nach oben

Surgical Endoscopy

Erschienen in:

01.09.2014 | Review

Intraoperative assessment of colorectal anastomotic integrity: a systematic review

verfasst von: Subramanian Nachiappan, Alan Askari, Andrew Currie, Robin H. Kennedy, Omar Faiz

Erschienen in: Surgical Endoscopy | Ausgabe 9/2014

Einloggen, um Zugang zu erhalten

Abstract

Background

Surgeons have attempted to minimize postoperative anastomotic complications by employing intraoperative tests and manoeuvres to assess colorectal anastomotic integrity. These have evolved over time with improvement in operative technology and techniques. This systematic review aims to examine the impact of such intraoperative assessments.

Methods

A systematic review of studies assessing intraoperative anastomotic assessments and their impact on postoperative anastomotic complications was performed. Intraoperative measures undertaken as a result of intraoperative assessments and postoperative anastomotic complications were analysed.

Results

37 Studies were identified. 13 studies evaluated basic mechanical patency tests, ten studies evaluated endoscopic visualisation techniques and 14 studies evaluated microperfusion techniques. Postoperative anastomotic complications were significantly lower in patients tested with basic mechanical patency tests compared to those untested (non-RCT: 4.1 vs. 8.1 %, p = 0.03, RCTs: 5.8 vs. 16.0 %, p = 0.024). There were no differences in postoperative anastomotic complications between tested and non-tested cohorts in non-randomised cohort studies evaluating endoscopic visualisation techniques. However, intraoperative measures taken after abnormal intraoperative tests may have reduced the number of postoperative complications. Perfusion analysis techniques are not in routine widespread clinical practice as yet, but newer techniques such as fluorescent dyes and imaging under near infrared light show technical feasibility.

Conclusions

Intraoperative colorectal anastomotic assessment has evolved together with advancement of technology in the surgical setting. Moderate benefit in terms of lower postoperative anastomotic complications has been shown with basic mechanical patency testing and more recently with intraoperative endoscopic visualisation of colorectal anastomoses. The next advance and possible introduction into routine practice may include the use of microperfusion techniques. The latest in this group of techniques, which utilise autofluorescent dyes such as Indocyanine green, hold great potential. Well-planned controlled studies or ideally, randomised controlled trials need to be conducted to further assess the benefit of these latest techniques.

Den Dulk M, Marijnen CAM, Collette L, Putter H, Påhlman L, Folkesson J, Bosset J-F, Rödel C, Bujko K, van de Velde CJH (2009) Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery. Br J Surg 96:1066–1075. doi:10.1002/bjs.6694 CrossRef

Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899. doi:10.1097/SLA.0b013e3182128929 PubMedCrossRef

Park JS, Choi G-S, Kim SH, Kim HR, Kim NK, Lee KY, Kang SB, Kim JY, Lee KY, Kim BC, Bae BN, Son GM, Lee S, Kang H (2013) Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group. Ann Surg 257(4):665–671. doi:10.1097/SLA.0b013e31827b8ed9 PubMedCrossRef

Kang CY, Halabi WJ, Chaudhry OO, Nguyen V, Pigazzi A, Carmichael JC, Mills S, Stamos MJ (2013) Risk factors for anastomotic leakage after anterior resection for rectal cancer. JAMA Surg 148:65–71. doi:10.1001/2013.jamasurg.2 PubMedCrossRef

Mäkelä JT, Kiviniemi H, Laitinen S (2003) Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 46:653–660. doi:10.1097/01.DCR.0000059328.10563.8C PubMedCrossRef

Buchs NC, Gervaz P, Secic M, Bucher P, Mugnier-Konrad B, Morel P (2008) Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int J Colorectal Dis 23:265–270. doi:10.1007/s00384-007-0399-3 PubMedCrossRef

Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 179:92–96PubMedCrossRef

Moran BJ (2010) Predicting the risk and diminishing the consequences of anastomotic leakage after anterior resection for rectal cancer. Acta Chir Iugosl 57:47–50PubMedCrossRef

Richards CH, Campbell V, Ho C, Hayes J, Elliott T, Thompson-Fawcett M (2012) Smoking is a major risk factor for anastomotic leak in patients undergoing low anterior resection. Colorectal Dis 14:628–633. doi:10.1111/j.1463-1318.2011.02718.x PubMedCrossRef

10.

