Towards a zero percent anastomotic leak rate using a defined risk reduction strategy

Background: Anastomotic leak is regarded as one of the most feared complications of bowel surgery; avoiding leaks is a major priority. Attempts to reduce or eliminate leaks have included alternate anastomotic techniques. Human oral mucosa stem cells (hOMSC) are self-renewing and expandable cells derived from buccal mucosa. Studies have shown that hOMSC can accelerate tissue regeneration and wound healing. The objective of this study was to evaluate whether hOMSC can decrease anastomotic leak rates in a murine model of colon surgery. Methods: Two experiments were performed. In the first study, mice underwent colonic anastomosis using five interrupted sutures. hOMSC (n = 7) or normal saline (NS; n = 17) was injected into the colon wall at the site of the anastomosis. To evaluate whether hOMSC can impact anastomotic healing, the model was stressed by repeating the first experiment, reducing the number of sutures used for the construction of the anastomosis from five to four. Either hOMSC (n = 8) or NS (n = 20) was injected at the anastomosis. All mice that survived were sacrificed on postoperative day 7. Anastomotic leak rate, mortality, daily weight, and daily wellness scores were compared. Results: In the five-suture anastomosis, there were no differences in anastomotic leak rate, mortality, or daily weight. Mice that received hOMSC had significantly higher wellness scores on postoperative day 2 (p < 0.05). In the four-suture anastomosis, there was a significant decrease in leak rate (70% [NS] vs. 25% [hOMSC], p = 0.029) and higher wellness scores in mice that received hOMSC (p < 0.05). Conclusion: Our study suggests that injecting hOMSC at the colonic anastomosis can potentially reduce anastomotic leak and improve postoperative wellness in a murine model of colon surgery.

Download Full-text

Best evidence topic: Is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis?

Annals of Medicine and Surgery ◽

10.1016/j.amsu.2020.11.075 ◽

2020 ◽

Vol 60 ◽

pp. 619-622

Author(s):

Sabry Abounozha ◽

Adel Kheder ◽

Talal Alshahri ◽

Rashid Ibrahim

Keyword(s):

Anastomotic Leak ◽

Leak Rate ◽

Anastomotic Leak Rate

Download Full-text

PWE-157 Reducing anastomotic leak rate in ivor lewis oesophagectomy – testing a change from mechanical to semi-mechanical anastomosis

Gut ◽

10.1136/gutjnl-2015-309861.605 ◽

2015 ◽

Vol 64 (Suppl 1) ◽

pp. A281.2-A282 ◽

Cited By ~ 1

Author(s):

J Clark ◽

G Sanders ◽

T Wheatley ◽

P Peyser ◽

J Rahamim ◽

...

Keyword(s):

Anastomotic Leak ◽

Leak Rate ◽

Ivor Lewis ◽

Anastomotic Leak Rate ◽

Mechanical Anastomosis

Download Full-text

548 COMPARISON OF ESOPHAGECTOMY OUTCOMES BETWEEN A NATIONAL CENTER, A NATIONAL AUDIT COLLABORATIVE, AND AN INTERNATIONAL DATABASE USING ECCG STANDARDIZED DEFINITIONS

Diseases of the Esophagus ◽

10.1093/dote/doab052.548 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Cited By ~ 1

Author(s):

John V Reynolds ◽

Jessie A Elliott ◽

Noel Donlon ◽

Claire Donohoe ◽

Narayanasamy Ravi ◽

...

Keyword(s):

Anastomotic Leak ◽

Leak Rate ◽

Collaborative Group ◽

Surgical Approaches ◽

Consecutive Series ◽

Recurrent Nerve ◽

En Bloc ◽

Curative Intent ◽

Chyle Leak ◽

Anastomotic Leak Rate

Abstract The ECCG developed a standardized platform for reporting operative complications, with consensus definitions, and DUCA adopted these definitions and have reported a comparison against these benchmarks. The aim of this study was to report five year complications data using the standardized definitions of the Esophageal Complications Consensus Group (ECCG), and to compare with published ECCG benchmark studies from the collaborative group and from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). Methods All patients undergoing multimodal therapy or surgery with curative intent from 2014 to 2018 inclusive were studied. All data were recorded prospectively and maintained internally as well as entered onto a secure online database (Esodata.org) from 2015. Statistical analysis was performed using SPSS® (version 18.0). Results 219 patients (mean age 67; 77% male) underwent open resection, 66.6% via transthoracic en bloc resection. 30-day and 90-day mortality were 0.0 and 0.9%, respectively. The anastomotic leak rate was 5.4%, and chyle leak 5.4%. Pneumonia was recorded in 18.2%, respiratory failure 10.9%, and ARDS in 2.7%. Atrial dysrhythmia occurred in 22.8%, recurrent nerve injury 3.1%, and delirium in 5.0%. Compared with both ECCG and DUCA, where MIE constituted 47% and 86% of surgical approaches, respectively, overall complications were similar in this open series, as was complications severity, however anastomotic leak rate were several-fold less, and mortality rates were lower. Conclusion In this unselected consecutive series and comparative audit with benchmark averages from the ECCG and DUCA publication, a low mortality and anastomotic leak rate were the key differential findings. Although not risk-stratified or directly matched, the severity of complications from this ‘open’ series is consistent with series containing large numbers of total or hybrid MIE, highlighting a need to adhere to these strictly defined definitions in further prospective research and randomized studies.

