Diagnosis and Management of Chronic Anastomotic Leak

2021 ◽  
Vol 34 (06) ◽  
pp. 406-411
Author(s):  
Anuradha R. Bhama ◽  
Justin A. Maykel
Keyword(s):  
Colorectal Anastomosis ◽  
Preoperative Assessment ◽  
Anastomotic Dehiscence ◽  
Low Grade ◽  
Anastomotic Leaks ◽  
Operative Strategy ◽  
Defunctioning Stoma ◽  
Bowel Continuity ◽  
Permanent Ostomy ◽  
Daunting Challenge

AbstractChronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

External Validation of the Simplified Preoperative Assessment for Low-Grade Mucinous Adenocarcinoma of the Appendix

2017 ◽  
Vol 24 (7) ◽  
pp. 1783-1786 ◽  
Author(s):  
Vladimir Milovanov ◽  
Armando Sardi ◽  
Nail Aydin ◽  
Carol Nieroda ◽  
Michelle Sittig ◽  
...  
Keyword(s):  
Mucinous Adenocarcinoma ◽  
External Validation ◽  
Preoperative Assessment ◽  
Low Grade

scholarly journals Comment on: External Validation of the Simplified Preoperative Assessment for Low-Grade Mucinous Adenocarcinoma of the Appendix

2017 ◽  
Vol 24 (S3) ◽  
pp. 627-627 ◽  
Author(s):  
Sean P. Dineen ◽  
Richard E. Royal ◽  
Paul F. Mansfield ◽  
Keith F. Fournier
Keyword(s):  
Mucinous Adenocarcinoma ◽  
External Validation ◽  
Preoperative Assessment ◽  
Low Grade

scholarly journals The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence – A Case Report

2020 ◽  
Vol 27 (6) ◽  
pp. 434-438
Author(s):  
Gaurav Patil ◽  
Arun Iyer ◽  
Ankit Dalal ◽  
Amit Maydeo
Keyword(s):  
Argon Plasma Coagulation ◽  
Colorectal Anastomosis ◽  
Significant Risk ◽  
Argon Plasma ◽  
Anastomotic Dehiscence ◽  
Sigmoid Diverticulitis ◽  
Anastomotic Site ◽  
Sigmoid Colectomy ◽  
Tissue Preparation ◽  
Technical Failure

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

scholarly journals PC3 - 191 Assessment of Preoperative Functional MRI Measurement of Language Lateralisation in Brain Tumour Patients

2016 ◽  
Vol 43 (S4) ◽  
pp. S20-S20
Author(s):  
E. Kosteniuk ◽  
J.C. Lau ◽  
J.F. Megyesi
Keyword(s):  
Brain Tumour ◽  
Preoperative Assessment ◽  
Sentence Completion ◽  
Hemispheric Dominance ◽  
Low Grade ◽  
Broca’S Area ◽  
Broca's Area ◽  
Lesion Type ◽  
Wernicke’S Area ◽  
Verb Generation

This study aims to evaluate reliability of clinical functional magnetic resonance imaging (fMRI) in identifying language lateralisation index (LI), verified with Edinburgh handedness inventory (EHI), in brain tumour patients. Methods In this retrospective study, 31 of a single surgeon’s brain tumour patients over a 12 year period have been selected. Lesion type varied, 12 (39 percent) were high grade gliomas, 10 (32 percent) low grade gliomas, 3 (10 percent) meningiomas, and 6 (19 percent) other types. Patients underwent language fMRI paradigms for preoperative assessment, and a neuroimaging analyst was able to identify an LI value for at least one Brodmann area (BA). For each paradigm, a neuroimaging analyst attempted to calculate LI for Wernicke’s area (BA 22) and Broca’s area (BA 44 and 45). Results Of 113 total LI values, 66 (58 percent) were concordant to EHI-predicted hemispheric dominance. Reliability of language LI appears dependent upon the type of language task performed. Verb generation correctly identified Broca’s area in 18 patients (64 percent) and Wernicke’s area in 11 patients (61 percent), sentence completion correctly identified Broca’s area in 18 patients (72 percent) and Wernicke’s area in 9 patients (60 percent), and naming correctly identified Broca’s area in 7 patients (47 percent) and Wernicke’s area in 3 patients (27 percent). Conclusions Results show limited correlation between language LI determined by fMRI and EHI. The main limitation of this study is that language LI is being compared to EHI, rather than gold standard measure of hemispheric dominance (e.g. Wada).

scholarly journals The role of Hartmann’s procedure in the elective management of rectal cancer: results of a Brazilian cohort study

