BackgroundAnastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak.MethodA literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string “colorectal anastomotic (“leak” OR “bleed”), “endoscopy”, endoscopic management”. Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed.ResultsA total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported.ConclusionEndoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
There are 41,000 patients diagnosed with colorectal cancer in the UK each year; approximately a third of these are rectal in origin [1]. As part of their treatment many of these patients will undergo surgical resection with formation of an anastomosis. In the intraoperative setting much focus is placed on techniques to ensure anastomotic integrity and avoid the well-established morbidity and mortality from an anastomotic leak.Further down the line patients can go to on develop a benign stricture at the level of the anastomosis. Rates have been shown to vary from 2% to 30% [2-4] but are often under-reported in the literature due to the need for long-term follow-up [5]. Neoadjuvant chemoradiotherapy and
Recently, the United Kingdom Haemophilia Centre Doctors Organisation published recommendations for the standard of care for assessment and treatment of patients with bleeding disorders in the emergency department (A&E). An audit was undertaken to compare the level of care to the acceptable standards in a tertiary hospital A&E, attached to a haemophilia comprehensive care centre. A&E attendances were found by cross referencing all patients with known bleeding disorders against the EDMS attendance system. Visits from the past 3 years were identified to produce sufficient data and electronic notes from these visits were then accessed, and marked against the proforma. Data were available from 45 of a total of 54 patients, who had a total of 75 emergency visits documented. In all aspects of care, the standards were not adequately met including the average length of time between booking and clinical assessment, early initiation of specific haemostatic treatment, seeking haematology advice and arrangement of follow-up. Also no specialist clotting investigations were done with only 9/11 patients admitted having their haematological diagnosis recorded. In addition, only very few patients had the severity of bleeding disorder noted and less than half their first line treatment documented. There were significant differences in the standard of care for haemophilia patients provided by the A&E department when compared with acceptable standards. Measures have been put in place and policies have been drafted to improve this situation and provide the best possible care to persons with haemophilia.
Aim In patients with low rectal cancer it is occasionally necessary to avoid a low coloanal anastomosis due to patient frailty or poor function. In such situations there are two alternative approaches: Hartmann's procedure (HP) or intersphincteric abdominoperineal excision (IAPE). There are few data to guide surgeons as to which of these two procedures is the safest. The aim of this study was to determine the surgical complication rates associated with each procedure. Method This was a multicentre, nonrandomized prospective cohort study of patients undergoing either HP or IAPE. The primary objective was to determine surgical complication rates. Secondary objectives included length of stay, time to adjuvant therapy and quality of life at 90 days. Results One hundred and seventy nine patients were recruited between April 2016 and June 2019; approximately two thirds of patients underwent HP and one third IAPE. The overall complication rate was high in both groups (54% for the HP group and 52% for the IAPE group). Surgery-specific complication rates were also high, but not significantly different: 43% for HP and 48% for IAPE. The pelvic abscess rate in HP was 11% and was significantly higher in patients with a palpable staple line (15% vs 2%). There was a higher incidence of serious medical complications following IAPE (16% vs 5%), along with a reduction in 90-day quality of life scores. Conclusion This is the largest prospective study to compare HP and IAPE in patients undergoing rectal cancer surgery where primary anastomosis is not deemed appropriate. With similar complication rates, these data support the ongoing use of either HP or IAPE in this patient group.
Aim Anastomotic leak (AL) after colorectal resection is associated with increased rates of morbidity and mortality: potential permanent stoma formation, increased local recurrence, reduced cancer‐related survival, poor functional outcomes and associated quality of life. Techniques to reduce leak rates are therefore highly sought. Method A literature search was performed for published full text articles using PubMed, Cochrane and Scopus databases with a focus on colorectal surgery 1990–2020. Additional papers were detected by scanning references of relevant papers. Results A total of 53 papers were included after a thorough literature search. Techniques assessed included leak tests, endoscopy, perfusion assessment and fluorescence studies. Air‐leak testing remains the most commonly used method across Europe, due to ease of reproducibility and low cost. There is no evidence that this reduces the leak rate; however, identification of a leak intra‐operatively provides the opportunity for either suture reinforcement or formal takedown with or without re‐do of the anastomosis and consideration of diversion. Suture repair alone of a positive air‐leak test is associated with an increased AL rate. The use of fluorescence studies to guide the site of anastomosis has demonstrated reduced leak rates in distal anastomoses, is safe, feasible and has a promising future. Conclusion Although over reliance on any assessment tool should be avoided, intra‐operative techniques with the aim of reducing AL rates are increasingly being employed. Standardization of these methods is imperative for routine use. However, in the interim it is recommended that all anastomoses should be assessed intra‐operatively for mechanical failure, particularly distal anastomoses.
Background and Objectives Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta‐analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery. Methods A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery. Results Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD −197.8 ml, 95% CI [−275.69, −119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD –0.45 mmol/L, 95% CI [−0.73, −0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]). Conclusions TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub‐specialities.
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