The aim of this study was to evaluate the reliability of intraoperative laser-Doppler measurements in predicting the occurrence of anastomotic leak in patients with colorectal cancer undergoing stapled straight anastomosis to the rectum.A prospective study was undertaken on 55 patients with rectal cancer or distal sigmoid cancer programmed for elective curative surgery. In all patients transmural colonic blood flow was measured by laser-Doppler flowmetry technique before bowel manipulation (baseline measurement) and after vascular ligation and division. Comorbidities at admission, intraoperative events, associated surgical procedures, and clinical outcome were tested for any association with anastomotic leak.Postoperative mortality was 1.8 percent (1/55 patients), and the overall morbidity was 21.3 percent. Anastomotic leak occurred in eight patients (14.5 percent). After colonic division a blood flow reduction at the rectal stump was observed in 42 patients (76.3 percent) as compared with baseline measurement. The mean rectal stump flow reduction was 6.2 percent in patients without anastomotic leak, whereas in patients who developed anastomosis breakdown it was 16 percent (P < 0.001). Mean proximal stump flow reduction was 5.1 percent in the uncomplicated patients, whereas in patients who had an anastomosis breakdown it was 12.9 percent (P < 0.01). A positive linear correlation was found between decrease in blood flow and rate of anastomotic leak.Blood flow reduction at the rectal stump is associated with an increased risk of anastomotic leak.

An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect long‐term survival is less clear because data are scarce. The aim of the study was to investigate the long‐term impact of Grade C anastomotic leak in a large, population‐based cohort.

The aim was to evaluate the impact of anastomotic leak (AL) after colon cancer (CC) and rectal cancer (RC) surgery on 5-year relative survival, disease-free survival (DFS), and disease recurrence.

Wound healing, as a normal biological process in the human body, is achieved through four precisely and highly programmed phases: hemostasis, inflammation, proliferation, and remodeling. For a wound to heal successfully, all four phases must occur in the proper sequence and time frame. Many factors can interfere with one or more phases of this process, thus causing improper or impaired wound healing. This article reviews the recent literature on the most significant factors that affect cutaneous wound healing and the potential cellular and/or molecular mechanisms involved. The factors discussed include oxygenation, infection, age and sex hormones, stress, diabetes, obesity, medications, alcoholism, smoking, and nutrition. A better understanding of the influence of these factors on repair may lead to therapeutics that improve wound healing and resolve impaired wounds.

Intestinal anatomosis is a complex and multicellular process that involving three overlapped phases: exudative phase, proliferative phase, and reparative phase. Undisturbed anastomotic healings are crucial for the recovery of patients after operations but unsuccessful healings are linked with a considerable mortality. This time, we concentrate on the immunologic changes during different phases of intestinal anastomotic healing and select several major immune cells and cytokines of each phase to get a better understanding of these immunologic changes in different phases, which will be significant for more precise therapy strategies in anastomoses.

There are currently no guidelines on the long‐term management of patients after an episode of acute ischaemic colitis. Our aim was to review the literature on the pattern of presentation and the pathophysiology of this condition and to understand the current status of the acute and long‐term management of ischaemic colitis. Furthermore, we aim to provide recommendations for the clinicians in regard to the acute and long‐term management of ischaemic colitis. A review of the English literature over the last 15 years was performed using Embase and Medline. Search terms were ischaemic OR ischemic, colitis OR colon. Two reviewers screened the papers against pre‐determined eligibility criteria. A senior consultant surgeon performed a final overview. Three hundred sixty‐eight papers were identified on the initial search; 318 were irrelevant and 17 were conference abstracts; both were excluded. Thirty‐three full articles were assessed for suitability; nine were further excluded. Twenty‐four articles were included in the final analysis and cross‐referenced against those listed in the systematic reviews. There is a large clinical heterogeneity in inclusion criteria (histological, radiological, endoscopic, surgical specimen). Twelve out of 24 articles included patients only based on histological diagnosis. The definition of right and left (or nonright) ischaemic colitis was variable based on whether hepatic or splenic flexure was used as the cut‐off point. Five retrospective case series highlighted that patients with isolated right‐sided ischaemic colitis had a worse prognosis than those with left‐sided colitis (higher mortality, need for surgery, length of hospital stay). The overall recurrence was 9%. There is a need for a higher‐level evidence to guide clinicians on the long‐term management of patients following an episode of acute colonic ischaemia. Further evidence is required to determine whether right colonic ischaemia should be managed differently from left.