Download Full-text

Obsidian ASG® Autologous Platelet-Rich Fibrin Matrix and Colorectal Anastomotic Healing: A Preliminary Study

Surgical Technology Online ◽

10.52198/21.sti.39.cr11508 ◽

2021 ◽

Vol 39 ◽

Author(s):

Andreas Shamiyeh ◽

◽

Bettina Klugsberger ◽

Carina Aigner ◽

Wolfgang Schimetta ◽

...

Keyword(s):

Anastomotic Leakage ◽

Anastomotic Leak ◽

Colorectal Resection ◽

Rectal Resection ◽

Leak Rate ◽

Anastomotic Healing ◽

Platelet Rich Fibrin ◽

Anastomotic Leak Rate ◽

Fibrin Matrix ◽

Autologous Platelet

Introduction: Anastomotic leakage (AL) following colorectal resection is a devastating complication affecting morbidity, mortality, and quality of life of patients in the long term. Different tissue sealants and biologic glues were tested showing conflicting results regarding their influence on anastomotic healing and leak prevention. Application of autologous platelet-rich fibrin (Vivostat A/S, Alleroed, Denmark), which acts as a source of angiogenic growth factors and cytokines, showed promising results in an in-vivo porcine model. Herein, we present the first human study of stapled colorectal anastomoses supplemented with an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®, Rivolution GmbH, Rosenheim, Germany and Vivostat A/S, Alleroed, Denmark). Materials and Methods: A retrospective analysis of prospectively accumulated data was performed in two colorectal centers (Linz, Vienna) on patients undergoing left-sided colorectal or coloanal stapled anastomosis between October 2018 and December 2019. The Obsidian ASG® Matrix was applied to the rectal stump, and after closure with the circular stapling device, at the circumference of anastomosis in every single case. Anastomoses were supplemented with intra- and extra-anastomotic application (IAA—intra-anastomotic application developed by Rivolution GmbH, Rosenheim, Germany) of Obsidian ASG® Matrix. The primary endpoints were incidence of perioperative complications and anastomotic leak rate. Results: Two-hundred-sixty-one (138 female) patients underwent left-sided colonic (n=177) or rectal resection (n=84). In 253 (96.9%) cases, a laparoscopic or robotic-assisted approach was used. There were no complications attributable to the intraoperative application of the Obsidian ASG® Matrix. All intraoperative leak tests were negative. Overall, anastomotic leak rate accounted for 2.3% (6/261). AL following colonic and rectal resection was seen in 2.3% (4/177) and 2.4% (2/84), respectively. Complication and leak rate was similar in the two participating centers. Postoperative fever and elevated CRP levels were significantly correlated to AL. There was no significant risk factor for AL on multivariate analysis. Conclusion: Application of an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®) at anastomotic site following colorectal resection is safe and associated with a low rate of anastomotic leakage.

Download Full-text

EFFECT OF FRAUD RISK REDUCTION STRATEGY ON THE LEVEL OF EMPLOYEE FRAUD IN NIGERIAN PUBLIC SERVICE ORGANIZATIONS

Problems of Management in the 21st Century ◽

10.33225/pmc/12.04.30 ◽

2012 ◽

Vol 4 (1) ◽

pp. 30-44

Author(s):

Joe Duke II ◽

Kechi A. Kankpang

Keyword(s):

Risk Reduction ◽

Public Service ◽

Survey Design ◽

Service Organizations ◽

Cross Sectional ◽

Reduction Strategy ◽

Risk Reduction Strategy ◽

Fraud Risk ◽

Public Service Organizations ◽

Employee Fraud

Given the rampant headline revelations of widespread fraud perpetrated in Nigerian public service organizations in recent times, this study addresses a topical subject that commands urgent attention, understanding and intervention. Using a survey design and case approach, a cross-sectional study was carried out on a sample of 54 systematically selected public service organizations spread across the South-South geopolitical region of Nigeria. The study showed that the fraud risk reduction strategy deployed in Nigerian public service organizations is not effective in reducing the overall level of employee fraud. The study showed that auditor’s monitoring strength is low. It also found that the prevailing reward and compensation system does not facilitate reduction of incentive for employee fraud. These results point to a need to review, strengthen and make more dynamic and responsive the current fraud risk reduction strategy used. Key words: employee fraud, organizations, Nigeria.

Download Full-text

Volume-outcome Relationship in Rectal Cancer Surgery

10.21203/rs.3.rs-276079/v1 ◽

2021 ◽

Author(s):

Leandro Siragusa ◽

Bruno Sensi ◽

Danilo Vinci ◽

Marzia Franceschilli ◽

Giulia Bagaglini ◽

...