2021 ◽  
Vol 48 ◽  
Author(s):  
ANDERSON RECH LAZZARON ◽  
INGRID SILVEIRA ◽  
PAULINE SIMAS MACHADO ◽  
DANIEL C DAMIN
Keyword(s):  
Rectal Cancer ◽  
Cancer Patients ◽  
Surgical Complications ◽  
Rectal Resection ◽  
Colorectal Anastomosis ◽  
Hartmann’S Procedure ◽  
Septic Complications ◽  
Elective Resection ◽  
Defunctioning Stoma ◽  
Hartmann's Procedure

ABSTRACT Background: although preservation of bowel continuity is a major goal in rectal cancer surgery, a colorectal anastomosis may be considered an unacceptably high-risk procedure, particularly for patients with multiple comorbidities. We aimed to assess rates of surgical complications in rectal cancer patients according to the type of procedure they had undergone. Materials and Methods: this cohort included all rectal cancer patients undergoing elective resection at a referral academic hospital over 16 years. There were three study groups according to the type of performed operation: (1) rectal resection with anastomosis without defunctioning stoma (DS); (2) rectal resection with anastomosis and DS; and (3) Hartmann’s procedure (HP). Postoperative complications and clinical outcomes were assessed. Results: four-hundred and two patients were studied. The 118 patients in group 3 were significantly older (>10 years), had higher Charlson Comorbidity Index scores, and more ASA class ≥3 than patients in the other two groups. Sixty-seven patients (16.7%) had Clavien-Dindo complications grade ≥ III, corresponding to an incidence of 11.8%, 20.9%, and 14.4% in groups 1, 2, and 3, respectively (p=0.10). Twenty-nine patients (7.2%) had major septic complications that required reoperation, with an incidence of 10.8%, 8.2% and 2.5% in groups 1, 2 and 3, respectively (p=0.048). Twenty-one percent of the group 2 patients did not undergo the stoma closure after a 24-month follow-up. Conclusion: HP was associated with a lower incidence of reoperation due to intra-abdominal septic complications. This procedure remains an option for patients in whom serious surgical complications are anticipated.

Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma

2021 ◽  
pp. 000313482110505
Author(s):  
Ara Ko ◽  
Sydney Radding ◽  
David V. Feliciano ◽  
Joseph J. DuBose ◽  
Rosemary A. Kozar ◽  
...  
Keyword(s):  
Operative Therapy ◽  
Organ Injury ◽  
Suture Repair ◽  
Low Grade ◽  
Trauma Patients ◽  
Splenic Preservation ◽  
Historical Cohort ◽  
Operative Strategy ◽  
Urban Level ◽  
Level I

Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

Challenges in Awake Craniotomy for Intrinsic Brain Tumors in Eloquent Cortex

2017 ◽  
Vol 2 (5) ◽  
Keyword(s):  
Brain Tumors ◽  
Neurological Deficit ◽  
Tumor Resection ◽  
Preoperative Assessment ◽  
Awake Craniotomy ◽  
Low Grade ◽  
Tumor Removal ◽  
Unique Challenge ◽  
Progressive Neurological Deficit ◽  
Eloquent Cortex

Introduction: Surgical treatment of brain tumors in the eloquent areas has high risk of functional impairment like speech or motor. These tumors represent a unique challenge as most of the patients have a higher risk of treatment related complications. A wake craniotomy is a useful surgical approach to help to identify and preserve functional areas in the brain and maximizes tumor removal and minimizes complications. Methods: Selected patients admitted with intrinsic brain tumor between from July, 2011 to August, 2016 in the eloquent area of brain like speech or motor area were chosen for awake craniotomy. A retrospective analysis was done. A preoperative assessment was also done. These patients were presented with seizure and or progressive neurological deficit like speech or motor. A standard anesthesia monitoring was done during surgery. Long acting local anesthesia (Bupivacaine) was used for scalp block. The surgeries were performed in a state of asleep-awake-asleep pattern, keeping the patients fully awake during tumor removal. Propofol and Fentanyl was used as anesthetic agents which was completely withdrawn prior to tumor removal. The speech and motor functions were closely monitored clinically by verbal commands during tumor resection. No brain mapping was performed due to lack of resources. All patients underwent noncontrast computed tomogram head in the first post-operative day. Results: A total of 35 patients were included in the study. The oldest patient was 55 years and youngest being 24 years (mean 36 years). 20 (57.14 %) were females and 15(42.85 %) males. 20 (57.14%) patients presented with predominantly seizure disorders and rest with progressive neurological deficit like speech or motor. 30 (85.71%) patients were discharged on second post-operative day. Complications were encountered in 4 (11.42 %) patients who developed brain swelling intraoperatively and 5(14.28 %) deteriorated neurologically in the immediate post-operative period however managed successfully and discharged in a week’s time. 5(14.28%) patients require ICU/ HDU care for different reasons. There was no mortality during the hospital stay. Histopathology revealed 25 (71.42 %) patients as low grade glioma, 8 (22.85%) as high grade glioma and 2 (5.71%) of them were metastases. Conclusion: A wake Craniotomy is a safe surgical management for intrinsic brain tumors in the eloquent cortex although surgery and anesthesia is a challenge. It offers great advantage towards disease outcome. However long follow up and more studies are required.