Most acute respiratory distress syndrome studies have been focused on the lung injury. Little is known about other organs during the development of acute respiratory distress syndrome. Herein, we investigated the injury and cell death in multiple organs after intestinal ischemia-reperfusion (IIR) in C57BL/6 mice. Terminal transferase dUTP nick end labeling staining was used as a marker of cell death. Caspase 3 and cathepsin B activation as markers of caspase-dependent and caspase-independent apoptosis, respectively, and electron microscopy for ultimate characterization of cell death were used. In comparison with control and sham-operated mice, the IIR group showed interstitial inflammatory infiltrates in the lung and significant increases of lung injury parameters and plasma lactate dehydrogenase and aspartate aminotransferase levels. Terminal transferase dUTP nick end labeling-positive cells and immunostaining for hemeoxygenase 1, an enzyme induced by inflammatory stimuli, were increased in the lung, heart, and kidney, but not in the liver. The number of hemeoxygenase 1-positive cells positively and significantly correlated to the number of terminal transferase dUTP nick end labeling-positive cells. Cell death was not associated with caspase 3 or cathepsin B activation. Electron microscopy showed morphological features compatible with oncotic rather than apoptotic cell death or necrosis, including mitochondrial swelling and cytoplasm disorganization in pulmonary and renal epithelial cells, lung and cardiac endothelial cells, and myocytes. These results indicate that, although lung injury is the most significant manifestation after IIR, oncotic cell death occurs in the lung, heart, and kidney, which may be related to ischemia and inflammation.

The aim of this study was to provide comprehensive evidence-based assessment of the discontinuity of the marginal artery at the splenic flexure (SF) and the rectosigmoid junction (RSJ).A systematic review was conducted of literature published to 26 December 2022 in the electronic databases PubMed, SCOPUS and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes were the pooled PPEs of the marginal artery at the SF and the RSJ. The secondary outcome was the size of vascular anastomoses.A total of 21 studies (n = 2,864 patients) were included. The marginal artery was present at the splenic flexure in 82% (95% CI: 62-95) of patients. Approximately 81% (95% CI: 63-94%) of patients had a large macroscopic anastomosis, while the remainder (19%) had small bridging ramifications forming the vessel. The marginal artery was present at the RSJ in 82% (95% CI: 70-91%) of patients.The marginal artery may be absent at the SF and the RSJ in up to 18% of individuals, which may confer a higher risk of ischaemic colitis. As a result of high interstudy heterogeneity noted in our analysis, further well-powered studies to clarify the prevalence of the marginal artery at the SF and the RSJ, as well as its relationship with other complementary colonic collaterals (intermediate and central mesenteric), are warranted.© 2023 Association of Coloproctology of Great Britain and Ireland.

The Arc of Riolan is a strategic vessel that provides collateral mesenteric circulation in 10% of individuals. The importance of identifying and preserving the arc of Riolan in reducing the risk of ischemia to the proximal anastomotic segment after high ligation anterior resection was evaluated.The arc of Riolan is a vessel that crosses anterior to the inferior mesenteric vein horizontally below the level of the pancreas. A retrospective review of all recorded videos of laparoscopic and robotic low and ultra-low anterior resections was performed in September to December 2012 and prospective evaluation in April to July 2013. The main outcome measures were arc of Riolan identification and preservation, and this was correlated with postoperative transmural colonic ischemia requiring surgical reintervention. From July 2013 onward, we routinely performed arc of Riolan-sparing anterior resections.Arc of Riolan was observed in 17.8% of cases. Between 2006 and 2012, before routinely looking for and preserving the arc of Riolan, our rate of acute colonic transmural ischemia requiring an emergency Hartmann procedure after anterior resection was 0.8% (6/723). Between 2012 and 2016, after we started performing arc of Riolan-sparing splenic flexure takedown, there were no cases of acute colonic transmural ischemia requiring surgical reintervention (0/576) after anterior resection.Recognizing and preserving the arc of Riolan, if visualized, during high inferior mesenteric vein ligation and splenic flexure takedown may be an important step in reducing the risk of acute colonic ischemia postanterior resection. See Video at http://links.lww.com/DCR/A535.

The aim of this study was to evaluate the arterial collateral vasculature between the superior mesenteric artery and the inferior mesenteric artery (IMA) from a surgical perspective.A total of 107 fresh adult cadavers (94 male) were studied with emphasis on the vascular anatomy of the left colon. Dissections were carried out mimicking the anterior resection technique. The vasculature of the left mesocolon and the collaterals between the superior mesenteric artery and the IMA with respect to their relationship to the inferior mesenteric vein (IMV) were assessed and classified. Collaterals were classified into three different groups: marginal anastomoses (via the marginal = pericolic artery), intermediate mesocolic anastomoses (parallel to the marginal artery but neither adjacent to the IMV nor close to the duodenum) and central mesocolic anastomoses (next to the IMV at the level of the duodenojejunal junction and the lower border of the pancreas).All patients had a marginal anastomosis. However, the marginal anastomosis, as the only anastomosis between the superior and inferior mesenteric arteries at the splenic flexure, was observed in 41 cases (38%). In addition to the marginal artery, intermediate mesocolic anastomoses were found in 49 (46%) and a central mesocolic anastomosis was observed in 17 (16%) of the 107 cases in the splenic flexure mesocolon. It is in this latter variant that collateral vessels can be compromised during ligation/transection of the IMV.This new classification can contribute to a precise mesocolic dissection technique and splenic flexure mobilization and help prevent ischaemic damage to the descending colon.© 2021 The Association of Coloproctology of Great Britain and Ireland.