Keyword(s):

Rectal Cancer ◽

Blood Transfusion ◽

Hospital Stay ◽

Anastomotic Leak ◽

Operative Time ◽

Cancer Surgery ◽

Leak Rate ◽

Perioperative Outcomes ◽

Rectal Cancer Surgery ◽

Anastomotic Leak Rate

Abstract Introduction Hospital centralization effect is reported to lower complications and mortality for high risk and complex surgery operations, including colorectal surgery. However, no linear relation between volume and outcome has been demonstrated. Aim of the study was to evaluate the increased surgical volume effect on early outcomes of patient undergoing laparoscopic restorative anterior rectal resection (ARR).Methods A retrospective analysis of all consecutive patients undergoing ARR with primary anastomosis between November 2016 and December 2020 after centralization of rectal cancer cases in an academic Centre. Short outcomes are compared to those of patients operated in the same unit during the previous 10 years before service centralization. The primary outcome was anastomotic leak rate. Mean operative time, need of conversion, postoperative use of blood transfusion, radicality, in-hospital stay, number and type of complications, readmission and reoperation rate, mortality and 1-year and stoma persistence rates were evaluated as secondary outcomes.Results 86 patients were operated in the study period and outcomes compared to those of 101 patients operated during the previous ten years. Difference in volume of surgery was significant between the two periods (p 0.019) and the estimated leak rate was significantly lower in the higher volume unit (p 0.05). Mean operative time, need of conversion, postoperative use of blood transfusion and in-hospital stay (p <0.05) were also significantly reduced in Group A.Conclusion: This study suggests that the shift toward higher volume in rectal cancer surgery is associated to decreased anastomotic leak rate. Potentiation of lower volume surgical units may yield optimal perioperative outcomes.

Download Full-text

PS01.212: OUTCOMES OF HYBRID VERSUS FULLY MINIMALLY INVASIVE 2-STAGE ESOPHAGECTOMY FOR CANCER OF THE DISTAL ESOPHAGUS AND GASTRO-ESOPHAGEAL JUNCTION

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.212 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 110-110

Author(s):

Kanatheepan Shanmuganathan ◽

Temisanren Akitikori ◽

Oluwasunmisola Soile ◽

Aadil Hussain ◽

Neda Farhangmehr ◽

...

Keyword(s):

Length Of Stay ◽

Minimally Invasive ◽

Anastomotic Leak ◽

Minimally Invasive Esophagectomy ◽

Hospital Length ◽

Leak Rate ◽

Hospital Length Of Stay ◽

Cardiac Complications ◽

Invasive Esophagectomy ◽

Anastomotic Leak Rate

Abstract Background Esophagectomy is associated with high complication rate and mortality. Numerous approaches have been introduced over the last two decades, with the ambition of reducing rate of complications, morbidity and mortality. Two-stage minimally invasive esophagectomies include hybrid (laparoscopic/thoracotomic) and fully minimally invasive and have recently gained popularity in the treatment of distal esophageal and gastro-esophageal junction cancer. We aim to compare the short-term outcomes between 2-stage hybrid and fully minimally invasive esophagectomy with intrathoracic hand-sewn anastomosis. Methods A retrospective analysis of a 4-year period prospectively collected data of 100 consecutive 2-stage minimally invasive esophagectomies was conducted. All operations were performed in a UK tertiary centre by a single surgical team between 2014 and 2018. All 3-stage and open esophagectomies were excluded from the study. A comparison of anastomotic leak rate, ITU length of stay, hospital length of stay, pulmonary complications, cardiac complications and 30 and 90-day mortality rates was made. Statistical analysis was performed using Graph-Prism 7.04. Results Seventy patients underwent hybrid and 30 underwent fully minimally invasive esophagectomy with intra-thoracic manual anastomosis. Chest infection and anastomotic leak rate were higher in the hybrid group (21.4% vs 16.8% and 10% vs 3.3%); however, cardiac complications were two times more common in fully minimally invasive compared to hybrid esophagectomies (3.3% vs 1.4%). Fully minimally invasive esophagectomies were associated with a shorter ITU stay as well as hospital length of stay compared to hybrid esophagectomies (5.5 vs 6.2 days, P = 0.47 and 10.5 vs 15.6 days P = 0.0018). Complete tumour resection (R0) rate was slightly higher in hybrid compared to fully minimally invasive esophagectomies (70.8% vs 64.3%). Thirty and 90-day mortality rate was 6.67% (1 cardiac and 1 respiratory arrest) in fully minimally invasive and 1.43% in hybrid esophagectomies. None of the mortality cases were related to surgical complications like anastomotic leak or conduit necrosis. Conclusion In our study 2-stage fully minimally invasive esophagectomy is associated with reduced post-operative complication rates compared to 2-stage hybrid oesophagectomy. Further larger studies are needed to assess the 30- and 90-day mortality risk associated with both procedures. Disclosure All authors have declared no conflicts of interest.

Download Full-text