BACKGROUND: The indications and efficacy of endoluminal vacuum therapy for the management of colorectal/coloanal anastomotic leakage are not well defined. OBJECTIVE: This study aimed to evaluate the efficacy and to define adequate indications of endoluminal vacuum therapy to treat colorectal/coloanal anastomotic leakage. DESIGN: The retrospective cohort evaluated in this study is based on a prospectively maintained database. SETTINGS: This study was conducted in 8 centers from the French GRECCAR study group. PATIENTS: Patients with colorectal/coloanal anastomotic leakage treated with endoluminal vacuum therapy were included. MAIN OUTCOME MEASURES: The primary outcome measured was the success rate of endoluminal vacuum therapy defined by the complete healing of the perianastomotic sepsis and a functional anastomosis. The predictive factors of success of endoluminal vacuum therapy and long-term functional result (low anterior resection syndrome score) were also analyzed. RESULTS: Among 62 patients treated for an anastomotic leakage of colorectal/coloanal anastomosis from 2012 to 2017, 47 fulfilled the inclusion criteria. The patients had a mean of 6.6 (±5.8) replacements for a total of 27 (±34) days treatment duration, associated with diverting stoma in 81%. After 37 months median follow-up, a successful treatment of anastomotic leakage using endoluminal vacuum therapy could be achieved in 26 patients (55%). The success rate was improved in patients undergoing primary endoluminal vacuum therapy compared to salvage endoluminal vacuum therapy (73% vs 33%, p = 0.006) and when endoluminal vacuum therapy was initiated within 15 days compared to more than 15 days after the diagnosis of anastomotic leakage (72.4% vs 27.8%, p = 0.003). At 12 months, 53% of patients who responded had minor low anterior resection syndrome and only 3 necessitated anastomotic stricture dilation. LIMITATIONS: This was a noncomparative cohort study. CONCLUSION: Endoluminal vacuum therapy appears to be effective to treat colorectal anastomotic leakage especially when it is used as primary treatment of the fistula. Long-term functional outcome of patients undergoing conservative management of anastomotic leakage may be improved with endoluminal vacuum therapy. See Video Abstract at http://links.lww.com/DCR/B103. RESULTADOS A CORTO Y LARGO PLAZO DE LA TERAPIA DE VACÍO ENDOLUMINAL PARA LA FUGA ANASTOMÓTICA COLORRECTAL O COLOANAL: RESULTADOS DE UN ESTUDIO DE COHORTE MULTICÉNTRICO A NIVEL NACIONAL DEL GRUPO FRANCÉS GRECCAR ANTECEDENTES: Las indicaciones y la eficacia de la terapia de vacío endoluminal para el tratamiento de la fuga anastomótica colorrectal / coloanal no están bien definidas. OBJETIVO: Evaluar la eficacia y definir indicaciones adecuadas de la terapia de vacío endoluminal para tratar la fuga anastomótica colorrectal / coloanal. DISEÑO: Cohorte retrospectivo basada en una base de datos mantenida prospectivamente. MARCO: Este estudio se realizó en 8 centros del grupo de estudio Francés GRECCAR. PACIENTES: Se incluyeron pacientes con fuga anastomótica colorrectal / coloanal tratados con terapia de vacío endoluminal. MEDIDAS DE RESULTADOS PRINCIPALES: Tasa de éxito de la terapia de vacío endoluminal definida por la curación completa de la sepsis perianastomótica y una anastomosis funcional. También se analizaron los factores predictivos del éxito de la terapia de vacío endoluminal y el resultado funcional a largo plazo (puntaje bajo del síndrome de resección anterior). RESULTADOS: Entre 62 pacientes tratados por una fuga anastomótica de anastomosis colorrectal / coloanal de 2012 a 2017, 47 cumplieron los criterios de inclusión. Los pacientes tuvieron una media de 6.6 (±5.8) reemplazos para un total de 27 (±34) días de duración del tratamiento, asociado con estoma de desvio en el 81%. Después de una mediana de seguimiento de 37 meses, se pudo lograr un tratamiento exitoso de la fuga anastomótica usando terapia de vacío endoluminal en 26 pacientes (55%). La tasa de éxito mejoró en pacientes sometidos a terapia de vacío endoluminal primaria en comparación con la terapia de vacío endoluminal de rescate (73% frente a 33%, p = 0.006) y cuando la terapia de vacío endoluminal se inició dentro de los 15 días en comparación con más de 15 días después del diagnóstico de fuga anastomótica (72.4% vs 27.8%, p = 0.003). A los 12 meses, el 53% de los pacientes que respondieron tenían síndrome de resección anterior baja leve y solo 3 necesitaban dilatación de estenosis anastomótica. LIMITACIONES: Estudio de cohorte no comparativo. CONCLUSION: La terapia de vacío endoluminal parece ser efectiva para tratar la fuga anastomótica colorrectal, especialmente cuando se usa como tratamiento primario de la fístula. El resultado funcional a largo plazo de los pacientes sometidos a un tratamiento conservador de la fuga anastomótica puede mejorarse con la terapia de vacío endoluminal. Consulte Video Resumen en http://links.lww.com/DCR/B103.
Squamous cell carcinoma of the rectum is a distinct entity. Before the final choice of treatment is made, digestive surgeons should bear in mind this rare tumour.
Background: Gastric pneumatosis (GP) is a rare radiologic nding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would bene t most from operative management. Methods: Between 2010 and 2020, all CT-scan reports in 4 tertiary centers were searched for the following terms: "gastric pneumatosis", "intramural gastric air" or "emphysematous gastritis". The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions' medical records.Results: Among 58 patients with GP portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identi ed the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2mmol/l, and absence of gastric dilatation.Multivariable analysis identi ed the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07 -1.79) and absence of gastric dilatation (OR: 0.07, 95% CI: 0.01 -0.79). None of the patients presenting with a baseline lactate rate <2 mmol/l died within 30 days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%).Conclusions: GP could be managed non-operatively, even in the presence of portal venous gas. However patients with arterial lactate level>2mmol/l, or absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.
Background: Gastric pneumatosis (GP) is a rare radiologic finding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would benefit most from operative management.Methods: Between 2010 and 2020, all CT-scan reports in 4 tertiary centers were searched for the following terms: “gastric pneumatosis”, “intramural gastric air” or “emphysematous gastritis”. The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions’ medical records. Results: Among 58 patients with GP portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identified the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2mmol/l, and absence of gastric dilatation. Multivariable analysis identified the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07 - 1.79) and absence of gastric dilatation (OR: 0.07, 95% CI: 0.01 - 0.79). None of the patients presenting with a baseline lactate rate <2 mmol/l died within 30 days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%).Conclusions: GP could be managed non-operatively, even in the presence of portal venous gas. However patients with arterial lactate level>2mmol/l, or absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.
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