To explore the value of treatment choice and clinical prognosis for Riolan's arch in chronic superior mesenteric artery (SMA) ischaemic disease in vascular surgery.The clinical data of 215 patients with SMA ischaemic disease (41 cases with Riolan's arch and 174 cases without) admitted to the Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University (China) from January 2019 to April 2023 were reviewed. Clinical characteristics, imaging findings, treatment, perioperative complications, and patient follow-up data were analysed to observe the impact of Riolan's arch on the prognosis of patients with SMA ischaemic disease.There were significant differences in body mass index (Riolan's arch group: 22.82 ± 3.28 vs 24.03 ± 4.26 in non-Riolan's arch group, P = 0.049), Takayasu's arteritis (4.9% vs 0, respectively, P = 0.036), and secondary intervention (3.3% vs 1.9%, respectively, P < 0.001) between the two groups. Propensity score matching was used to exclude the effect of baseline data on patient outcomes. There were significant differences related to therapy method (conservative treatment, Riolan's arch group: 24.1% vs 39.7% in the non-Riolan's arch group; operative treatment, Riolan's arch group: 51.7% vs 20.7% in the non-Riolan's arch group, P = 0.014), as well as in-hospital time (9.79 ± 4.20 vs 6.86 ± 4.32, respectively, P = 0.011). There was no statistically significant difference in Kaplan-Meier curves between the two groups (log-rank test P = 0.476).Riolan's arch plays an important compensatory role in SMA ischaemic disease, especially in chronic disease. We found significant differences in the treatment methods and length of hospital stay of Riolan's arch, which may suggest that Riolan's arch has some reference value in the choice of treatment mode.© 2024. The Author(s).

The branching of the inferior mesenteric artery and vein varies among individuals. Three-dimensional CT angiography is a less invasive modality than traditional angiographic examination to assess the artery and vein.We aimed to demonstrate the clinical applicability of CT angiography by evaluating bifurcations of the inferior mesenteric artery and the positional relationship between the inferior mesenteric artery and vein.This was a prospective observational study of patients undergoing preoperative CT angiography.This study was conducted at a single tertiary care institution in Japan.A total of 471 consecutive patients who underwent preoperative CT angiography from April 2012 to December 2013 were prospectively enrolled.The branching pattern of the inferior mesenteric artery, the positional relationship between the inferior mesenteric artery and vein, and the associations between inferior mesenteric artery length and clinical features were evaluated.The length of the inferior mesenteric artery varied widely, from 10.1 to 82.2 mm. In 41.2% patients, the left colic artery arose independently from the sigmoid artery, and in 44.7% of the patients, the left colic artery and sigmoid artery had a common trunk, whereas the left colic artery did not exist in 5.1%. The left colic artery was located lateral to the inferior mesenteric vein at the level of the origin of the inferior mesenteric artery in 73.0% of the patients. The incidence of a short inferior mesenteric artery was significantly increased in men with high BMIs (75.0%).Three-dimensional reconstruction was performed by the use of a single software, and angiographic examination was not performed. Therefore, accuracy and reliability of the 3-dimensional reconstruction could not be established for each modality.Using 3-dimensional CT angiography, preoperative understanding of the anatomic vascular variations can be easily obtained, which would help surgeons to safely perform laparoscopic surgery in the left-side colon and rectum.

Aortoiliac calcification may be a surrogate marker of decreased visceral perfusion causing anastomotic leak (AL). The aim of this study was to evaluate the predictive role of aortoiliac calcification for AL after rectal cancer surgery.We enrolled patients with primary rectal cancer who had restorative resection at our institution between January 2013 and December 2015. An aortoiliac calcification score was calculated as the sum of calcification scores at the infrarenal aorta (0: no, 1: ≤ 3 cm, 2: > 3 cm) and the common iliac arteries (0: no, 1: unilateral, 2: bilateral). AL was classified into three grades: grade A, requiring no intervention; grade B, requiring therapeutic intervention without re-laparotomy; and grade C, requiring re-laparotomy. Clinicopathological characteristics were analyzed to identify risk factors for AL.There were 583 patients. Three-hundred forty-five (59.2%) had an aortoiliac calcification score ≥ 3, and 37 (6.3%) patients experienced AL, in 30 cases (5.1%) grade C AL. Patients with an aortoiliac calcification score ≥ 3 had a higher incidence of grade C AL (6.7% vs. 2.9%, p = 0.045). Multivariate logistic regression analysis revealed that an aortoiliac calcification score ≥ 3 was an independent risk factor for grade C AL (odds ratio = 2.669, 95% confidence interval 1.066-6.686, p = 0.036).Aortoiliac calcification may be considered a risk factor for grade C AL after rectal cancer surgery.