Telem DA, Chin EH, Nguyen SQ, Divino CM (2010) Risk factors for anastomotic leak following colorectal surgery: a case-control study. Archiv Surg 145:371–376. doi:10.1001/archsurg.2010.40 CrossRef

11.

Karliczek A, Harlaar NJ, Zeebregts CJ, Wiggers T, Baas PC, van Dam GM (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 24:569–576. doi:10.1007/s00384-009-0658-6 PubMedCrossRef

12.

Ho Y-H (2010) Techniques for colorectal anastomosis. World J Gastroenterol 16:1610. doi:10.3748/wjg.v16.i13.1610 PubMedCentralPubMedCrossRef

13.

Slieker JC, Daams F, Mulder IM, Jeekel J, Lange JF (2013) Systematic review of the technique of colorectal anastomosis. JAMA Surg 148:190–201. doi:10.1001/2013.jamasurg.33 PubMedCrossRef

14.

Lazorthes F, Chiotassol P (1986) Stapled colorectal anastomoses: peroperative integrity of the anastomosis and risk of postoperative leakage. Int J Colorectal Dis 1:96–98PubMedCrossRef

15.

Davies AH, Bartolo DC, Richards AE, Johnson CD, Mortensen MCC (1988) Intra-operative air testing: an audit on rectal anastomosis. Ann R Coll Surg Engl 70:345–347PubMedCentralPubMed

16.

Griffith CD, Hardcastle JD (1990) Intraoperative testing of anastomotic integrity after stapled anterior resection for cancer. J R Coll Surg Edinb 35:106–108PubMed

17.

Pritchard GA, Krouma FF, Stamatakis JD (1990) Short note Intraoperative testing of colorectal anastomosis can be misleading. 77:101105

18.

Dixon AR, Holmes JT (1991) Colorectal anastomotic integrity after anterior resection: is there a role for intraoperative testing? J R Coll Surg Edinb 36:35–36PubMed

19.

Yalin R, Aktan AO, Yeğen C, Döşlüoğlu H, Okboy N (1993) Importance of testing stapled rectal anastomoses with air. Eur J Surg 159:49–51PubMed

20.

Gilbert JM, Trapnell JE (1988) Intraoperative testing of the integrity of left-sided colorectal anastomoses: a technique of value to the surgeon in training. Ann R Coll Surg Engl 70:158–160PubMedCentralPubMed

21.

Wheeler JM, Gilbert JM (1999) Controlled intraoperative water testing of left-sided colorectal anastomoses: are ileostomies avoidable? Ann R Coll Surg Engl 81:105–108PubMedCentralPubMed

22.

Smith S, McGeehin W, Kozol RA, Giles D (2007) The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis. BMC Surg 7:15. doi:10.1186/1471-2482-7-15 PubMedCentralPubMedCrossRef

23.

Chen C-W, Chen M-J, Yeh Y-S, Tsai H-L, Chang Y-T, Wang J-Y (2012) Intraoperative anastomotic dye test significantly decreases incidence of anastomotic leaks in patients undergoing resection for rectal cancer. Tech Coloproctol 17(5):579–583. doi:10.1007/s10151-012-0910-x PubMedCrossRef

24.

Ricciardi R, Roberts PL, Read TE, Marcello PW, Hall JF, Schoetz DJ (2012) How often do patients return to the operating room after colorectal resections? Colorectal Dis 14:515–521. doi:10.1111/j.1463-1318.2011.02846.x PubMedCrossRef

25.

Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW (1990) Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg 77:1095–1097PubMedCrossRef

26.

Ivanov D, Cvijanovic R, Gvozdenovic L (2011) Intraoperative air testing of colorectal anastomoses. Srp Arh Celok Lek 139:333–338. doi:10.2298/SARH1106333I PubMedCrossRef

27.

Ishihara S, Watanabe T, Nagawa H (2008) Intraoperative colonoscopy for stapled anastomosis in colorectal surgery. Surg Today 38:1063–1065. doi:10.1007/s00595-007-3740-0 PubMedCrossRef

28.

