vs 2.76±1.28,P<0.001),and later cancer stage(P<0.001)compared to the controls.Patients who developed AL exhibited a larger VFA(125.68±73.59 vs 97.03±57.66,P=0.008)and a smaller APD(77.30±23.23 vs 92.09±26.40,P<0.001)and TD(22.90±2.23 vs 24.21±2.90,P=0.002)compared to their matched controls.Feature importance analysis revealed that TD,APD,and VFA were the three most important abdominal composition-related features.CONCLUSION AL patients have a higher visceral fat content and a narrower abdominal structure compared to matched controls.