Anastomotic leakage (AL) is one of the most feared postoperative complications after anterior resection (AR) of rectal cancer. An adequate blood supply at the anastomotic site is regarded as a prerequisite for healing. We hypothesize that the Aortic Calcification Index (ACI) might reflect the severity of atherosclerosis in patients, and thereby be a risk factor for AL.AL was investigated retrospectively according to the definition of the International Study Group of Rectal Cancer in 423 rectal cancer patients who underwent anterior rectal resection. The ACI was measured by preoperative abdominal CT scan. The cross-section of the aorta was evenly divided into 12 sectors, the number of calcified sectors was counted as the calcification score of each slice. Lasso logistic regression and multivariate regression analysis were used to identify risk factors for AL.The percentage of AL after AR was 7.8% (33/423); the mortality of patients who sustained a leak was 3.0% (1/33). Patients with a high ACI had a significantly higher percentage of AL than patients with low ACI (11.2% vs 5.6%, P = 0.04). Among patients with AL, a higher ACI was associated with greater severity of AL (the ACI of patients with grade A leakage, grade B leakage and grade C leakage was 0.5% ± 0.2%, 11.5% ± 9.2% and 24.2% ± 21.7%, respectively; P = 0.008). After risk adjustment, multivariate regression analysis showed that a higher ACI was an independent risk factor for AL (OR 2.391, P = 0.04).A high ACI might be an important prognostic factor for AL after AR for rectal cancer. Confirmatory studies are required.Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Diabetes mellitus is a costly disease and nearly one-third of these costs are attributed to management of diabetic foot disease including chronic, non-healing, diabetic foot ulcers. Therefore, much effort has been placed into understanding the pathogenesis of diabetic wounds and novel therapeutics. A relatively new area of interest has been macrophage polarization and its role in diabetic wound healing. Diabetic wounds show dysregulated and persistent M1 (pro-inflammatory) macrophage polarization whereas normal wounds will display a transition to M2 (pro-healing) macrophages around day three after wounding. We reviewed factors known to affect macrophage polarization, mostly focused on those that contribute to M2 macrophage polarization, and potential treatments that at least in part target macrophage polarization in the diabetic wound bed. Much of the work has been aimed at reducing hyperglycemia and encouraging pro-inflammatory cytokine neutralization or decreased expression given this has a significant role in producing M1 macrophages. Treatment of diabetic wounds will likely require a multi-modal approach including management of underlying diabetes and control of hyperglycemia, topical therapeutics, and prevention of secondary infection and inflammation.Copyright © 2021. Published by Elsevier Inc.

Diabetes mellitus has been commonly associated with poor surgical outcomes. The aim of this meta-analysis was to assess the impact of diabetes on postoperative complications following colorectal surgery.Medline, Embase and China National Knowledge Infrastructure electronic databases were reviewed from inception until May 9th 2020. Meta-analysis of proportions and comparative meta-analysis were conducted. Studies that involved patients with diabetes mellitus having colorectal surgery, with the inclusion of patients without a history of diabetes as a control, were selected. The outcomes measured were postoperative complications.Fifty-five studies with a total of 666,886 patients comprising 93,173 patients with diabetes and 573,713 patients without diabetes were included. Anastomotic leak (OR 2.407; 95% CI 1.837-3.155; p < 0.001), surgical site infections (OR 1.979; 95% CI 1.636-2.394; p < 0.001), urinary complications (OR 1.687; 95% CI 1.210-2.353; p = 0.002), and hospital readmissions (OR 1.406; 95% CI 1.349-1.466; p < 0.001) were found to be significantly higher amongst patients with diabetes following colorectal surgery. The incidence of septicemia, intra-abdominal infections, mechanical failure of wound healing comprising wound dehiscence and disruption, pulmonary complications, reoperation, and 30-day mortality were not significantly increased.This meta-analysis and systematic review found a higher incidence of postoperative complications including anastomotic leaks and a higher re-admission rate. Risk profiling for diabetes prior to surgery and perioperative optimization for patients with diabetes is critical to improve surgical outcomes.

Wound healing is a complex, dynamic process supported by a myriad of cellular events that must be tightly coordinated to efficiently repair damaged tissue. Derangement in wound-linked cellular behaviours, as occurs with diabetes and ageing, can lead to healing impairment and the formation of chronic, non-healing wounds. These wounds are a significant socioeconomic burden due to their high prevalence and recurrence. Thus, there is an urgent requirement for the improved biological and clinical understanding of the mechanisms that underpin wound repair. Here, we review the cellular basis of tissue repair and discuss how current and emerging understanding of wound pathology could inform future development of efficacious wound therapies.

The double-stapled technique is the most common method of colorectal anastomosis. Despite its widespread use, emerging data suggests that this technique may be a risk factor for anastomotic complications, as it is believed that crossing staple lines and resultant dog-ears are potentially weak points that are prone to ischemia and anastomotic leak. Herein, we describe technical variations of single-stapled colorectal anastomoses which surgeons can readily adopt and integrate into their armamentarium of anastomotic techniques.© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).

Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage.

Several univariate and multivariate studies have already identified the number of stapler firings for laparoscopic rectal transection for rectal cancer as an independent risk factor for anastomotic leakage. The aim of this study was to perform a systematic review and meta-analysis of the anastomotic leakage rate in laparoscopic rectal surgery according to the need of using one or two stapler firings for rectal transection.PubMed, Ovid, the Cochrane Library database and ClinicalTrials.gov were searched. All of the statistical analyses were performed using Revman software.Five studies were included (1267 patients). The overall anastomotic leakage rate was 5.5% [0.7-8.4%]. Anastomotic leak occurred in 3.5% (17/491) of the cases where 1 stapler firing was used versus 6.7% (50/786) of the cases in which 2 firings were needed (50/786). Two stapler firings were significantly associated with an increased risk of anastomotic leakage (OR 2.44, 95% CI 1.34-4.42, p = 0.003, I = 1%).Our systematic review and meta-analysis suggest that two firings imply a higher rate of anastomotic leak than a single firing after laparoscopic rectal surgery with a double stapling technique. Coloproctologists should strive to reduce the number of linear stapler firings and try to transect the rectum with a single firing.