Li VKM, Wexner SD, Pulido N, Wang H, Jin HY, Weiss EG, Nogeuras JJ, Sands DR (2009) Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 23:2459–2465. doi:10.1007/s00464-009-0416-4 PubMedCrossRef

29.

Brugiotti Carlo, Valerio Corazza AP (2012) The efficacy of intraoperative endoscopic control of the colorectal stapled anastomosis after anterior resection of the rectum for rectal cancer. Colorectal Dis 14:1–76

30.

Velchuru V, Bibi S, Kamal T, Zawadzki M, Threepuraneni G, Park J, Marecik S, Abcarian H, Prasad L (2013) Redoing of anastomosis following positive intra-operative leak test identified by flexible sigmoidoscopy following colo-rectal anastomosis. Dis Colon Rectum 56:e2–e249. doi:10.1097/DCR.0b013e31828d97c9

31.

Ghole S, Nguyen A, Jafari M, Mills S, Carmichael J, Stamos M, Pigazzi A (2013) Going beyond the air leak test-our initial experience with a new grading system utilizing flexible endoscopy for the intraoperative evaluation of rectal anastomoses. Dis Colon Rectum 56:e249. doi:10.1097/DCR.0b013e31828d97c9

32.

Sakanoue Y, Nakao K, Shoji Y, Yanagi H, Kusunoki M, Utsunomiya J (1993) Intraoperative colonoscopy. Surg Endosc 7:84–87PubMedCrossRef

33.

Schmidt O, Merkel S, Hohenberger W (2003) Anastomotic leakage after low rectal stapler anastomosis: significance of intraoperative anastomotic testing. Eur J Surg Oncol 29:239–243. doi:10.1053/ejso.2002.1416 PubMedCrossRef

34.

Lanthaler M, Biebl M, Mittermair R, Ofner D, Nehoda H (2008) Intraoperative colonoscopy for anastomosis assessment in laparoscopically assisted left-sided colon resection: is it worthwhile? J Laparoendosc Adv Surg Tech Part A 18:27–31. doi:10.1089/lap.2007.0058 CrossRef

35.

Lieto E, Orditura M, Castellano P, Pinto M, Zamboli A, De Vita F, Pignatelli C, Galizia G (2011) Endoscopic intraoperative anastomotic testing may avoid early gastrointestinal anastomotic complications: a prospective study. J Gastroint Surg 15:145–152. doi:10.1007/s11605-010-1371-z CrossRef

36.

Shamiyeh A, Szabo K, Ulf Wayand W, Zehetner J (2012) Intraoperative endoscopy for the assessment of circular-stapled anastomosis in laparoscopic colon surgery. Surg Laparosc Endosc Percutan Tech 22:65–67. doi:10.1097/SLE.0b013e3182401e20 PubMedCrossRef

37.

Ambrosetti P, Robert J, Mathey P, Rohner A (1994) Left-sided colon and colorectal anastomoses: doppler ultrasound as an aid to assess bowel vascularization. A prospective evaluation of 200 consecutive elective cases. Int J Colorectal Dis 9:211–214PubMedCrossRef

38.

Hallböök O, Johansson K, Sjödahl R (1996) Laser Doppler blood flow measurement in rectal resection for carcinoma–comparison between the straight and colonic J pouch reconstruction. Br J Surg 83:389–392PubMedCrossRef

39.

Vignali A, Gianotti L, Braga M, Radaelli G, Malvezzi L, Di Carlo V (2000) Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak. Dis Colon Rectum 43:76–82PubMedCrossRef

40.

Seike K, Koda K, Saito N, Oda K, Kosugi C, Shimizu K, Miyazaki M (2007) Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery. Int J Colorectal Dis 22:689–697. doi:10.1007/s00384-006-0221-7 PubMedCrossRef

41.

Boyle NH, Manifold D, Jordan MH, Mason RC (2000) Intraoperative assessment of colonic perfusion using scanning laser Doppler flowmetry during colonic resection. J Am Coll Surg 191:504–510PubMedCrossRef

42.