scholarly journals Quantitative diffusion and perfusion MRI in the evaluation of endometrial cancer: validation with histopathological parameters

2021 ◽  
pp. 20210054
Author(s):  
Serena Satta ◽  
Miriam Dolciami ◽  
Veronica Celli ◽  
Francesca Di Stadio ◽  
Giorgia Perniola ◽  
...  
Keyword(s):  
Endometrial Cancer ◽  
Lymph Nodes ◽  
Mixed Type ◽  
Preoperative Assessment ◽  
Figo Stage ◽  
Imaging Biomarkers ◽  
Lymph Node Status ◽  
Low Grade ◽  
Stage Ia

Objectives: To investigate the role of quantitative Magnetic Resonance Imaging (MRI) in preoperative assessment of tumor aggressiveness in patients with endometrial cancer, correlating multiple parameters obtained from diffusion and dynamic contrast-enhanced (DCE) MR sequences with conventional histopathological prognostic factors and inflammatory tumour infiltrate. Methods: Forty-four patients with biopsy-proven endometrial cancer underwent preoperative MR imaging at 3T scanner, including DCE imaging, diffusion-weighted imaging (DWI) and intravoxel incoherent motion imaging (IVIM). Images were analyzed on dedicated post-processing workstations and quantitative parameters were extracted: Ktrans, Kep, Ve and AUC from the DCE; ADC from DWI; diffusion D, pseudo diffusion D*, perfusion fraction f from IVIM and tumour volume from DWI. The following histopathological data were obtained after surgery: histological type, grading (G), lympho-vascular invasion (LVI), lymph node status, FIGO stage and inflammatory infiltrate. Results: ADC was significantly higher in endometrioid histology, G1-G2 (low grade), and stage IA. Significantly higher D* were found in endometrioid subptype, negative lymph nodes and stage IA. The absence of LVI is associated with higher f values. Ktrans and Ve values were significantly higher in low grade. Higher D*, f and AUC occur with the presence of chronic inflammatory cells, D * was also able to distinguish chronic from mixed type of inflammation. Larger volume was significantly correlated with the presence of mixed-type inflammation, LVI, positive lymph nodes and stage ≥IB. Conclusions: Quantitative biomarkers obtained from pre-operative DWI, IVIM and DCE-MR examination are an in vivo representation of the physiological and microstructural characteristics of endometrial carcinoma allowing to obtain the fundamental parameters for stratification into Risk Classes. Advances in knowledge: Quantitative imaging biomarkers obtained from DWI, DCE, and IVIM may improve preoperative prognostic stratification in patients with endometrial cancer leading to a more informed therapeutic choice.

Anastomotic Leaks after Colorectal Anastomosis Occurring More than 30 Days Postoperatively: A Single-institution Evaluation

2014 ◽  
Vol 80 (9) ◽  
pp. 868-872 ◽  
Author(s):  
Wei Phin Tan ◽  
En Yaw Hong ◽  
Benjamin Phillips ◽  
Gerald A. Isenberg ◽  
Scott D. Goldstein
Keyword(s):  
Risk Factors ◽  
Interventional Radiology ◽  
Colorectal Anastomosis ◽  
Anastomotic Leaks ◽  
Single Institution ◽  
National Hospital ◽  
Elective Colorectal Surgery ◽  
History Of ◽  
Prospective Database

National hospital registries only report colorectal anastomotic leaks (ALs) within 30 days post-operatively. The aim of our study was to determine the incidence and significance of ALs that occur beyond 30 days postoperatively. We performed a retrospective review of our prospective database from June 2008 to August 2012. A total of 504 patients were included. These patients were operated on by two surgeons. Any clinical or radiographic abnormalities were considered to be an anastomotic imperfection. A total of 504 patients were reviewed with a total of 18 (3.6%) anastomotic leaks. Six leaks (31.6% of leaks) were diagnosed more than 30 days postoperatively ( P < 0.001). Of the 18 leaks, interventional radiology drainage was performed for four cases and 14 patients required reoperation. All six delayed leaks required reoperation. There was one leak that occurred under 30 days, which was discovered on autopsy. The median follow-up was 12 months (range, 1 to 4 months). All the delayed leak patients presented with fistulas, whereas 58 per cent of typical leak patients presented with the triad of leukocytosis, fever, and abdominal pain. Colorectal anastomotic leaks can occur after the 30-day postoperative period. In patients with vague and atypical abdominal findings, anastomotic leak must be suspected. More systematic, prospective studies are required to help us further understand the risk factors and natural history of anastomotic failures in elective colorectal surgery.

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