Excessive tension at the anastomosis contributes to anastomotic leakage (AL) in low anterior resection (LAR). However, the specific tension has not been measured. We assessed whether "Bridging," characterized by the proximal colon resembling a suspension bridge above the pelvic floor, is a significant risk factor for AL following LAR for rectal cancer.This retrospective study reviewed the medical records and laparoscopic videos of 102 patients who underwent laparoscopic LAR using the double stapling technique at Yachiyo Hospital between January 2014 and December 2023. Patients were classified based on whether they had Bridging (tight or sagging) or were in a Resting state of the proximal colon, and the association between Bridging and AL was examined.AL occurred in 31.3% of the Tight Bridging group, 20% of the Sagging Bridging group, and 2.2% of the Resting group (P = 0.002). The incidence of AL was significantly higher in patients with Bridging than in those without (23.2% vs. 2.2%, P = 0.003). Multivariate analysis revealed that Bridging is an independent risk factor for AL (odds ratio = 6.97; 95% confidence interval: 1.45-33.6; P = 0.016).The presence of Bridging is a significant risk factor for AL following LAR for rectal cancer, suggesting the need for implementing preventive measures in patients with this condition.© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

To demonstrate the clinical applicability of 3-dimensional CT angiography (3D-CTA) in evaluating the anatomic variations of inferior mesenteric artery (IMA) and left colic artery (LCA), to help make pre-operative strategies of rectal cancer surgery.188 patients with abdominal and pelvic contrast-enhanced CT scan were retrospectively enrolled and 3D-CTA was reconstructed. The origin and branching patterns of IMA, tracking patterns of LCA, intersectional patterns among IMA, LCA and inferior mesenteric vein (IMV) were examined, and their associations with clinical features were analyzed.The origin of IMA was located 42.1 ± 7.7 mm above iliac artery bifurcation, 64.4% within the area of the 3rd lumbar vertebra. 47.3% of LCA arose independently from IMA, 27.1% arose at the root of sigmoid artery (SA), 20.7% shared a common trunk with SA while 4.8% of LCA was absent. As for track of LCA before anastomosis with marginal artery, 53.2% went straight upward while medial to the inner border of left kidney (Type A), 27.1% traveled diagonally across left kidney (Type B) and14.9% went infero-laterally to the lower border of left kidney (Type C). Short IMA trunk was independently associated with type A LCA and lower site of IMA origin. At the horizontal level of IMA origin, 29% of the LCA went distant from IMV, while 71% (21% medial, 50% lateral) were mutually close, and the close type was independently associated with type A LCA.Preoperative understanding of the vascular variations and the mutual relationship among LCA, IMA and IMV could be obtained by 3D-CTA, which would further help surgeons to set detailed plans for laparoscopic rectal cancer surgery.Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid–low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15–5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level &gt; 5 ng/mL [OR = 2.20, 95% CI = 1.20–4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid–low rectal cancer patients.

A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma.

Anastomotic blood supply is vital to anastomotic healing. The aim of this study was to demonstrate the effect of the left colic artery (LCA) on blood supply in the anastomotic area, explore the relationship between individual differences in the LCA and blood supply in the anastomotic area, and elucidate the relevant indications for LCA retention during radical resection for sigmoid or rectal cancer.Radical sigmoid or rectal cancer resection with LCA retention was performed in 40 patients with colorectal cancer who participated in this study. Systemic pressure, LCA diameter, and the distance from the root of the LCA to the root of the inferior mesenteric artery were measured and recorded. The marginal artery stump pressure in the anastomotic colon before and after the LCA clamping was measured, respectively.There is a significant difference between the marginal artery stump pressure before LCA ligation and after ligation (53.1 ± 12.38 vs 42.76 ± 12.71, p < 0.001). The anastomotic blood supply positively and linearly correlated with body mass index and systemic pressure. Receiver-operating curve analysis revealed that LCA diameter (area under the curve 0.971, cutoff 1.95 mm) was an effective predictor of LCA improving anastomosis blood supply. No relationship was found between the LCA root location and anastomotic blood supply.Preserving the LCA is effective in improving blood supply in the anastomotic area, and larger LCA diameters result in a better blood supply to the anastomotic area.© 2022. The Author(s).