Sheridan WG, Lowndes RH, Young HL (1987) Tissue oxygen tension as a predictor of colonic anastomotic healing. Dis Colon Rectum 30:867–871PubMedCrossRef

43.

Hall NR, Finan PJ, Stephenson BM, Lowndes RH, Young HL (1995) High tie of the inferior mesenteric artery in distal colorectal resections–a safe vascular procedure. Int J Colorectal Dis 10:29–32PubMedCrossRef

44.

Karliczek A, Benaron DA, Baas PC, Zeebregts CJ, Wiggers T, van Dam GM (2010) Intraoperative assessment of microperfusion with visible light spectroscopy for prediction of anastomotic leakage in colorectal anastomoses. Colorectal Dis 12:1018–1025. doi:10.1111/j.1463-1318.2009.01944.x PubMedCrossRef

45.

Hirano Y, Omura K, Tatsuzawa Y, Shimizu J, Kawaura Y, Watanabe G (2006) Tissue oxygen saturation during colorectal surgery measured by near-infrared spectroscopy: pilot study to predict anastomotic complications. World J Surg 30:457–461. doi:10.1007/s00268-005-0271-y PubMedCrossRef

46.

Parmeggiani F, De Angelis N, Carra MC, Bizzarri B, Fornaroli F, Gnocchi A, Madia C, Nervi G, Valle RD, DeAngelis GL (2012) Intraoperative colonoscopy control for colorectal-anastomotic leakage: a new solution for an old problem a pilot study. Gastrointest Endosc 75:AB178. doi:10.1016/j.gie.2012.04.162 CrossRef

47.

Kudszus S, Roesel C, Schachtrupp A, Höer JJ (2010) Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbecks Archiv Surg 395:1025–1030. doi:10.1007/s00423-010-0699-x CrossRef

48.

Jafari MD, Lee KH, Halabi WJ, Mills SD, Carmichael JC, Stamos MJ, Pigazzi A (2013) The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery. Surg Endosc 27(8):3003–3008. doi:10.1007/s00464-013-2832-8 PubMedCrossRef

49.

Sherwinter DA (2012) Transanal near-infrared imaging of colorectal anastomotic perfusion. Surg Laparosc Endosc Percutan Tech 22:433–436. doi:10.1097/SLE.0b013e3182601eb8 PubMedCrossRef

50.

Sherwinter DA, Gallagher J, Donkar T (2013) Intra-operative transanal near infrared imaging of colorectal anastomotic perfusion: a feasibility study. Colorectal Dis 15:91–96. doi:10.1111/j.1463-1318.2012.03101.x PubMedCrossRef

51.

Smith LE (1981) Anastomosis with EEA stapler after anterior colonic resection. Dis Colon Rectum 24:236–242PubMedCrossRef

52.

Björck M, Hedberg B (1994) Early detection of major complications after abdominal aortic surgery: predictive value of sigmoid colon and gastric intramucosal pH monitoring. Br J Surg 81:25–30PubMedCrossRef

53.

Vahl AC, Ozkaynak-Yilmaz EN, Nauta SH, Scheffer GJ, Felt-Bersma RJ, Brom HL, Rauwerda JA (1997) Endoluminal pulse oximetry combined with tonometry to monitor the perfusion of the sigmoid during and after resection of abdominal aortic aneurysm. Cardiovasc Surg 5:65–70PubMedCrossRef

54.

Millan M, García-Granero E, Flor B, García-Botello S, Lledo S (2006) Early prediction of anastomotic leak in colorectal cancer surgery by intramucosal pH. Dis Colon Rectum 49:595–601. doi:10.1007/s10350-006-0504-7 PubMedCrossRef

55.

Singh DB, Stansby G, Bain I, Harrison DK (2009) Intraoperative measurement of colonic oxygenation during bowel resection. Adv Exp Med Biol 645:261–266. doi:10.1007/978-0-387-85998-9_39 PubMedCrossRef

56.

Dworkin MJ, Allen-Mersh TG (1996) Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon. J Am Coll Surg 183:357–360PubMed

57.

Novell JR, Lewis AA (1990) Peroperative observation of marginal artery bleeding: a predictor of anastomotic leakage. Br J Surg 77:137–138PubMedCrossRef

58.

