A PROSPECTIVE ANALYSIS OF RISK FACTORS, PRESENTATION AND OUTCOME OF LEAKAGE AFTER GASTROINTESTINAL ANASTOMOSES

Background: Despite advancements in modern surgery and postoperative care, disruption of gastrointestinal anastomosis remains the most dreaded complication, even in experienced surgical hands. The cause of leakage is multifactorial consisting of a complete spectrum of pre, intra and postoperative factors. Search for an ideal gastrointestinal anastomosis still remains an unquenched thirst. Study Design: Prospective, hospital based, time bound observational study. Methods: After ethical clearance, 288 consenting adult patients who underwent gastrointestinal anastomosis were observed for risk factors, presentation and outcome of leakage and evaluated using appropriate statistical tools. Results: An overall gastrointestinal anastomotic leak rate of 15.28% with peak incidence at 41-50 years (19.51%) was seen. Peritonitis (p=0.0009, OR=2.9611), COPD (p=0.0181, OR=2.7306), low serum albumin concentration (p=0.0028, OR=3.1442), ASA status of ≥III (p=0.0001, OR=4.0281) and a perioperative blood transfusion requirement of ≥2 units (p=0.0028, OR=3.1442) were the most signicant risk factors associated with leakage. Obstruction (p=0.0160, OR=2.2310), malignancy (p=0.0149, OR=2.6961), steroid therapy (p=0.0176, OR=2.2741), chemoradiation (p=0.0400, OR=2.4889), diabetes (p=0.0427, OR=2.2689), undernutrition (p= 0.0308, OR= 2.1099), anaemia (p=0.0325, OR=2.0183) and sepsis (p=0.0187, OR=2.2702) also showed clear risk augmentation. Risk of leakage was increased with a surgical duration of >4 hours (p=0.0078, OR=2.5610), when anastomosis was done as an emergency procedure (p=0.0427, OR=2.6571) or by a surgeon with expertise of ≤5 years (p=0.0338, OR=2.7733). Neither the level, type, technique of anastomosis; nor the usage of surgical staplers had an impact on leakage. Preoperative bowel preparation and creation of a proximal stoma also had minimal effect on leakage rates; though, the infectious complications that follow were greatly reduced. The most common presentation of anastomotic leak was a suspicious drain output with a mean time of 7.59± 2(2.48) postoperative days; resulting in a prolongation of hospitalization by more than ten days (p<0.0001), along with an increased mortality rate (p<0.0001). Conclusions: Accurately predicting anastomotic leakage still requires more evidence-based information. Even with good risk stratication, many causative factors may not be amenable to immediate correction in the pre-operative period. In such cases, the patient must be considered as a candidate for an enterostomy to help tide the crisis over.

A Chinese Survey of Current Practice Patterns of Preoperative Bowel Preparation in Colorectal Surgery

Background Bowel preparation has long been considered as the standard preoperative management for colorectal surgery. However, there are still controversies about bowel preparation and the importance of bowel preparation gradually declined. The purpose of this study is to describe the current attitudes and practice patterns of preoperative bowel preparation among Chinese surgeons. Methods An online 11-question anonymous survey was randomly assigned to Chinese surgeons. The questionnaire sought information on each surgeon’s current practice of preoperative bowel preparation. Results 384 Chinese surgeons from 26 provincial administrative regions took part in this survey. The most common reason for choosing bowel preparation was preventing surgical site infection (SSI). Meanwhile, 74% Chinese surgeons believed bowel preparation could avoid anastomotic leakage. Only 34% thought that bowel preparation was considered to reduce risk of postoperative bleeding. In terms of bowel preparation methods, 57% Chinese surgeons preferred to choose laxatives alone. Regarding the choices of agents, Chinese surgeons were more likely to choose polyethylene glycol-electrolyte lavage solution (PEG-ELS). Conclusions Surgeons choose bowel preparation mostly to avoid SSI and anastomotic leakage, and they prefer using laxatives alone. Our study shows that surgeons do not have clear guidelines that can govern their clinical practice and there are still controversies about bowel preparation. Further study is required to provide strong evidences to inform clinical and policy decisions.