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described aiming to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered as possible risk factors for anastomotic leakage.The purpose of this study was to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis following minimally invasive surgery.A systematic review was undertaken of the published literature. PubMed/MEDLINE, Web of Science, and EMBASE databases were screened up to July 2023.Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction as compared to the conventional method of double-stapled anastomosis were included.Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared.The rate of anastomotic leak was the primary endpoint of interest. Perioperative details including postoperative morbidity were also appraised.There were 2537 patients from 12 studies included for data extraction, with no significant differences on age, body mass index and proportion of high American Society of Anesthesiologists Score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure compared to the conventional procedure (odds ratio = 0.38 [95% CI: 0.26, 0.56]. The incidences of overall postoperative morbidity (odds ratio = 0.57 [95% CI: 0.45, 0.73] and major morbidity (odds ratio = 0.48 [95% CI: 0.32, 0.72] following were significantly lower than following conventional double-stapled anastomosis.The retrospective nature of most included studies is a main limitation, essentially due to the lack of randomization, and the risk of selection and detection bias.The available evidence supports the modification of the conventional double-stapled technique with elimination of one of both dog-ears as it is associated with lower incidence of anastomotic-related morbidity.Copyright © The ASCRS 2024.

This meta-analysis aims to evaluate the efficacy of powered circular staplers (PCS) compared to manual circular staplers (MCS) in reducing anastomotic leakage (AL) and postoperative bleeding (AB) in colorectal surgery.Extensive searches were performed in the Embase, PubMed, and SCOPUS electronic bibliographic databases. Most studies were of an observational nature, and only one randomized clinical trial was identified.Twelve studies met the inclusion criteria for anastomotic leakage and five for anastomotic hemorrhage. The number of patients included for AL analysis was 4524. The leakage rate was 4.6% (208 cases). The number of patients with AB was 2868 with a bleeding rate of 4.99% (143 patients). After identifying outliers and studies with possible selection bias, the odds ratio (OR) for leaks and PCS was 0.38 (95% CI 0.26-0.55), the relative risk was - 0.05 (95% CI - 0.07 to 0.03), and the number needed to treat to prevent one leak was 20. For bleeding, the PCS OR for PCS was 0.20 (95% CI 0.0772-0.5177).Powered circular staplers could be associated with a significantly lower risk of leakage and anastomotic bleeding than two-row manual circular staplers. Further prospective randomized trials are needed to validate these findings.© 2025. The Author(s).

Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity.PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates.Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB.This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.

In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.© 2023. The Author(s).

Performing a bowel anastomosis is a critical step in colorectal resection. Assessing the risk of anastomotic leakage remains challenging, even for experienced surgeons.To evaluate the use of indocyanine green (ICG) fluorescence imaging in assessing perfusion at the anastomotic site before and after anastomosis and determine whether it helps reduce anastomotic leakages.ICG-COLORAL is a prospective, randomized, multicenter study conducted from September 1, 2018, to December 31, 2023. Participants were recruited during preoperative outpatient clinic visits by clinicians not involved in the study, as well as by researchers. Participants were elective patients scheduled for laparoscopic resections, excluding low anterior resections, with planned primary anastomosis in 5 Finnish public hospitals experienced in laparoscopic colorectal surgery.The intervention group received 5 mg of ICG intravenously before and after anastomosis formation. The fluorescence signal was assessed with a near-infrared-capable camera. The control group did not receive ICG fluorescence imaging.The primary outcome measure was the anastomotic leak rate as detected by computed tomography.Among 1136 patients in the intention-to-treat population, 526 (46.3%) were female and 610 (53.7%) male; they had a mean (SD) age of 70 (11) years, body mass index of 28 (5), and age-adjusted Charlson Comorbidity Index of 5 (3). Overall, the anastomotic leak rate was 5.8% (33/567) in the ICG fluorescence imaging group vs 7.9% (45/569) in the control group (odds ratio [OR], 0.73; 95% CI, 0.48-1.13; P = .16). For right-sided operations, the anastomotic leak rate with ICG fluorescence imaging was 5.9% (16/273) vs 6.7% (20/298) in the control group (OR, 0.87; 95% CI, 0.46-1.65). For left-sided operations, the anastomotic leak rate was 5.2% (14/267) with ICG fluorescence imaging vs 9.5% (23/243) without (OR, 0.55; 95% CI, 0.29-1.05). No patients reported adverse events related to ICG.This study found that routine use of ICG fluorescence imaging does not significantly reduce the overall anastomotic leak rate in laparoscopic colorectal surgery if low anterior resections are excluded but may be beneficial in left-sided operations.ClinicalTrials.gov Identifier: NCT03602677.

The aim of the present randomized controlled trial was to evaluate the superiority of indocyanine green fluorescence imaging (ICG-FI) in reducing the rate of anastomotic leakage in minimally invasive rectal cancer surgery.The role of ICG-FI in anastomotic leakage in minimally invasive rectal cancer surgery is controversial according to the published literature.This randomized, open-label, phase 3, trial was performed at 41 hospitals in Japan. Patients with clinically stage 0-III rectal carcinoma less than 12 cm from the anal verge, scheduled for minimally invasive sphincter-preserving surgery were preoperatively randomly assigned to receive a blood flow evaluation by ICG-FI (ICG+ group) or no blood flow evaluation by ICG-FI (ICG- group). The primary endpoint was the anastomotic leakage rate (Grade A+B+C, expected reduction rate of 6%) analyzed in the modified intention-to-treat population.Between December 2018 and February 2021, A total of 850 patients were enrolled and randomized. After exclusion of 11 patients, 839 were subject to the modified intention-to-treat population (422 in the ICG+ group and 417 in the ICG- group). The rate of anastomotic leakage (Grade A+B+C) was significantly lower in the ICG+ group (7.6%) than in the ICG- group (11.8%) (relative risk, 0.645; 95% confidence interval 0.422-0.987; P=0.041). The rate of anastomotic leakage (Grade B+C) was 4.7% in the ICG+ group and 8.2% in the ICG- group (P=0.044), and the respective reoperation rates were 0.5% and 2.4% (P=0.021).Although the actual reduction rate of anastomotic leakage in the ICG+ group was lower than the expected reduction rate and ICG-FI was not superior to white light, ICG-FI significantly reduced the anastomotic leakage rate by 4.2%.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