Senagore A, Milsom JW, Walshaw RK, Dunstan R, Mazier WP, Chaudry IH (1990) Intramural pH: a quantitative measurement for predicting colorectal anastomotic healing. Dis Colon Rectum 33:175–179PubMedCrossRef

59.

Donati A, Cornacchini O, Loggi S, Caporelli S, Conti G, Falcetta S, Alò F, Pagliariccio G, Bruni E, Preiser J-C, Pelaia P (2004) A comparison among portal lactate, intramucosal sigmoid Ph, and delta CO₂ (PaCO₂ - regional Pco₂) as indices of complications in patients undergoing abdominal aortic aneurysm surgery. Anesth Analg 99:1024–1031. doi:10.1213/01.ANE.0000132543.65095.2C PubMedCrossRef

60.

Kvietys PR, Shepherd AP, Granger DN (1985) Laser-Doppler, H₂ clearance, and microsphere estimates of mucosal blood flow. Am J Physiol 249:G221–G227PubMed

61.

Nice Guidelines Quality Assessment for Case Series. http://www.nice.org.uk/nicemedia/pdf/Appendix_04_qualityofcase_series_form_preop.pdf. Accessed 30 June 2013

62.

Wells GA Shea B, O’connell D, Peterson J, Welch V, Losos M (2000) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. In: 3rd Symposium on Systematic Reviews: Beyond the Basics, pp 3–5

63.

Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJMH (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12PubMedCrossRef

Titel: Intraoperative assessment of colorectal anastomotic integrity: a systematic review
verfasst von: Subramanian Nachiappan
Alan Askari
Andrew Currie
Robin H. Kennedy
Omar Faiz
Publikationsdatum: 01.09.2014
Verlag: Springer US
Erschienen in: Surgical Endoscopy / Ausgabe 9/2014
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-014-3520-z

Neu im Fachgebiet Chirurgie

Wie erfolgreich ist eine Re-Ablation nach Rezidiv?

23.04.2024 Ablationstherapie Nachrichten

Nach der Katheterablation von Vorhofflimmern kommt es bei etwa einem Drittel der Patienten zu Rezidiven, meist binnen eines Jahres. Wie sich spätere Rückfälle auf die Erfolgschancen einer erneuten Ablation auswirken, haben Schweizer Kardiologen erforscht.

Hinter dieser Appendizitis steckte ein Erreger

23.04.2024 Appendizitis Nachrichten

Schmerzen im Unterbauch, aber sonst nicht viel, was auf eine Appendizitis hindeutete: Ein junger Mann hatte Glück, dass trotzdem eine Laparoskopie mit Appendektomie durchgeführt und der Wurmfortsatz histologisch untersucht wurde.

Mehr Schaden als Nutzen durch präoperatives Aussetzen von GLP-1-Agonisten?

23.04.2024 Operationsvorbereitung Nachrichten

Derzeit wird empfohlen, eine Therapie mit GLP-1-Rezeptoragonisten präoperativ zu unterbrechen. Eine neue Studie nährt jedoch Zweifel an der Notwendigkeit der Maßnahme.

Ureterstriktur: Innovative OP-Technik bewährt sich

19.04.2024 EAU 2024 Kongressbericht

Die Ureterstriktur ist eine relativ seltene Komplikation, trotzdem bedarf sie einer differenzierten Versorgung. In komplexen Fällen wird dies durch die roboterassistierte OP-Technik gewährleistet. Erste Resultate ermutigen.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Aktuelle BDC Leitlinien-Webinare

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare

CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare

CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske

Dr. med. Benjamin Meyknecht

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare

CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric

Springer Medizin

Abstract

Background

Methods

Results

Conclusions

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 9/2014

Laparoscopic right hemicolectomy with complete mesocolic excision

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

A systematic review of synthetic and biologic materials for abdominal wall reinforcement in contaminated fields

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients

Warmed, humidified carbon dioxide insufflation versus standard carbon dioxide in laparoscopic cholecystectomy: a double-blinded randomized controlled trial

Endoscopic piecemeal resection of large colorectal polyps with long-term followup

Update Chirurgie