Intestinal motility distal of a deviating ileostomy after rectal resection with the construction of a primary anastomosis: results of the prospective COLO-MOVE study

Purpose No consensus exists regarding the use of preoperative bowel preparation for patients undergoing a low anterior resection (LAR). Several comparative studies show similar outcomes when a single time enema (STE) is compared with mechanical bowel preparation (MBP). It is hypothesized that STE is comparable with MBP due to a decrease in intestinal motility distal of a newly constructed diverting ileostomy (DI). Methods In this prospective single-centre cohort study, patients undergoing a LAR with primary anastomosis and DI construction were given a STE 2 h pre-operatively. Radio-opaque markers were inserted in the efferent loop of the DI during surgery, and plain abdominal X-rays were made during the first, third, fifth and seventh postoperative day to visualize intestinal motility. Results Thirty-nine patients were included. Radio-opaque markers were situated in the ileum or right colon in 100%, 100% and 97.1% of the patients during respectively the first, third and fifth postoperative day. One patient had its most distal marker situated in the left colon during day five. In none of the patients, the markers were seen distal of the anastomosis. Conclusion Intestinal motility distally of the DI is decreased in patients who undergo a LAR resection with the construction of an anastomosis and DI, while preoperatively receiving a STE.

Preoperative Bowel Preparation in Minimally Invasive and Vaginal Gynecologic Surgery

Bowel preparation traditionally refers to the removal of bowel contents via mechanical cleansing measures. Although it has been a common practice for more than 70 years, its use is based mostly on expert opinion rather than solid evidence. Mechanical bowel preparation in minimally invasive and vaginal gynecologic surgery is strongly debated, since many studies have not confirmed its effectiveness, neither in reducing postoperative infectious morbidity nor in improving surgeons’ performance. A comprehensive search of Medline/PubMed and the Cochrane Library Database was conducted, for related articles up to June 2019, including terms such as “mechanical bowel preparation,” “vaginal surgery,” “minimally invasive,” and “gynecology.” We aimed to determine the best practice regarding bowel preparation before these surgical approaches. In previous studies, bowel preparation was evaluated only via mechanical measures. The identified randomized trials in laparoscopic approach and in vaginal surgery were 8 and 4, respectively. Most of them compare different types of preparation, with patients being separated into groups of oral laxatives, rectal measures (enema), low residue diet, and fasting. The outcomes of interest are the quality of the surgical field, postoperative infectious complications, length of hospital stay, and patients’ comfort during the whole procedure. The results are almost identical regardless of the procedure’s type. Routine administration of bowel preparation seems to offer no advantage to any of the objectives mentioned above. Taking into consideration the fact that in most gynecologic cases there is minimal probability of bowel intraluminal entry and, thus, low surgical site infection rates, most scientific societies have issued guidelines against the use of any bowel preparation regimen before laparoscopic or vaginal surgery. Nonetheless, surgeons still do not use a specific pattern and continue ordering them. However, according to recent evidence, preoperative bowel preparation of any type should be omitted prior to minimally invasive and vaginal gynecologic surgeries.

MODERN VIEW ON DIFFERENT KINDS OF BOWEL PREPARATION FOR ELECTIVE COLORECTAL SURGERY

Purpose: to assess current data on the effect of different approaches to preoperative bowel preparation before elective colorectal surgery on short-term treatment outcomes.Material and Methods. Online system PubMed of U.S. National Library of Medicine was used to find articles with key words “mechanical bowel preparation”, “surgical site infection”, “oral antibiotics”. A total of 226 articles were reviewed. 31 articles were selected for final review. Furthermore, ClinicalTrials.gov site was used to find actual and recruiting trials.Results. Mechanical bowel preparation (MBP) used to be a standard procedure for a long time. Nowadays, routine use of MBP seems to be debatable. Alternative approaches, e.g. absolutely no preparation or the use of MBP in combination with oral antibiotics, are considered. Data on performing different kinds of bowel preparation is reviewed in this article.Conclusion. Optimal approach of preoperative bowel preparation is still questionable. Combination of mechanical bowel preparation and oral antibiotics seems to be a preferable method. However, there is not enough evidence to exclude anothertechniques. It’s required to conduct additional randomized controlled trials.