Ischemia at the site of an intestinal anastomosis is one of the most important risk factors for anastomotic leakage (AL). Consequently, adequate intestinal microperfusion is essential for optimal tissue oxygenation and anastomotic healing. As visual inspection of tissue viability does not guarantee an adequate objective evaluation of intestinal microperfusion, surgeons are in dire need of supportive tools to decrease anastomotic leakage after colorectal surgery.

Inadequate blood supply is one of the major risk factors for anastomotic leak after low anterior rectal resection. Early detection of ischemia might predict complicated healing and enable anastomotic salvage, which is associated with better outcomes. A microdialysis offers a real-time evaluation of adequate bowel perfusion through monitoring of tissue metabolism. In this experimental study, we assessed the role of microdialysis in detecting early ischemia after colorectal anastomosis.Colorectal anastomosis was performed in six miniature pigs. A microdialysis catheter was placed on the bowel serosa 5 mm proximal to the anastomosis. Metabolic changes were monitored hourly before and after initiating ischemia, which was induced by ligation of the inferior mesenteric artery and skeletonization of the mesocolon.Significant increase in tissue levels of lactate was detected after 60 min of ischemia (13.6 [10.4-16.1] versus 6.75 [1.8-9.6] mmol/L at baseline; P < 0.005). The lactate/pyruvate ratio increased accordingly. The concentration of glycerol increased significantly after 2 hours-from a baseline value of 29.5 (3-84) to 125 (79-201) mmol/L (P < 0.005). The decrease in glucose levels was also significant after 60 minutes-0 (0-0.2) versus 4.7 (3.3-6.8) mmol/L at baseline. However, its values started to decline before ischemia.Surface microdialysis can detect ischemic changes early and may be a promising method in postoperative monitoring of colorectal anastomosis.Copyright © 2020 Elsevier Inc. All rights reserved.

Colon perfusion status is one of the most important factors for the determination of postoperative anastomotic complications. Colonic hypoperfusion can be induced by inferior mesenteric artery (IMA) ligation in some patients. This study aimed to evaluate atherosclerotic risk assessment and vascular parameters of CT angiography as predictors of colonic hypoperfusion.This prospective study was conducted at a tertiary referral hospital and included 46 rectosigmoid colon cancer patients undergoing laparoscopic anterior resection between August 2013 to July 2014. Atherosclerotic risk scores were assessed using the Framingham cardiovascular risk score system. The IMA length, branching pattern, atherosclerotic calcification, and intermesenteric artery and mesenteric vascular diameters were evaluated using CT angiography. Mesenteric marginal artery pressures were measured before and after IMA clamping. The mean arterial pressure (MAP) index was calculated by dividing the mesenteric marginal MAP into the systemic MAP to determine the mesenteric hypoperfusion status after IMA clamping. A critically low MAP index was defined as <0.4.Critically low MAP index (<0.4) was observed in 6 cases (13.0%) after IMA clamping. Atherosclerotic calcification of the IMA and superior mesenteric artery occurred in 11 (23.9%) and 5 patients (10.9%), respectively. Low MAP index was associated with high atherosclerotic risk score and short IMA length, rather than atherosclerotic calcification and other vascular parameters of the major mesenteric arteries. Multivariate analysis indicated that high atherosclerotic risk and short IMA length were independent predictors of critically low MAP index.Atherosclerotic risk assessment and IMA length were useful predictors of the mesenteric hypoperfusion status following IMA ligation during laparoscopic rectosigmoid colon surgery.

Ischemia reperfusion injury is unavoidable in the setting of transplantation and may lead to primary dysfunction of the transplanted organ. Similarly, intestinal ischemia reperfusion injury may have deleterious effects causing intestinal failure. Montelukast is a selective reversible cysteinyl-leukotriene type 1 receptor antagonist used in clinical practice for its anti-inflammatory effects. In this study, we investigated the effects of Montelukast on colon anastomosis performed after intestinal ischemia reperfusion injury.40 adult male Wistar Albino rats were used. All rats underwent intestinal ischemia reperfusion injury. Afterwards, the entire group was divided into two for either right or left colonic resection and anastomosis. Rats in the control groups were given intra-peritoneal normal saline for 1 week while the animals in the treatment groups were given intra-peritoneal Montelukast (10 mg/kg; 1 ml). All animals were subjected to ischemia reperfusion injury followed by either right or left colonic segmental resection and anastomosis in the first day of the experiment. On postoperative day 7 adhesion scoring, anastomotic bursting pressure, anastomotic tissue hydroxyproline content were assessed for all groups.Significant differences were detected in adhesion scores between the treatment and control groups regardless of the colonic resection site. Anastomotic bursting pressures and hydroxyproline content of the anastomotic sites were significantly higher in the treatment groups when compared with the control groups. Anastomotic tissues treated with Montelukast showed more prominent vascularization in histopathological examinations.Montelukast has a potential to attenuate the detrimental effects of ischemia reperfusion injury on intestinal anastomosis.Copyright © 2019. Published by Elsevier Taiwan LLC.

Anastomotic leak after colorectal surgery, which remains a serious clinical problem that causes augmented morbidity and mortality, is usually favored by ischemia. The aim of this study was to determine whether alprostadil may improve anastomotic wound healing under ischemic condition.Ninety-three adult Wistar rats were randomized into three groups: control, ischemia (by devascularization along the first 2 cm at each anastomotic end), and ischemia plus alprostadil. Resection of a colonic segment at the colorectal junction and an anastomosis was performed. Animals were euthanized at 8 d. Surgical site infection, anastomotic leak, and grade of intra-abdominal adhesions using a validated scale were determined. Bursting pressure and tension were calculated and histologic examination of the anastomosis was performed.The ischemic group revealed an increased anastomotic leak rate (14/31 versus 3/31) and a lower bursting pressure and tension when compared to control group, validating therefore the experimental model. After intraperitoneal injection of alprostadil, anastomotic leak rate was significantly lower (5/31) and the bursting pressure and tension were significantly increased. Histologic examination revealed a lower presence of inflammatory cells, and a significantly higher neovascularization and a higher presence of fibroblasts in treated animals when compared with the ischemic group.Alprostadil may have a positive effect on colonic anastomotic wound healing under relative ischemic condition. Alprostadil administration increases anastomotic bursting pressure, decreases leak rate, and reverses most of the histological changes caused by blood flow decrease. These protective effects could be caused by vasodilation, stimulation of neovascularization, and immunomodulatory properties.Copyright © 2018 Elsevier Inc. All rights reserved.

Anastomotic leakage (AL) as a result of creation of a colorectal/anal anastomosis still represents a frequent complication of colorectal surgery, with short- and long-term consequences on postoperative morbidity, quality of life and oncological outcomes. However, early diagnosis of AL may result in improved outcomes. The aims of this study were to evaluate the diagnostic accuracy of water-soluble contrast enema (WSCE), contrast enema computed tomography (CECT) and endoscopy in identifying AL and to identify the diagnostic procedure that is most accurate.A systematic review and meta-analysis of 19 studies accounting for a total of 25 tests reporting diagnostic accuracy estimates was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines up to June 2021. For the diagnostic tests we evaluated the pooled estimates and conducted pairwise comparisons.For WSCE, the pooled sensitivity was 0.50, the pooled specificity was 0.99 and the area under the curve (AUC) was 0.91. For endoscopy, the pooled sensitivity was 0.69, specificity was 1.00 and AUC was 0.99. The pooled sensitivity and specificity for CECT were 0.89 and 1.00, respectively; the AUC was 0.99. The comparison between CECT and WSCE highlighted a significantly greater sensitivity (p = 0.04) for CECT, whereas no difference was found for specificity. Compared with CECT, endoscopy was not significantly more accurate in terms of either sensitivity or specificity. Endoscopy was found to be significantly more specific than WSCE (p = 0.031) but no difference was found for sensitivity.Water-soluble contrast enema, endoscopy and CECT have an elevated diagnostic accuracy. However, WSCE is less accurate than either endoscopy or CECT. Although greater sensitivity was demonstrated for CECT compared with endoscopy, this was not significant.© 2023 Association of Coloproctology of Great Britain and Ireland.

Hyperbaric oxygen treatment (HBOT) has been found to improve the healing of poorly oxygenated tissues. This study aimed to investigate the influence of HBOT on the healing in ischemic colorectal anastomosis.Forty Wistar rats were randomly divided into a treatment group that received HBOT for 10 consecutive days (7 days before and 3 days after surgery), or in a control group, which did not receive the therapy. Colectomy with an ischemic anastomosis was performed in all rats. In each group, the rats were followed for 3 or 7 days after surgery to determine the influence of HBOT on anastomotic healing.Five rats from each group died during follow-up. No anastomotic dehiscence was seen in the HBOT group, compared to 37.5 % and 28.6 % dehiscence in the control group on postoperative day (POD) 3 and 7, respectively. The HBOT group had a significantly higher bursting pressure (130.9 ± 17.0 mmHg) than the control group (88.4 ± 46.7 mmHg; p = 0.03) on POD 3. On POD 3 and POD 7, the adhesion severity was significantly higher in the control groups than in the HBOT groups (p < 0.005). Kidney function (creatinine level) of the HBOT group was significantly better than of the control group on POD 7 (p = 0.001). Interestingly, a significantly higher number of CD206+ cells (marker for type 2 macrophages) was observed in the HBOT group at the anastomotic area on POD 3.Hyperbaric oxygen enhanced the healing of ischemic anastomoses in rats and improved the postoperative kidney function.